Every finding on record at Sierra Vista Healthcare

Based on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food and ice in accordance with professional standards for food service safety when:1. The kitchen ice machine was observed to have several areas with a removable black substance when wiped with a white paper towel and was not sanitized according to manufacturer's directions.2. The kitchen's sanitizer solution was not the appropriate concentration to sanitize the food preparation area.3. A high calorie/protein nutritional supplement drink was observed in station two's refrigerator, open, and with no open date written on the carton. These failures had the potential to cause cross contamination (the process by which germs are unintentionally transferred from one substance or object to another, with harmful effect) and the growth 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) of residents' food and ice which could lead to food-borne illness (stomach illness acquired from ingesting contaminated food) for the 91 residents admitted to the facility.1. During an observation on 1/6/26 at 10:40 a.m. in the kitchen, Dietary Aid (DA) 1 was observed pouring ice from the ice machine into pitchers with water. DA 1 stated the ice in the pitchers was from the ice machine and was used for the carts for the residents.During a concurrent observation and interview on 1/6/26 at 3:40 p.m. with the Dietary Manager (DM) in the kitchen, a paper towel was used to wipe the inside chute of the ice machine. DM was shown the white paper towel used to wipe the ice chute of the kitchen's ice machine, that had a visible black substance on it. DM acknowledged seeing the black substance and stated she would inform maintenance about the findings.During an observation on 1/6/26 at 3:58 p.m., on the nursing station for station one, there was an ice chest filled with ice and on the counter an orange beverage dispenser that showed a sign that stated ice water.During a concurrent interview and record review on 1/7/26 at 8:30 a.m. with Maintenance Assistant (MA), the ice machine's manufacturer instructions titled, Cleaning/Sanitizing Procedure instructions was posted up on the ice machine's door. The instructions indicated, three ounces of sanitizer should be run through the system as part of the cleaning process for a 30 (inch) wide ice machine. MA stated that he was responsible for cleaning the ice machine monthly and last cleaned it on 12/30/25. MA stated that during the cleaning of the ice machine he first ran 5 ounces of the ice machine descaler through the system, then used two ounces per three gallons of water to clean all parts of the ice machine inside and out. MA stated he received training when the ice machine was installed in 2022 and was instructed to use the sanitizer to clean the machine parts inside and out. MA stated he was not instructed to put the sanitizer through the ice machine as part of the cleaning process. MA stated he did not run three ounces of sanitizer through the ice machines system. The ice machine's water curtain was wiped with a white paper towel and a black substance was observed on the white paper towel. MA acknowledged the black substance removed from the ice machine. During an interview on 1/7/26 at 3:50 p.m. with DM, DM stated the only ice machine in the facility was in the kitchen. DM stated ice from the ice machine is used for water pitchers, the nurses station hydration jug, and ice chests. During a review of the facility's monthly ice machine cleaning log titled, [Name of facility] Monthly Ice Machine Cleaning Schedule, (undated), the Monthly Ice Machine Cleaning Schedule indicated, Date.12/30/25.Signature for Ice Machine Cleaning. followed by MA signature.During a review of the ice machine manufacturer's directions, titled, Section 4 Maintenance, dated 2/20, the Section 4 Maintenance document indicated, .Step 13.Add the proper amount of ice machine sanitizer to the water trough by pouring between the water curtain and evaporator.During a review of the facility's policy and procedure (P&P) titled, Sanitization, dated October 2008, the Sanitization P&P indicated, .12. Ice machines and ice storage containers will be drained, cleaned and sanitized per manufacturer's instructions.2. During a concurrent observation and interview on 1/7/26 at 10:05 a.m. with Dietary [NAME] (DC) 1 in the kitchen, DC 1 was observed cleaning the stainless-steel food preparation counter after preparing minced and moist (texture) chicken. DC 1 used a towel from the green bucket to wash the counter, then used a clean towel and put it in water from the faucet in the food preparation sink and wiped down the counter. DC 1 then used a towel from the red sanitation bucket containing quaternary ammonium solution to wipe down the food preparation counter. The red bucket's sanitizer solution concentration was tested by DC 1. DC 1 stated the sanitizer concentration was 100 parts per million (ppm-a unit typically used to express the concentration of a substance in a solution or mixture) while holding the test strip up to the manufacturer's directions. DC 1 stated 100 ppm was not okay and the sanitizer concentration needed to be 200 ppm. During a review of the facility's policy and procedure (P&P) titled, Sanitization, dated October 2008, the Sanitization P&P indicated, .4. Sanitizing of environmental surfaces must be performed with one of the following solutions.150-200 ppm quaternary ammonium compound. 3. During a concurrent observation and interview on 1/6/26 at 3:52 p.m. with Licensed Vocational Nurse (LVN) 7 at station two, station two's refrigerator contents were observed. A high calorie/protein nutritional supplement drink was observed in station two's refrigerator, open, half full and undated with no open date written on the carton. LVN 7 stated the high calorie/protein nutritional supplement drinks were good for three days after opening. LVN 7 looked at the carton and stated there was no open date, and she would discard it immediately.During a review of the carton on the facility's high calorie/protein nutritional supplement drink storage and handling directions, the high calorie/protein nutritional supplement drink storage and handling directions indicated, .Refrigerate after opening and use within 3 days.

Based on observation, interview, and record review, the facility failed to ensure nutritional needs of the residents were met when the menus were not followed for three residents (Residents 7, 21, and 55) on a large portion diet when Resident 21 received three ounces of meatloaf (regular portion) instead of four ounces (large portion), Residents 7 and 55 received 4 ounces of meatloaf and should have received 6 ounces during lunch on 1/6/26. These failures had the potential to result in unintended weight loss, weakness, fatigue, or increased fall risk, and decreased quality of life.During a review of the facility's menu titled, Diet Spreadsheet dated Day: 17 - Tuesday [1/6/26], the Diet Spreadsheet indicated, .Large Portion.Lunch. Homestyle Meatloaf.Portion Size 4 oz (ounces). The Diet Spreadsheet indicated for the lunch meal the regular meatloaf portion size was 3 oz., the regular minced and moist meatloaf with thick gravy was a #8 scoop (4 ounces), the regular puree meatloaf was a # 8 scoop.During an observation of the lunch meal service on 1/6/26 at 12:38 p.m. in the kitchen, Resident 7's meal tray was being prepared by Dietary Manager (DM) and Dietary [NAME] (DC) 1. Resident 7 received a #8 scoop (4 oz.) for the minced meatloaf.During an observation of the lunch meal service on 1/6/26 at 12:41 p.m. in the kitchen, Resident 21's meal tray was being prepared by DM and DC 1. Resident 21 received three oz. of meatloaf.During an observation of the lunch meal service on 1/6/26 at 12:45 p.m. in the kitchen, Resident 55's meal tray was being prepared by DM and DC 1. Resident 55 received a #8 scoop for the pureed meatloaf.During a review of Resident 7's Order Summary Report (OSR) dated January 8, 2026, the OSR indicted, .Regular Large Portions diet.Minced and Moist.During a review of Resident 21's Order Summary Report (OSR) dated January 8, 2026, the OSR indicted, .Regular Large Portions diet Regular Texture .During a review of Resident 55's Order Summary Report (OSR) dated January 8, 2026, the OSR indicted, .Regular Large Portions diet Pureed texture .During a concurrent observation and interview on 1/6/26 at 12:48 p.m. with DC 2 in the kitchen, DC 2 weighed Resident 21's meatloaf before placing the tray into the tray cart (enclosed kitchen cart used to transport meal trays to resident rooms). DC 2 stated the meatloaf was 3 oz. but should have been 4 oz. DC 2 checked Residents 7 and 55's plates and meal tickets and stated the meatloaf was already 4 ounces for the large portion, so they do not give a bigger portion for the minced meatloaf or pureed meatloaf. During a concurrent interview and record review on 1/7/26 at 3:00 p.m. with Registered Dietitian (RD), the facility's Dining Service Menu Guide titled, Small Portion/Large Portion . Dining Service Menu Guide. dated 2022 was reviewed. The Dining Service Menu Guide indicated, . Large Portions Diet . Lunch and Supper: Serve 1 1/2 servings of the entree . RD stated large portions for puree and minced and moist should get more than the menu for the regular portion of those diets. RD stated her expectation was that the resident with a puree large portion should have received more of the meatloaf. RD stated the menu guide for large portions stated they would receive 1 1/2 servings for the entree (6 oz). RD stated that if the residents only received the regular size portion of the entree, that was incorrect. RD stated the entree should have been increased to 1 1/2 servings according to the Dining RD menu guide. RD stated her expectation is that kitchen staff follow the menu and adjust for the appropriate diets.During a review of the facility's document from the Dining Service Menu Guide, titled, Small Portion/Large Portion dated 2022, the Dining Service Menu Guide, titled, Small Portion/Large Portion indicated, .Large Portions Diet.Lunch and Supper: Serve 1 1/2 servings of the entree.

Based on observation, interview, and record review, the facility failed to establish and maintain an effective infection prevention and control program for five of 22 sampled residents (Resident 4, 38, 58, 71, and 98) when:1. Resident 98's foley catheter drainage bag (a bag connected to a tube that is inserted into the urinary bladder to collect urine) was lying on the floor in his room. LVN 5 proceeded to enter his room and manipulate his catheter and did not put on a gown as specified by enhanced barrier precaution (EBP- standards in place in healthcare facilities to prevent the spread of infection) standards. This failure had the potential to cross contaminate (transfer of bacteria from one surface or object to another) Resident 98's catheter and LVN 6's clothing and cause them to be affected by and spread multi drug resistant organisms (MDRO-germs that are resistant to multiple antibiotics, making infections difficult to treat).2. Resident 4's nasal cannula (flexible tube with two prongs that fit inside the nostrils), and oxygen tubing (flexible tube connected to an oxygen source) were found wrapped around Resident 4's bed rail.This failure placed Resident 4 at risk for cross-contamination and infection.3. Resident 58 was symptomatic with a dry, intermittent non-productive cough, and suspected of having a transmissible respiratory infection and was not placed on transmission-based precautions pending lab results. This failure resulted in other residents, staff, and visitors being exposed to Influenza A (commonly known as the flu, a respiratory infection with the influenza A virus, spread through droplets) which could lead to an influenza outbreak and result in serious medical issues. 4. Resident 38 and Resident 71's oxygen (O2) nasal cannula (NC a tube that directs oxygen into the nose) was found unbagged on top of the resident's Oxygen concentrator (medical device that helps you breathe better up to 95% pure oxygen.)This failure had the potential to result in the spread of germs and bacteria that could result in infection and illness.Findings: 1.During a review of Resident 98's admission Record (AR- a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 1/9/26, the AR indicated Resident 98 was admitted with a diagnosis of a urinary tract infection (UTI- an infection that develops in the urinary system) During an observation on 1/6/26 at 11:19 a.m. in Resident 98's room. Resident 98's catheter was on the floor while he was in bed. During a concurrent observation and interview on 1/6/26 at 11:30 a.m. with LVN 5, LVN 5 entered Resident 98's room, which was on EBP precautions, and did not put on a gown, LVN 5 then proceeded to pick up Resident 98's catheter off the ground. LVN 5 stated the catheter should not have been on the ground because there was a possibility that the catheter bag could have become contaminated or dirty. LVN 5 stated because Resident 98 had a catheter, so he was automatically placed on EBP precautions, and she needed to don(put on) both a gown and gloves to prevent cross contamination from occurring. During an interview on 1/9/26 at 9:46 a.m. with the Infection Preventionist (IP), the IP stated anytime a resident had a catheter in place staff needed to don gloves and a gown before they touched or manipulated it. The IP stated LVN's could potentially cross contaminate their scrubs and carry germs on to another resident by not wearing a gown. The IP stated additionally a Resident's foley catheter bag should not have been on the floor, it was the responsibility of the nurses to ensure foley catheter drainage bags were hooked up and away from the floor because the catheter bag could become contaminated with bacteria from the floor and transfer to the resident. During an interview on 1/9/26 at 10:12 a.m. with the Director of Nursing (DON), The DON stated it was unacceptable for the foley catheter drainage bag to be on the floor. The DON stated staff also needed to do additional rounding to prevent any catheter bags from lying on the floor. The DON stated Resident 98 was already at a higher risk for infection because of the foley catheter he had and staff members should have either hung up the bag off the floor or reported the problem to someone who could take care of it. The DON stated all nurses need to put on a gown and gloves when entering an EBP room and touching a foley catheter, the precautions are there to prevent the spread of infection and nurses needed to abide by those infection control standards. During a review of the facility's policy and procedure (P&P) titled, Catheter Care, Urinary, dated 9/14, the P&P indicated, . The purpose of this procedure is to prevent catheter-associated urinary tract infections . Use standard precautions when handling or manipulating the drainage system. Be sure the catheter tubing and drainage bag are kept off the floor . During a review of the facility's P&P titled, Enhanced Barrier Precaution, dated 6/20/24, the P&P indicated, . [EBP] – used in conjunction with the standard precautions and expand the use of [personal protective equipment] to donning of gown and gloves during high-contact resident care activities and in situations of expected exposure to blood, body fluids, skin breakdown, or mucous membranes that provide opportunities for transfer of MDROs to staff hands and clothing to reduce transmission . 4. Facility staff shall perform hand hygiene and will don gown and gloves before performing the following high-contact resident care activities . Device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator . 2. During a concurrent observation and interview on 1/7/26 at 4:35 p.m. with Certified Nursing Assistant (CNA) 2 in Resident 4's room, Resident 4's oxygen tubing and nasal cannula were observed wrapped around Resident 4's bed rail. CNA 2 stated Resident 4's oxygen tubing should have been put in the plastic bag when not in use and not wrapped around his bedrail. CNA 2 stated putting the oxygen tubing in the plastic bag was to prevent the tubing from getting dirty and causing an infection. CNA 2 stated it was for infection control. During a review of Resident 4's AR, dated 1/8/26, the AR indicated Resident 4 was admitted to the facility from an acute care hospital on [DATE] with diagnoses of chronic respiratory failure (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), type 2 Diabetes Mellitus (when the blood sugar levels in the body are too high), acquired absence of right leg (surgical removal of leg) above the knee, heart failure (a condition when the heart muscle doesn't pump enough blood to meet the body's needs which can cause fatigue and shortness of breath), and end stage renal disease (a condition where the kidneys can no longer function on their own and dialysis [a process of removing excess water, and waste products from the blood] or kidney transplant is required to survive). During a review of Resident 4's Minimum Data Set (MDS - a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment), dated 11/25/25, the MDS section C indicated Resident 4 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 14 (a score of 0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired, 13-15 suggests cognitively intact), which suggested Resident 4 was cognitively intact. During an interview on 1/7/26 at 4:58 p.m. with the Registered Nurse (RN), the RN stated Resident 4's oxygen tubing should have been put in a bag when not in use to prevent Resident 4 from getting an infection if the oxygen tubing became dirty and Resident 4 used it. The RN stated putting the oxygen tubing in a bag when not in use was for infection control. During an interview on 1/08/26 at 2:37 p.m. with the Director of Staff Development (DSD), the DSD stated resident's oxygen tubing and nasal cannula should not have been wrapped around the resident's bed rail, it should have been placed in a plastic bag when not in use. The DSD stated the oxygen tubing should not have been used if it was wrapped around the bed rail as it was an infection control issue. The DSD stated the oxygen tubing should have been removed and put in the trash and the CNA should have let the nurse know to replace it. The DSD stated there was the potential for cross contamination if the oxygen tubing was used after being wrapped around the resident's bed rail. The DSD stated the tubing could have had bacteria on it and if the resident used the dirty tubing, the bacteria could have gone into the resident's nose and caused an infection. During a review of the facility's P&P titled, Respiratory Therapy – Prevention of Infection, dated 11/15/23, indicated . the purpose of this procedure is to guide prevention of infection associated with respiratory therapy tasks and equipment, including ventilators, among residents and staff . keep the oxygen cannulae and tubing used PRN [ as needed} in a plastic bag when not in use . 3. During a review of Resident 58's AR, dated 1/8/26, the AR indicated Resident 58 was admitted to the facility on [DATE] with diagnosis of heart failure (heart muscle does not pump blood well), hypertension (high blood pressure) and depression (mood disorder causing persistent sadness). During a review of Resident 58's MDS, dated 10/8/25, the MDS assessment indicated Resident 58's BIMS assessment score was 13 out of 15 which indicated Resident 58 was cognitively intact. During a concurrent observation and interview on 1/6/26 at 2:55 p.m. with Resident 58, in Resident 58's room, Resident 58's room entrance and room was not observed with transmission-based precaution signage (TBP) or protective personal equipment (PPE). Resident 58 was observed wearing a mask with a hacking cough. Resident 58 stated she was not feeling well. Resident 58 stated, I have something you can catch, you need a mask. Resident 58's roommate, Resident 63 stated, .get out she probably has COVID [Coronavirus disease-an infectious disease caused by the SARS-CoV-2 virus, spread through droplets and aerosols]. During an interview on 1/6/26 at 3:00 p.m. with LVN 4, LVN 4 stated Resident 58 had been exhibiting respiratory symptoms, an intermittent non-productive cough, since the morning. LVN 4 stated the provider had been notified and lab tests had been ordered to rule out COVID, Respiratory Syncytial Virus (commonly called, RSV, a virus that affects the respiratory tract, spread through droplets) and Influenza. LVN 4 stated Resident 58 had not been placed on TBP and PPE had not been provided at her room entrance or room for staff or visitors to use. LVN 4 stated Resident 58's lab results for COVID, RSV and Influenza were not back yet. During an interview on 1/6/26 at 3:03 p.m. with the IP, the IP stated Resident 58 had not been placed on TBP and PPE had not been provided for entry to Resident 58's room. The IP stated Resident 58's COVID, RSV and Influenza lab results were not back yet and it could take up to 24 hours to get those results. During an observation on 1/6/26 at 3:08 p.m. in front of Resident 58's room, two facility staff members were observed entering Resident 58's room with no mask, goggles, gown or gloves and closed the door to provide care. During a concurrent observation and interview on 1/8/26 at 9:22 a.m. with Housekeeper (HSK) 2, Resident 58's door was open and HSK 2 was observed cleaning Resident 58's floor. Resident 58 had a droplet precaution (infection control measure to prevent transmitting germs via large respiratory droplets when an infected person coughs, sneezes, or talks, requiring healthcare workers and visitors to wear surgical masks) sign posted on her door. The sign indicated everyone needed to cover their eyes, nose and mouth while in the room. HSK 2 was observed not wearing a face shield or goggles to cover her eyes. HSK 2 exited the room after cleaning Resident 58's floor and stated she should have had a face shield or goggles on, per the droplet TBP signage, to cover her eyes and prevent exposure to Resident 58's transmissible infection. HSK 2 stated it was important to follow TBP signage to prevent exposure or transmission to others. HSK 2 stated she relied on TBP signage to indicate if a resident was on precautions and how to protect herself and limit the spread of infections. HSK 2 stated she expected the facility to implement TBP signage for suspected and known residents with transmissible infections for public safety. HSK 2 stated if a resident was suspected of having a transmissible infection, she expected a TBP sign posted on the room door while awaiting lab results to prevent exposures and transmission of infections to other staff, visitors and residents. During a concurrent interview and record review on 1/8/26 at 2:24 with the IP, Resident 58's Medical Record, dated 1/8/26 was reviewed. The IP stated a transmissible infection was anything that could be spread through contact, droplet or airborne transmission, such as COVID, RSV or Influenza. The IP stated she utilized The Centers for Disease Control and Prevention (CDC) guidelines for infection control and prevention standards of practice. The IP stated Resident 58 was first noted to have respiratory symptoms on 1/6/26 at 1:30 p.m. and COVID, RSV, and Influenza labs were ordered. The IP stated Resident 58's rapid COVID test resulted negative on 1/6/26 at 1:35 p.m. The IP stated Resident 58's Influenza A test came back as positive on 1/7/26 at 3:55 p.m. The IP stated Resident 58 was then moved to a private room and TBP droplet precaution signage was initiated and PPE provided outside her room. The IP stated Resident 58's RSV came back as negative on 1/8/26 at 10:21 a.m. The IP stated infection control and prevention standards of practice or facility policy were not implemented when Resident 58 was symptomatic and suspected of having multiple transmissible respiratory infections and TBP precautions were not initiated. The IP stated residents, staff and visitors were placed at risk of acquiring Influenza A which could result in serious medical issues or an outbreak if not contained. The IP stated she expected staff and visitors to adhere to TBP signage and infection control and prevention policy when providing care to prevent the transmission of infections to others. During an interview on 1/9/26 at 9:16 a.m. with the DON, the DON stated she expected the facility to always adhere to infection control and prevention standards of practice and facility policy and procedure. The DON stated the IP was responsible for implementing infection control and prevention policies within the facility. The DON stated Resident 58 should have had TBP signage posted and PPE provided at her room entrance while she was symptomatic and suspected of having a transmissible respiratory infection to ensure all residents, staff and visitors took appropriate precautions to prevent the spread of the potential respiratory infection. The DON stated residents, staff and visitors were placed at risk of transmitting and acquiring Influenza A while Resident 58's lab results were pending. During a review of the facility's P&P titled, Isolation-Category of Transmission-Based Precautions, dated 10/2018, the P&P indicated, .Transmission-Based Precautions are initiated when a resident develops signs and symptoms of a transmissible infection.and is at risk of transmitting the infection to other residents.Transmission-based precautions are additional measures that protect staff, visitors, and other resident from becoming infected.when a resident is placed on transmission-based precautions, appropriate notification is placed on the room entrance door and on the front of the chart so that personnel and visitors are aware of the need for ad the type of precaution.the signage informs the staff of the type of CDC precaution (s), instructions for PPE.droplet precautions may be implemented for an individual documented or suspected to be infected with microorganisms transmitted by droplet. During a review of the facility's P&P titled, Quality of Life-Dignity, dated 8/2009, the P&P indicated, .in the interest of public health, posting the resident's isolation status or Transmission-Based Precautions is permissible as long as the type of infection remains confidential. During a review of the facility's P&P titled, Influenza, Prevention and Control of Seasonal, dated 8/2014, the P&P indicated, .during periods of increased community influenza activity, rapid screening of residents for symptoms of influenza and separation from other residents during screening may be necessary.droplet precautions will be implemented for residents with suspected or confirmed influenza for seven (7) days after illness onset or until 24 hours after the resolution of fever and respiratory symptoms, whichever is longer. During a review of the facility's job duty titled, Infection Control Nurse, dated 2003, the job duty indicated, .ensure the facility is in compliance with current CDC, OSHA, and local regulations concerning infection control or standard/universal precautions. During a professional reference review retrieved from https://www.cdc.gov/infection-control/hcp/viral-respiratory-prevention/index.html titled, Preventing Transmission of Viral Respiratory Pathogens in Healthcare Settings, dated 5/21/25, the professional reference review from CDC indicated,. apply appropriate Transmission-Based Precautions, including placement in a single-person room, when examining a patient with known or suspected respiratory infection. Precautions should be based on the clinical syndrome and the likely etiologic agents (e.g., which respiratory viruses are circulating in the community, contact with someone known to have influenza) and modified once the pathogen is identified or a transmissible infectious etiology is ruled out. 4. During observation of Resident 71 in Resident 71's room on 1/6/26 at 12:43 p.m. O2 NC tubing was seen not in use and not in bag, the tubing was laying on top of the oxygen concentrator. During a review of Resident 71's AR dated 1/7/26, the AR indicated, Resident 71 was initially admitted to the facility on [DATE] with diagnoses of heart failure (severe failure of the heart to function properly,) Atrial Fibrillation ([AFib] is an irregular and often very rapid heart rhythm), and hypertensive heart disease (heart problems that occur because of high blood pressure that is present over a long time). During a review of Resident 71's MDS, dated [DATE], the MDS section C indicated Resident 71 had a Brief Interview for Mental Status (BIMS) score of 3, which suggested Resident 38 had severe cognitive impairment. During a review of Resident 71's Order Summary Report (OSR) dated 1/8/26, the OSR indicated, .Oxygen- At 3 liters (unit of measurement) per/minute via Nasal cannula continuously . During an interview on 1/7/26 at 4:10 p.m. with CNA 2, photos of Resident 71's oxygen tubing were reviewed not in a bag laying over the oxygen concentrator. CNA 2 stated when tubing is not in use the tubing is placed in a bag to keep clean. CNA 2 stated that nurses and or CNAs can take the NC off the resident and place in the bag, this is done for infection control. CNA 2 further indicated the NC in the photo should not have been left laying over the oxygen concentrator it should have been placed inside a bag for storage until needed. During an interview on 1/7/26 at 4:20 p.m. with DSD, the DSD stated, the NC should not have been laying over the oxygen concentrator and should have been replaced and placed inside a bag when not in use. The DSD stated failure to store respiratory equipment properly could result in contamination and did not align with facility expectation. During an observation of Resident 38 in Resident 38's room on 1/6/26 at 12:36 p.m. O2 NC tubing was seen not in use and not in bag, the tubing was laying on top of the oxygen concentrator. During a review of Resident 38's AR dated 1/7/26, the AR indicated, Resident 38 was initially admitted to the facility on [DATE] with diagnoses of Parkinson's disease with dyskinesia (involuntary, uncontrolled erratic movements) and dementia (a progressive state of decline in mental abilities). During a review of Resident 38's MDS, dated 12/31/25, the MDS section C indicated Resident 38 had a BIMS score of 3, which suggested Resident 38 had severe cognitive impairment. During a review of Resident 38's OSR dated 1/8/26, the OSR indicated, .Oxygen- At 2 liters (unit of measurement) per/minute via Nasal cannula as needed for SOB (shortness of breath) . During an interview on 1/7/26 at 4:10 p.m. with CNA 2, photos of Resident 38's oxygen tubing not in a bag laying over the oxygen concentrator were reviewed. CNA 2 stated when tubing is not in use the tubing is placed in a bag to keep clean. CNA 2 stated that nurses and/ or CNAs can take the NC off the resident and place it in the bag, this is done for infection control. CNA 2 further indicated the NC in the photo should not have been left laying over the oxygen concentrator it should have been placed inside a bag for storage until needed. During an interview on 1/7/26 at 4:20 p.m. with the DSD, the DSD stated, the NC should not have been laying over the oxygen concentrator and should have been replaced and placed inside a bag when not in use. The DSD stated failure to store respiratory equipment properly could result in contamination and did not align with facility expectation. During a review of the facility's P&P titled, Respiratory Therapy-Prevention of Infection, dated 11/15/23, the P&P indicated, .Infection control considerations related to oxygen administration.Keep the oxygen canulae and tubing used PRN in a plastic bag when not in use. During a review of a professional reference from https://www.homecaremag.com/february-2020/dont-let-oxygen-concentrator-lead-infection titled Don't Let an Oxygen Concentrator Lead to Infection, Dated 1/2020, the professional reference indicated, .2 'In Use' Nasal Cannula . For patients switching to portable oxygen or pro re nata home oxygen administration, nasal cannula storage can be problematic. The nasal cannula prongs often become contaminated when patients don't properly protect the cannula between uses (i.e., leaving the nasal cannula on the floor, furniture, bed linens, etc.). Then the patient puts the contaminated nasal cannula back in their nostrils and directly transfers potentially pathogenic organisms from these surfaces onto the mucous membranes inside their nasal passages, putting them at risk of developing a respiratory infection. Educate the patient on how to store the nasal cannula between uses in a manner that does not allow it to have direct contact with potentially contaminated surfaces. Either keep the in-use nasal cannula somewhere that does not allow contact with a surface or place it on a clean surface, inside an open clean container, or in an open plastic bag .

Based on interview, and record review the facility failed to ensure one of six residents (Resident 53) received a level II Pre-admission Screening and Resident Review (PASARR- evaluation for individuals suspected of having a Serious Mental Illness [SMI] or Intellectual/Developmental Disability [I/DD]/Related Condition [RC], triggered by a positive Level I screen, to determine if they need 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 53 had a PASARR level I screening result positive for SMI, and the facility did not ensure a PASARR level II screening was completed.This failure resulted in Resident 53 not receiving the required PASARR level II screening which had the potential to result in missed identification of specialized services needed and put Resident 53 at risk of delayed treatment.Findings:During an observation on 1/06/26 at 12:35 p.m., in the facility dining room, Resident 53 was observed sitting in a wheelchair, dozing off while staff attempted to feed Resident 53 his pureed lunch meal (food that has been ground, pressed, and/or strained to a soft, smooth consistency, like a pudding). Observed staff sitting next to Resident 53 and encouraged Resident 53 to wake up and take a bite of his meal several times. Resident 53 observed closing his eyes after each bite.During a review of Resident 53'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 1/8/26, the AR indicated Resident 53 was admitted to the facility from an acute care hospital on 8/16/21 with diagnoses of dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life, repeated falls, major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities), and post-traumatic stress disorder (a disorder in which a person has difficulty recovering after witnessing or experiencing a terrifying event).During a review of Resident 53's Minimum Data Set (MDS - a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment), dated 12/4/25, the MDS section C indicated Resident 53 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 3 (a score of 0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired, 13-15 suggests cognitively intact), which suggested Resident 53 was severely cognitively impaired.During a review of Resident 53's Department of Healthcare Services (DHCS) letter dated 1/4/22, the letter indicated, . Level I date: 08/16/2021 . unable to complete Level II evaluation. Federal law requires all individuals seeking admission to a Medicaid Certified Nursing Facility (NF) receive a Level I Mental Health Screening. The Level I Mental Health Screening identifies if an individual has a suspected Mental Illness (MI) or an Intellectual/Developmental Disability or Related Condition (ID/DD/RC). If MI is suspected, then a Level II Mental Health Evaluation may be conducted to determine if the individual can benefit from specialized mental health services . after reviewing the Positive Level I Screening and speaking with staff, a Level II Mental Health Evaluation was not scheduled for the following reason: . the individual was isolated as a health or safety precaution. The case is now closed. To reopen, please submit a new Level I Screening . No further documentation was found regarding re-opening Resident 53's case.During a record review of resident 53s Care Plan Report (CP), dated 1/8/26, the CP indicated, . the resident has a behavior problem related to (r/t) dementia, res(ident) Getting out of bed unassisted, and walking around the hallway. Episodes of angry outbursts by throwing items like blanket and care items, hoarding food and drinks, with episodes of trying to get out of the facility sometimes . date initiated: 08/30/2021 . revision on: 10/15/2025 . wander guard applied to the left hand . date initiated 10/25/2024 . risk for wandering or elopement related to exit seeking behavior, frequently asking to go out, dementia, wanders aimlessly . initiated 09/10/2021 . apply wander guard [a device that monitors at-risk residents and protects them from elopement or wandering off the facility premises] as ordered . initiated 09/10/2021 . high risk for falls and injury related to poor safety awareness, limitation of mobility, perceived self as independent and will not call for assistance, recent fall in the last 30 days, history of falls(s), use of psychotropic medication(s), . cognitive impairment, dementia . date initiated 08/16/2021 . use of sensor pad alarm when in bed to alert the staff when resident is attempting to get out of bed unattended . date initiated 06/19/2024 . sensor pad alarm on wheelchair . date initiated: 01/05/2026.During an observation on 1/08/2026 at 2:34 p.m. in Resident 53's room, Resident 53 was observed asleep in bed, covered with a sheet. Resident 53's wheelchair observed next to his bed with a sensor pad alarm on the right wheelchair handle. A bed sensor pad alarm noted on Resident 53's left bed rail, and a fall mat observed on the right side of Resident 53's bed. Resident 53 did not respond when knocked on his room door or when spoken to.During an interview on 1/8/2026 at 3:24 p.m. with Resident 53's Responsible Party (RP) 1, RP 1 indicated Resident 53 has had several falls without injury and has had a couple of episodes where he had wandered throughout the facility and expressed a desire to leave the facility. RP 1 stated the facility called her to inform her of each incident and at times she has had to go to the facility or speak with Resident 53 on the phone to put him at ease.During a concurrent interview and record review on 1/08/26 at 10:27 a.m. with the Director of Nursing (DON), Resident 53's letter from the DHCS, dated 1/4/22 was reviewed. The letter indicated, . Level I date: 08/16/2021 . after reviewing the Positive Level I Screening and speaking with staff, a Level II Mental Health Evaluation was not scheduled for the following reason: The individual was isolated as a health or safety precaution. The case is now closed. To reopen, please submit a new Level I Screening . The DON stated a new Level I screening was not scheduled. The DON stated Resident Moore's Level II screening should have been followed up, and a new Level I screening should have been scheduled. The DON stated a PASARR was a screening to see if a resident had a developmental delay or serious mental illness and needed to be placed in a mental health institution. The DON stated the PASARR assessed the accuracy of placing the residents in a Skilled Nursing Facility (SNF) and if the facility was able to meet the resident's needs. The DON stated if the resident screened positive for level 1, HCS requested records and documentation to clear the resident for the SNF. The DON could not verify if a positive PASARR Level II screening for developmental delay or severe mental health indicated if specialized services were needed for the residents. The DON stated Resident 53 should have had a level II evaluation if he triggered a positive level I screening. The DON stated it could be a risk to the resident if there was no level II screening, that a different facility would be more appropriate for addressing the resident's needs if the resident had a severe mental health illness. The DON stated it was a team effort to verify PASARRs were completed and would not give information regarding who was responsible for verifying the PASARRs were complete.During a review of the facility's policy and procedure (P&P) titled, Resident Assessment -Coordination with PASRR Program, dated 10/2025, indicated, . this facility coordinates assessments in accordance with the preadmission screening and Resident review(PASRR) program requirements under Medicaid to ensure that individuals with a mental disorder, intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs . applicants to this facility will be screened for serious mental disorders or intellectual disabilities and related conditions in accordance with the State's Medicaid rules for screening . Positive Level I Screen - necessitates a PASRR Level II evaluation prior to admission. (cannot be completed by the facility) that determines whether the individual has MD, ID, or related condition, determines the appropriate setting for the individual, and recommends any specialized services and/or rehabilitative services the individual needs . if a Resident who was not screened due to an exception above and the Resident remains in the facility longer than 30 days . the facility should screen the individual using the State's Level I screening process and refer any Resident who has or may have MD, ID or a related condition to the appropriate state-designated authority for Level II PASRR evaluation and determination . the Level II Resident review should be completed within 40 calendar days of admission . recommendations, such as any specialized services, from a PASRR level II determination and/or PASRR evaluation report will be incorporated into the Resident's assessment, care planning, and transitions of care.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. This is achieved by completing the PASRR process. The PASRR process consists of a Level I Screening, Level II Evaluation, and a final Determination.Level I Screening.the Screening is submitted online by the facility and is a tool that helps identify possible SMI and/or ID/DD/RC.If the Screening is positive for possible SMI and/or ID/DD/RC, then a Level II Evaluation will be performed. The Level II Evaluation helps determine placement and specialized services.the SMI Determination will be available online and will include placement and treatment recommendations for the individual.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, . the PASRR process requires that all applicants to Medicaid-certified nursing facilities be given a preliminary assessment to determine whether they might have SMI or ID. This is called a Level I screen. Those individuals who test positive at Level I are then evaluated in depth, called Level II PASRR. The results of this evaluation result in a determination of need, determination of appropriate setting, and a set of recommendations for services to inform the individual's plan of care.

Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan (CP - a detailed approach to care customized to an individual resident's needs) for one of six sampled residents (Resident 6), when Resident 6 had a known hernia (a sac protrusion of intestine or other tissue through a weakness or gap in the abdominal wall) and the condition was not addressed in the care plan. This failure placed Resident 6 at risk of experiencing severe and serious medical complications, and had the potential to cause unintentional weight loss, pain, and psychological harm when resident reported discomfort and bloating after eating, and the hernia was not addressed.During a review of Resident 6's admission Record (AR- 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), dated 1/7/26, the AR indicated, Resident 6 was admitted to the facility on [DATE] with the original admit date of 11/16/21 with a diagnosis of Adult hypertrophic pyloric stenosis (narrowing of the opening between the stomach and the small intestine), Gastrointestinal hemorrhage (bleeding is a sign of a disorder in the digestive tract), Type 2 diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing), anemia (a condition where the body does not have enough healthy red blood cells), and abdominal hernia.During a concurrent observation and interview on 1/7/26 at 9:30 a.m., with Resident 6, in Resident 6's room. Resident 6 was sitting in bed watching TV, dressed in a t-shirt and blanket partially covered to the abdomen. When Resident 6 was asked about his most recent hospital stay, Resident 6 removed his blanket and stated his stay was because of this, and pointed to a large mass visible through his t-shirt in the middle of his stomach. Resident 6 stated it was a hernia that had been there for years, and the facility knew about it. Resident 6 stated the hernia had caused discomfort after meals. When Resident 6 was asked about the care received to the hernia and the discomfort and pain, Resident 6 stated they tell me they are working on the insurance to pay. Resident 6 stated surgery was scheduled but the insurance had denied it.During a record review of Resident 6's Admission/readmission Screen and Baseline Care Plan, dated 10/22/25, the document indicated, Resident 6 was admitted from a hospital, with the admitting diagnosis of Gastric outlet obstruction. During further review of the document undersection XII. Gastrointestinal (relating to the stomach and the intestines) number four relevant history/comments did not have a notation of the hernia. Continuing to section B. Skin and wound assessment, 2b. other did not have any notes about the hernia.During a record review of Resident 6's Discharge Summary/Order Report (DS), dated 7/28/24, the DS indicated Resident 6 had an Esophagogastroduodenoscopy (EGD- is a diagnostic procedure used to visualize the oropharynx, esophagus, stomach) on 7/26/24 and was found to have a 2 cm (centimeter-a unit of measure) hiatal hernia (occurs when the upper part of the stomach bulges through the diaphragm into the chest cavity).During a record review of Resident 6's Progress notes, dated 12/5/24, indicated acknowledgement of hospitalization July 2024, recent EGD showing a small hernia on June 18th.During a record review of Resident 6's After Visit Summary, dated 11/4/24, the document indicated Resident 6 was seen for abdominal pain and diarrhea, and diagnosis of Ventral hernia without obstruction (Blockage). During a record review of Resident 6's DS, dated 10/22/25, indicated Resident was hospitalized on [DATE], MRI dated 9/29/25 .hernia containing loops of small bowel. Hernia may be causing component of gastric outlet obstruction. During further review of document Resident was discharged from the hospital on [DATE].During Review of Resident 6's Admissions notes, dated 10/22/25, Resident 6 returned to the facility with Diagnosis of abdominal hernia without obstruction.During a concurrent interview and record review on 1/8/26 at 10:28 a.m. with Licensed Vocational Nurse (LVN) 5, LVN 5 stated they were not aware of Resident 6's abdominal hernia. LVN 5 mentioned Resident 6 had not complained of abdominal pain; otherwise, an assessment would have been carried out. LVN 5 further explained that resident assessments are conducted weekly, the last documented weekly assessment was reviewed and dated 1/4/26, it did not mention the hernia in the skin assessment.During a concurrent interview and record review on 1/8/26 at 11:34 a.m. with the Social Services Director (SSD), Resident 6's Electronic Medical Record (EMR) was reviewed. The SSD acknowledged resident 6 has had this hernia since 10/24. SSD stated Resident 6's insurance had denied surgery and they were working on processing the referral. The SSD stated Resident 6 had a preop ( an office visit before having surgery) on 9/16/25, the nurses notes indicated no new orders. The SSD confirmed resident 6 was in the facility until 9/27/25 when Resident 6 was sent to the hospital for a Gastrointestinal bleed (GI- bleeding is a sign of a disorder in the digestive tract). SSD stated the EMR indicated Resident 6 returned on 10/22/25. There was no mention of hernia upon return from hospital.During an interview on 1/8/26 at 3:06 p.m., with the Director of Nursing (DON). The DON stated Resident 6's skin assessment dated [DATE] listed the hernia among a long list of diagnoses; however, the hernia was not reflected as an active condition requiring interventions or monitoring. The DON acknowledged Resident 6 had an active diagnosis and it should be assessed, documented, and included in the care plan with appropriate interventions. The DON further emphasized that the medical records should reflect accurate assessments and monitoring to determine if the condition was worsening.During a concurrent observation and interview on 1/8/26 at 3:06 p.m., the DON visually observed Resident 6 in their room. The DON, upon seeing Resident 6 with their shirt on, remarked, Oh yeah, I see it, referring to the hernia.During a review of the facility's P&P titled, Charting and Documentation, dated 7/2017, the P&P indicated, .documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate.During a review of the facility's P&P titled, Care Plans, Comprehensive Person-Centered, dated 12/2016, the P&P indicated, .The comprehensive, person centered care plan will. Incorporate identified problem areas; . Reflect treatment goals, timetables and objectives in measurable outcomes;. Reflect currently recognized standards of practice for problem areas and conditions. Identifying problem areas and their causes, and developing interventions that are targeted and meaningful to the resident. The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required comprehensive assessment (MDS). Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change.

Based on observation, interview and record review the facility failed to ensure professional standards of practice for one of seven sampled residents (Resident 96) who self-administered medication at bedside when:Resident 96 was self-administering vitamin D3 (dietary supplemental providing vitamin D) 10,000 IU (International Units (IU- a unit of measurement for drug dosage), and guaifenesin extended-release (thins and loosens mucus in the airway) 1200 mg (milligrams- a unit of measurement for drug dosage) at bedside with no order.Resident 96 had an order for ferrous sulfate (iron supplement) 325 mg, but the order did not indicate it could be self-administered at bedside.This failure resulted in Resident 96 self-administering medication without complete, and accurate provider orders which could lead to inadequate monitoring, duplicate therapy and/or adverse effects.During a review of Resident 96'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 96 was admitted to the facility on [DATE] with diagnoses of atrial fibrillation (irregular heart rhythm), type 2 Diabetes Mellitus (when the blood sugar levels in the body are too high), anemia (low levels of red blood cells), and hyperlipidemia (high levels of fat in blood).During a review of Resident 96'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 96 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 96 was cognitively intact.During a review of Resident 96's Order Summary Report (OSR), dated [DATE], the OSR indicated, Resident 96 did not have an order for vitamin D3 10,000 IU or guaifenesin extended-release 1200 mg. The OSR indicated Resident 96 had an order for ferrous sulfate 325 mg, but the order did not indicate self-administration at bedside.During a concurrent observation and interview on [DATE] at 10:03 a.m. with Resident 96, in Resident 96's room, ferrous sulfate 325 mg, vitamin D3 10,000 IU, and guaifenesin extended release 1200 mg, were observed on Resident 96's bedside table. Resident 96 stated she self-administered and stored her over the counter (OTC) medication at bedside. Resident 96 stated she ordered her OTC medication online and had it delivered to her bedside. Resident 96 stated she self-administered ferrous sulfate 325 mg, vitamin D3 10,000 IU, and guaifenesin extended release 1200 mg at bedside every day.During a concurrent observation and interview on [DATE] at 10:43 a.m. with Certified Nursing Assistant (CNA) 4, in Resident 96's room, ferrous sulfate 325 mg, vitamin D3 10,000 IU, and guaifenesin extended release 1200 mg, were observed on Resident 96's bedside table. CNA 4 stated Resident 96 self-administered and stored her medication at bedside. CNA 4 stated Resident 96 ordered OTC medications online and had them delivered bedside. CNA 4 stated all staff on Resident 96's care team were responsible to inventory and identify new items at bedside, including OTC medications. CNA 4 stated it was important OTC medications were identified and inventoried to ensure OTC medications were accounted for and safe to self-administer. During a concurrent observation and interview on [DATE] at 10:49 a.m. with Licensed Vocational Nurse (LVN) 3, ferrous sulfate 325 mg, vitamin D3 10,000 IU, and guaifenesin extended release 1200 mg, were observed on Resident 96's bedside table.During a concurrent interview and record review on [DATE] at 10:55 a.m. with LVN 3, Resident 96's Medical Record, dated [DATE] was reviewed. LVN 3 stated Resident 96 self-administered and stored her medication at bedside. LVN 3 stated Resident 96 did not have an order for vitamin D3 10,000 IU or guaifenesin extended release 1200 mg. LVN 3 stated all medications being administered required an order. LVN 3 stated without an order it would be unknown by staff Resident 96 was taking vitamin D3 10,000 IU or guaifenesin extended release 1200 mg, which could result in medication interactions and/or inadequate monitoring. LVN 3 stated Resident 96 had an order for ferrous sulfate 325 mg, but the order did not indicate the medication was for self-administration at bedside. LVN 3 stated all medications being self-administered and stored at bedside needed to be included in the medication order to prevent duplicate therapy. LVN 3 stated Resident 96 was at risk of being administered ferrous sulfate by nursing staff which could result in increased lab levels, constipation, and/or adverse effects. LVN 3 stated nursing staff was responsible to observe Resident 96 self-administer medications per orders and facility policy and procedure.During an interview on [DATE] at 8:49 a.m. with the Pharmacist Consultant (PC), the PC stated nursing staff was responsible for observing Resident 96 self-administer medications and identifying medications not authorized for self-administration at bedside. The PC stated Resident 96 was at risk for vitamin D3 toxicity, which could result in lethargy and feelings of being un-well, self-administering vitamin D3 10,000 IU without an order. The PC stated vitamin D3 10,000 IU was a high dose and required lab monitoring. The PC stated guaifenesin extended release 1200 mg required an order for self-administration at bedside to ensure medication was appropriate for Resident 96. The PC stated guaifenesin extended release 1200 mg could result in adverse effects if administered improperly and without provider oversight, such as renal stones (kidney stones). The PC stated Resident 96 was at risk for duplicate therapy by self-administering ferrous sulfate 325 mg, when the order did not indicate it was for self-administration at bedside, which could result in high blood levels of iron. The PC stated order instructions needed to indicate if medication was being self-administered at bedside to prevent nursing staff from administering the medication.During a concurrent observation and interview on [DATE] at 9:16 a.m. with the Director of Nursing (DON), ferrous sulfate 325 mg, vitamin D3 10,000 IU, and guaifenesin extended release 1200 mg, were observed on Resident 96's bedside table. The DON stated all medications for self-administration required an order and order instructions indicating the medication was for self-administration at bedside. The DON stated nursing staff was responsible for identifying medications at bedside, reporting any new medications at bedside, and observing residents self-administering medications at bedside. The DON stated facility policy and procedure was not followed when Resident 96 self-administered vitamin D3 10,000 IU and guaifenesin extended release 1200 mg at bedside with no order and ferrous sulfate 325 mg with no order instructions to self-administer. The DON stated resident 96 was at risk for inadequate monitoring, adverse side effects and duplicate therapy which could result in a serious medical condition.During a review of the facility's policy and procedure (P&P) titled, Medications Brought to the Facility by the Resident/Family, dated 4/2007, the P&P indicated, .residents and families must report to the nursing staff any medications that they want to bring, or have brought into the facility. if a medication is not otherwise available and/or it is determined to be essential to the resident's life, health, safety, or well-being to be able to take a medication brought in from outside, the Director of Nursing Services and nursing staff, with support of the Attending Physician and Consultant Pharmacist, shall check to ensure that.the medications have been ordered by the resident's Attending Physician, and documented on the physician's order sheet.the contents of each container have been verified by a licensed pharmacist.During a review of the facility's P&P titled, Self -Administration of Medications, dated 12/2016, the P&P indicated, .staff shall identify and give to the Charge Nurse any medications found at the bedside that are not authorized for self-administration, for return to the family or responsible party.the nursing staff will routinely check self-administered medications and will remove expired, discontinued, or recalled medications .

Based on observation, interview, and record review the facility failed to ensure one of seven sampled residents (Resident 96), who self-administered medication, stored their medication safely and securely at bedside when Resident 96 kept nine over the counter medications (OTC) on her bedside table.This failure resulted in Resident 96's OTC medications being accessible to residents, visitors and staff which could result in unauthorized access and unintended use of Resident 96's medication. During a review of Resident 96'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 1/8/26, the AR indicated Resident 96 was admitted to the facility on [DATE] with diagnoses of atrial fibrillation (irregular heart rhythm), type 2 Diabetes Mellitus (when the blood sugar levels in the body are too high), anemia (low levels of red blood cells), and hyperlipidemia (high levels of fat in blood).During a review of Resident 96's Minimum Data Set (MDS - a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment), dated 12/24/25, the MDS section C indicated Resident 96 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 96 was cognitively intact.During a concurrent observation and interview on 1/6/26 at 10:03 a.m. with Resident 96, in Resident 96's room, nine OTC medications were observed on her bedside table. The OTC medications observed were calcium (supplement providing the mineral calcium) 1200 milligram (mg- a unit of measurement for drug dosage), cranberry concentrate with acerola (dietary supplement to support urinary tract health) 36,000 mg per serving, D-Mannose (simple sugar dietary supplement to promote urinary tract health) 2100 mg per serving, GOLO release (dietary supplement to help manage blood sugar, reduce insulin resistance, and support weight loss), hyaluronic acid with methylsulfonylmethane (HA with MSM- dietary supplement supporting joint health)1000 mg, ferrous sulfate (iron supplement) 325 mg, vitamin D3 (dietary supplemental providing vitamin D) 10,000 International Units (IU- a unit of measurement for drug dosage), guaifenesin extended release (thins and loosens mucus in the airway) 1200 mg, and dextromethorphan polistirex extended release (cough suppressant). Resident 96 stated she self-administered her own medication and had always stored her OTC medications on her bedside table.During a concurrent observation and interview on 1/8/26 at 10:43 a.m. with Certified Nursing Assistant (CNA) 4, in Resident 96's room, nine OTC medications were observed on Resident 96's bedside table. The OTC medications observed were calcium 1200 mg, cranberry concentrate with acerola 36,000 mg per serving, D-Mannose 2100 mg per serving, GOLO release, HA with MSM 1000 mg, ferrous sulfate 325 mg, vitamin D3 10,000 IU, guaifenesin extended release 1200 mg, and dextromethorphan polistirex extended release. CNA 4 stated Resident 96 had always stored her OTC medications on her bedside table. CNA 4 stated she would not consider OTC medications stored on a bedside table as safe or secure. CNA 4 stated it was important that all medications were stored safely and securely to prevent unauthorized access and use by other residents, staff or visitors.During a concurrent observation and interview on 1/8/26 at 10:49 a.m. with Licensed Vocational Nurse (LVN) 3, nine OTC medications were observed on Resident 96's bedside table. The OTC medications observed were calcium 1200 mg, cranberry concentrate with acerola 36,000 mg per serving, D-Mannose 2100 mg per serving, GOLO release, HA with MSM 1000 mg, ferrous sulfate 325 mg, vitamin D3 10,000 IU, guaifenesin extended release 1200 mg, and dextromethorphan polistirex extended release. LVN 3 stated Resident 96 self- administered her own medication and had always stored her medication on her bedside table. LVN 3 stated Resident 96 refused to store her medication anywhere other than on her bedside table. LVN 3 stated residents who self-administered and stored medications at bedside had to undergo Self-Administration of Medication Assessments (SAM). LVN 3 stated the purpose of the SAM was to determine if a resident could safely and reliably take and store their own medications in accordance with facility policy and procedure.During a concurrent interview and record review on 1/8/26 at 10:55 a.m. with LVN 3, Resident 96's Medical Record, dated 1/8/26 was reviewed. LVN 3 stated Resident 96 had a SAM completed on 12/25/25 which indicated Resident 96 verbalized the need for safe storage of medication and agreed to terms and policies for self-administration of medication. LVN 3 stated if Resident 96 could not safely store her medication at bedside and agree to terms and policies for self-administration of medications she would not be an appropriate candidate for self-administration of medication. LVN 3 stated Resident 96 was not safely or securely storing her OTC medications at bedside and was known to refuse safe storage of bedside medication. LVN 3 stated facility policy and procedure were expected to be followed for residents self-administering and storing medications at bedside. LVN 3 stated Resident 96's OTC medications were at risk of unauthorized access and unintended use by other residents, staff or visitors which could result in overdose, allergic reactions or theft.During an interview on 1/9/26 at 8:49 a.m. with the Pharmacist Consultant (PC), the PC stated a SAM was completed to ensure residents stored and self-administered medications at bedside safely and per facility policy. The PC stated if residents were known or observed to be non-compliant storing medications at bedside then they were not an appropriate candidate to keep medication at bedside. The PC stated residents were required to adhere to facility policy and procedure for safe storage of medication at bedside. The PC stated storing nine OTC medications on the bedside table was not safe or secure. The PC stated Resident 96's OTC medications were at risk for unauthorized access and unintended use which could result in overdose, allergic reactions or adverse side effects.During a concurrent observation and interview on 1/9/26 at 9:16 a.m. with the Director of Nursing (DON), Resident 96's bedside table was observed, the DON stated Resident 96 had nine OTC medications stored unsafely on her bedside table. The DON stated Resident 96 was known to be noncompliant with safe storage of self-administration medication at bedside. The DON stated Resident 96 was known to leave her bedside table with medications in the hallway and refuse safe storage of medications at bedside. The DON stated she had documented the non-compliance and education in Resident 96's Progress Notes. The DON stated Resident 96's SAMS were not assessed appropriately if she was known and documented to be noncompliant with safe and secure storage of medication at bedside. The DON stated Resident 96's OTC medications were at risk of being accessed by residents, visitors and staff which could result in unauthorized access and unintended use. The DON stated she expected the facility to uphold policy and procedure for residents storing self-administration medications at bedside.During a review of Resident 96's document titled, Care Plan Report (CP), dated 1/8/26, the CP indicated, date initiated 3/9/24.assess PRN [as needed] to review compliance and continuous ability to self-administer medication(s).During a review of Resident 96's document titled, Progress Note, dated 10/30/25, the Progress Note indicted, .offered resident a medication lock box for her OTC medications that she self-administers. Resident refused and stated that she will just make sure her table is not placed in the hallway anymore when they get her up. Reminder teaching of importance of securing her medications so no other resident has access and she verbalized.During a review of Resident 96's document titled, Self-Administration of Medication, dated 3/8/25, 4/1/25, 9/26/25, 10/13/25 and 12/25/25, the documents indicated, .yes. to .resident can verbalize to staff the need for safe storage of medication. and .resident agrees to terms and policies for self-administration of medication.During a review of the facility's policy and procedures (P&P) titled, Self-Administration of Medications, dated 12/2016, the P&P indicated, .Residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so.if the team determines that a resident cannot safely self-administer medications, the nursing staff will administer the resident's medications.self-administered medications must be stored in a safe and secure place, which is not accessible by other residents. If safe storage is not possible in the resident's room, the medications of residents permitted to self-administer will be stored on a central medication cart or in the medication room. Nursing will transfer the unopened medication to the resident when the resident requests them.

Based on observation, interview, and record review, the facility failed to properly follow procedures for medication disposal when two of four medication carts inspected had denture containers being used as medication waste containers.This failure resulted in improper medication disposal during the medication pass and created the potential for medication diversion due to failure to dispose of medications at the required time.Findings:During a concurrent observation and interview on 1/8/26 at 8:19 a.m. during Licensed Vocational Nurse (LVN) 5's medication pass, LVN 5 dropped a thiamine (a medicine used to protect the brain, nerves, and heart by preventing or treating vitamin deficiency) 100 milligrams (MG- a unit of measurement) tablet and then proceeded to place the dropped tablet in an unlabeled denture container. LVN 5 stated the denture container was used to discard medications during the med pass. LVN 5 stated all tablets, capsules, and liquids were discarded in the denture cup and then placed in the actual medication disposal container at the end of the shift. During a concurrent observation and interview on 1/8/26 at 8:46 a.m. during LVN 5's medication pass, LVN 5 dropped a folic acid (medicine used to help make healthy red blood cells) 1 mg tablet and then proceeded to place the dropped tablet in the denture container. LVN 5 stated the med cart should have contained an appropriate container for disposing medications in order to prevent any diversion and to help nurses dispose of the medicine at the same time the need for disposition was required.During a concurrent observation and interview on 1/8/26 at 4:00 p.m. with LVN 6, the second medication cart in station one was reviewed. The medication cart contained a denture container which was used for disposing medication. LVN 6 stated any medications that needed to be discarded were placed in the denture container. LVN 6 stated she dumps the medications collected in the container in the proper waste receptacle located in the med room at the end of her medication pass. LVN 6 stated if a nurse forgets they had medications in the denture container they could potentially forget to properly discard them at the end of their medication pass. LVN 6 stated medications that needed to be discarded should have been placed in the proper disposal container during the exact time they needed to be discarded, not at the end of the medication pass or at the end of shift. LVN 6 stated improper disposition practices could confuse newer nurses or even lead to someone diverting the medications.During an interview on 1/9/26 at 8:42 a.m. with the Pharmacy Consultant (PC), the PC stated medications should not have been disposed of in denture cups. The PC stated there were proper disposal containers available in sizes that could fit in the medication carts. The PC stated it was important to provide tamper proof medication disposal containers because it helped prevent diversion of medications and it ensured medications were properly disposed of during the exact time they needed to be.During an interview on 1/9/26 at 10:12 a.m. with the Director of Nursing (DON) the DON stated proper disposition of medications should be done in an appropriate container designated for medication disposition. The DON stated medications also needed to be disposed of right at the exact time it was required, not at the end of medication pass or at the end of the shift, this ensured discarded medications were disposed of properly and eliminated any chance for diversion.During a review of the professional reference (PR) retrieved from https://www.epa.gov/system/files/documents/2022-10/10_step_blueprint_guide_final_9-22.pdf titled, A 10-Step Blueprint for Managing Pharmaceutical Waste in US Healthcare Facilities, dated 2022, the PR indicated, , the [medication waste] container must also be secured in a way that prevents unauthorized access to its contents . a healthcare facility can use containers that are designed to prevent access to the contents . Healthcare facilities often require personnel to place, squirt, etc., . controlled substance wastage into a sequestration device. Sequestration devices are containers that are designed to collect liquid and other forms of drug wastage in a way that is highly resistant to diversion . Containers must be labeled with the words Hazardous Waste Pharmaceuticals .

Based on observation, interview, and record review the facility failed to label medications in accordance with accepted professional principles for one of two nasal spray medications located in station 1's medication cart 1 when the medication fluticasone propionate (nasal spray medicine used in the nose to reduce swelling and irritation) did not have patient identifier information on the bottle.This failure had the potential for cross-contamination (process of transferring germs and bacteria from one area to another) if another resident who was prescribed the same medication received Resident 102's unlabeled fluticasone propionate.Findings:During a review of the Resident 102's Order Summary Report (OSR), the OSR indicated Resident 102 was prescribed fluticasone propionate 50 MCG (Micrograms- a unit of measurement) to be given once a day in each nostril.During a concurrent observation and interview on 1/8/26 at 2:40 p.m. with Licensed Vocational Nurse (LVN) 5, medication cart 1 in nurses station 1 was reviewed. The medication cart had Resident 102's fluticasone propionate nasal per spray bottle unlabeled with a resident identifier. LVN 5 stated the medication was a nasal spray and it worked by inserting the tip of the bottle into Resident 102's nose to deliver the medication. LVN 5 stated Resident 102's name was not on the medication bottle. LVN 5 stated fluticasone was a very common medication and not labeling the bottle could cause confusion among staff if another resident had the same medication. LVN 5 stated the wrong resident could potentially receive another resident's medication. LVN 5 stated properly labeling the bottle also helped reduce the risk of infection because it minimized the chance of residents inserting someone else's medicine into their nose.During an interview on 1/9/26 at 8:42 a.m. with the Pharmacy Consultant (PC), the PC stated the fluticasone propionate bottle needed to have the appropriate resident identifiers to avoid giving the medication to another resident who could be prescribed the same medication. The PC stated the facility could have placed a label on the medication or even written the resident's name on the bottle.During an interview on 1/9/26 at 9:46 a.m. with the Infection Preventionist (IP), the IP stated Resident 102's fluticasone nasal spray should have had a patient identifier on the bottle itself because it was currently flu season and another resident could be prescribed the same medication and accidentally insert the wrong one into their nose and cross contaminate themselves.During an interview on 1/9/26 at 10:12 a.m. with the Director of Nursing (DON), The DON stated the fluticasone propionate bottle and all other similar medications needed to have the patient name on the bottle itself. The DON stated this was done in order to ensure the right med and the right dosage was given to the right patient.During a review of the facility's policy and procedure (P&P) titled, Labeling of medication Containers, dated 4/07, the P&P indicated . all medications maintained in the facility shall be properly labeled in accordance with current state and federal regulations . labels for individual drug containers shall include all necessary information such as: a. the resident's name .

Based on observation, interview, and record review, the facility failed to ensure pureed (food that's been blended into a smooth pudding like consistency) food was prepared in a form designed to meet individual needs for three of five sampled residents (Residents 5, 55, and 84) when Residents 5, 55, and 84's physician ordered pureed lunch meals on 1/6/26 and 1/7/26 did not hold shape or form. This failure had the potential to result in aspiration (food entering the airway or lungs), choking, and inadequate nutrition due to decreased flavor, which may result in weight loss and malnutrition.During a review of the facility's menu titled, Diet Spreadsheet dated Day: 17 - Tuesday [1/6/26], the Diet Spreadsheet indicated, . Pureed . (texture) . lunch pureed homestyle meat loaf, pureed potato gratin with thyme, and pureed steamed spinach .During an observation of the lunch meal service on 1/6/26 at 12:33 p.m. in the kitchen, Resident 5 and Resident 55's puree meat and vegetables were touching and unable to hold their shape or form when plated.During an interview on 1/6/26 at 10:36 a.m. with Dietary [NAME] (DC)1, DC 1 stated she knew if the pureed food looked like pudding it was pureed adequately. DC 1 stated the cooks do not do any type of testing to check for adequacy in the food's consistency.During a review of the facility's menu titled, Diet Spreadsheet dated Day: 18 - Wednesday [1/7/26], the Diet Spreadsheet indicated, . Pureed . (texture) . lunch Italian grilled chicken and vegetable pasta . pureed breadstick .During an observation of the preparation of puree pasta and concurrent interview with Dietary [NAME] (DC) 2 on 1/7/26 at 10:52 a.m., DC 2 stated she will blend mixture until it is lump free and she wants the consistency of the food to be smooth and to hold its shape when plated. During an observation of the lunch meal service on 1/7/26 at 12:12 p.m. in the kitchen, Resident 84's pureed grilled chicken and vegetable pasta all touched, ran into each other, and did not hold form when plated.During a concurrent observation and interview on 1/7/26 at 12:52 p.m. with Dietary Manager (DM) and Corporate Registered Dietitian (CRD) at station two, two sample meal trays (food that is meant to be tasted for adequacy) containing regular prepared food and pureed food were sampled. The pureed Italian Grilled Chicken, Vegetable Pasta, and breadstick served, were observed to be running into each other and not holding their shape or form. DM and CRD stated the pureed food on the sample meal tray was not holding its shape or form. DM stated the current recipes don't state how much liquid or thickener to add to the recipes. DM stated it was important for food to hold its form for appearance and also to hold its temperature.During a concurrent interview and record review on 1/7/26 at 3:50 p.m. with DM, DM stated that when pureed food is plated, they want it to hold its shape and form as is shown in the picture titled, Proper Puree Consistency placed near the kitchen stove on the wall for staff to see. DM stated the pureed foods were too thin. DM stated staff tried to add gel thickener (a substance that makes liquids or semi-liquids thicker without significantly changing their flavor or other properties) but that made the food too glossy and did not thicken it as it should have. DM stated that the pureed food served on the sample meal tray looked more like the one side of the photo that said, Incorrect Consistency.During review of the facility's document titled Proper Puree Consistency (undated), the document indicated, one picture on the left of five different foods which did not hold form and ran into each other. The picture on the right had four different foods that were well formed in a round scoop shape that held their form. The document indicated, Pureed food that is too thin can increase the risk of aspiration and choking. It can also lead to inadequate nutrition due to decreased flavor, which may result in weight loss and malnutrition .During a concurrent observation and interview on 1/7/26 at 3:26 p.m. with Registered Dietitian (RD), RD stated when observing a picture of Resident 84's pureed lunch meal on 1/7/26 at 12:35 p.m. was not the correct consistency and was not holding its form.During a review of Resident 5 admission Records (AR) dated January 8, 2026, the AR indicated, Resident 5 had diagnosis of dysphagia (difficulty swallowing). During a review of Resident 5's Order Summary Report (OSR) dated January 8, 2026, the OSR indicted, . CCHO (Consistent Carbohydrate Diet) /NAS (No added Salt) diet Pureed texture . During a review of Resident 55, AR dated January 8, 2026, the AR indicated, Resident 55 had diagnosis of dysphagia. During a review of Resident 55's OSR dated January 8, 2026, the OSR indicted, . Regular large portions diet Pureed texture . During a review of Resident 84, AR dated January 8, 2026, the AR indicated, Resident 84 had diagnosis of dysphagia. During a review of Resident 84's OSR dated January 8, 2026, the OSR indicted, . NAS (No added Salt) diet Pureed texture . During a review of the facility's Inservice document titled, Class Attendance Roster (CAR), dated 2/7/25, the CAR indicated, .Type of Training.Continuous Improvement.Course Topic(s): IDDSI: Terminology, Proper Puree Texture, Tray Ticket Accuracy .Trainee Name.Trainee signature. CAR included DC 1 and DC 2's names under the Trainee Name and Trainee Signature section of the document. Included in the documents, was the facility's document titled Proper Puree Consistency and a copy of Resident 5's meal tray ticket. There was no documentation of an evaluation of competency after the in-service was given.During a review of the facility's Inservice document titled, Class Attendance Roster (CAR), dated 4/29/25, the CAR indicated, .Type of Training.Continuous Improvement.Course Topic(s): CAHF: Diets and Food Consistencies (video).Trainee Name.Trainee signature. CAR included DC 1 and DC 2's names under the Trainee Name and Trainee Signature section of the document. During a review of the facility's Inservice document titled, California Association of Health Facilities (CAHF).Video 5-Diets and Food Consistencies Quiz., dated 4/29/25, the CAHF.Video 5-Diets and Food Consistencies Quiz was filled out and completed by both DC 1 and DC 2.During a review of the facility's document from the Dining Service Menu Guide, titled, Pureed dated 2022, the Dining Service Menu Guide, titled, Pureed indicated, . process until there is a smooth, pudding-like or smooth mashed potato consistency . Dining Service Menu Guide .

Based on interview and record review, the facility failed to ensure medical records were complete, accurate, readily accessible and systematically organized for two of thirteen sampled residents (Resident 12 and Resident 10) when:1.Resident 12's consent for the use of bedside rails, was not completed, lacking the indication for use, who the consent was discussed with, licensed nurse signature, and dates of consent, were not present in the medical record.This failure had the potential for improper use of bedside rails and potential injury of resident. 2. Resident 10's Informed Consent for the use of Bed Rails, from 8/24/20-11/3/22, could not be located for over 24 hours and had to be retrieved from an off-site location, was not complete or accurate, and was being used for Resident 10's current bed rail order.This failure had the potential to lead to miscommunication among caregivers, inconsistent care delivery, improper use of side rails, and potential injury of resident. 1.During an observation on 1/6/25 at 9:04 a.m. in Resident 12's room, Resident 12 was seen sitting up in bed watching TV, with both upper bed rails up in use. During a review of Resident 12's document titled, OSR dated 1/9/26, the OSR indicated Resident 12 had a bed rail order on 11/6/25, Bilateral (- having or relating to two sides) 1/2 side rails up as an aid to bed mobility, turning and repositioning, and to assist with transfers. During a review of Resident 12's document titled, Informed Consent for the Use of Bed Rail/s (BRC), which was undated, the document failed to list the specific medical or clinical condition that required the use of the bed rails, who the consent was discussed with, the signature of a licensed nurse, and was not dated. The BRC indicated the resident and ordering physicians' signatures were signed but did not provide the necessary dates of signatures. During a concurrent interview and record review on 1/8/26 at 10:28 a.m. with LVN 5, Resident 12's BRC, was reviewed. LVN 5 stated Resident 12's had an active order for bed rails since 11/6/25. LVN 5 stated consents are in the residents' electronic medical records or in the paper chart. LVN 5 stated Resident 12's BRC was not completed, it was missing the reason why the bed rails were needed, who this information was discussed with, a nurse's signature and the dates of when the signature of the resident and physicians was obtained. LVN 5 stated bed rails should not have been initiated until the consent was properly completed. During a concurrent interview and record review on 1/8/26 at 4:50 p.m., in the medical record office, with the MRD, Resident 12's BRC was reviewed. The MRD stated Resident 12's BRC was an incomplete medical record, because it was missing several areas; the indication for use, who this was discussed with, the nurse's signature and dates of when Resident 12 and the ordering physician singed the consent. MRD stated this was not considered complete and bed rails should not have been implemented until this medical record was properly completed. During a review of the facility's P&P titled, Informed Consent, dated 1/2024, the P&P indicated, .when processing a new order.the following must be done.obtain informed consent from resident or responsible party. During a review of the facility's P&P titled, Bed Safety, dated 12/2018, the P&P indicated, .the staff shall obtain consent for the use of side rails from the resident or the resident's legal representative prior to their use. During a review of the facility's P&P titled, Charting and Documentation, dated 7/2017, the P&P indicated, .documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate. 2. During a review of Resident 10's document titled, Order Summary Review (OSR), dated 1/8/26, the OSR indicated Resident 10 had a bed rail order from 8/24/20-11/3/22. The OSR indicated Resident 10 had bed rails re-ordered on 11/7/22 and were still in use. During a review of Resident 10's document titled, Informed Consent for the use of Bed Rail/s (BRC), dated 8/19/20, the document indicated a Licensed Vocational Nurse (LVN) signed the consent on 8/19/20 and the provider signed the consent on 8/20/20. The document indicated Resident 10's representative (RP) gave verbal consent on, .8/19/202. The document did not include the entire written year the RP gave verbal consent. The document did not include a check in the box, .legal representative has given permission for the use of bed rail/s . During a concurrent interview and record review on 1/8/26 at 10:34 a.m. with Licensed Vocational Nurse (LVN) 3, Resident 10's Medical Record, dated 1/8/26, was reviewed. LVN 3 stated Resident 10 had an order for bed rails since 11/7/22. LVN 3 could not locate Resident 10's BRC in the electronic or paper chart. LVN 3 stated all consents were expected to be readily accessible for easy reference. LVN 3 stated all new orders for bed rails required consent to ensure risk and benefits were explained to the resident and/or their representative (RP). LVN 3 stated bed rails could cause entrapment which could lead to injury or death. LVN 3 stated Resident 10 was at risk for improper use of side rails without a consent which indicated intended use. During an interview on 1/8/26 at 11:06 a.m. with Medical Records (MR), MR stated she was unable to locate Resident 10's BRC. During an interview on 1/8/26 at 11:10 a.m. with Medical Records Director (MRD), the MRD stated she was unable to locate Resident 10's BRC. The MRD stated bed rails required a new consent for each new order and upon return from hospitalization or discharge to ensure risk and benefits were explained to the resident and/or their RP. The MRD stated Resident 10 had four folders at an offsite storage location. The MRD could not state what documents were at the offsite storage location. The MRD stated it was important that consents were readily accessible and organized to ensure treatment was being implemented as intended by the provider. During a concurrent interview and record review on 1/9/26 at 10:57 a.m. with the MRD, Resident 10's document titled, BRC, dated 8/19/20, was reviewed. The MRD stated she could only locate one BRC in Resident 10's four folders from the offsite storage location. The MRD stated the consent was not complete or accurate as the BRC did not have a complete date to indicate when verbal consent was obtained from Resident 10's RP. The MRD stated the consent was not complete or accurate as the BRC did not indicate by checking the box if Resident 10's RP gave permission to use bed rails. The MRD stated the BRC was not complete or accurate as the BRC was for Resident 10's 8/24/20-11/3/22 bed rail order and not the 11/7/22 bed rail order. The MRD stated Resident 10's BRC should have been re-obtained with the new bed rail order to ensure risks and benefits were explained to the resident and/or their RP. The MRD stated a new BRC was required for all new bed rail orders to ensure the resident and or/their RP were aware of bed rail use. During a concurrent interview and record review on 1/9/26 at 11:29 a.m. with the Director of Nursing (DON), Resident 10's Medical Record, dated 1/9/26, was reviewed. The DON stated Resident 10 had a bed rail order from 8/24/20-11/3/22. The DON stated Resident 10 's bed rails were re-ordered on 11/7/22 and were still in use. The DON stated Resident 10's BRC was not complete or accurate as it could not be determined what year Resident 10's RP gave verbal consent. The DON stated Resident 10's BRC was not complete or accurate as the box to give permission to use bed rails had not been checked. The DON stated consents were expected to be readily available and accessible for all active treatments and orders that required informed consents. The DON stated she expected the facility to be in compliance with policy and procedure at all times for bed rail use. The DON stated Resident 10 was at risk for improper use of bed rail use which could result in entrapment, injury or death. During a review of the facility's policy and procedures (P&P) titled, Informed Consent, dated 1/2024, the P&P indicated, .when processing a new order.the following must be done.obtain informed consent from resident or responsible party. During a review of the facility's P&P titled, Bed Safety, dated 12/2018, the P&P indicated, .the staff shall obtain consent for the use of side rails from the resident or the resident's legal representative prior to their use. During a review of the facility's P&P titled, Charting and Documentation, dated 7/2017, the P&P indicated, .documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate.

Based on observation, interview, and record review, the facility failed to provide care in a manner that maintained or enhanced a resident's privacy, dignity and respect when two of 12 sampled residents (Resident 95 and 14), foley catheter (an indwelling urinary catheter - a thin tube placed in the bladder to drain urine into a bag) drainage bags were without a dignity cover (a bag used to the cover and hold the urine drainage and collection bag so it was not visible).This failure violated Resident 95 and Resident 14's privacy and had the potential to affect the self-esteem, self-worth, and quality of life of Resident 95 and Resident 14.Findings: During an observation on 1/06/2026 at 9:25 a.m. in Resident 95's room, Resident 95 was observed in bed sleeping, wearing a gown, lying on her left side. A urine bag was observed hanging on the left side of Resident 95's bed, uncovered, on the lower rail. During a review of Resident 95'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 1/8/26, the AR indicated Resident 95 was admitted to the facility from an acute care hospital on [DATE] with diagnoses of hemiplegia (paralysis [the loss of the ability to move and sometimes to feel anything] of one side of the body) and hemiparesis (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles) following a cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area) affecting the right, dominant side, type 2 Diabetes Mellitus (when the blood sugar levels in the body are too high) and gastrostomy (the surgical formation of an opening through the abdominal wall into the stomach for nutritional support). During a review of Resident 95's Minimum Data Set (MDS - a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment), dated 12/24/25, the MDS section C indicated Resident 95 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 3 (a score of 0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired, 13-15 suggests cognitively intact), which suggested Resident 95 was severely cognitively impaired. During a concurrent observation and interview on 1/6/2026 at 4:35 p.m. with Certified Nursing Assistant (CNA) 1, in Resident 95's room, Resident 95's urine bag was observed on the lower right side of Resident 95's bed uncovered. CNA 1 stated the CNAs drained and changed resident's urine bags. CNA 1 stated Resident 95's urine bag should have had a cover over the bag to protect Resident 95's privacy and dignity. CNA 1 stated Resident 95 did not need people seeing their urine. CNA 1 stated nurses could have also covered Resident 95's urine bag. During a concurrent observation and interview on 1/06/2026 at 4:39 p.m., with the Registered Nurse (RN), in the hallway outside Resident 95's room, Resident 95's urine bag was observed uncovered on the lower left side of Resident 95's bed. The RN stated Resident 95's bag should have been covered for her privacy. During an interview on 1/08/26 at 2:37 p.m. with the Director of Staff Development (DSD), the DSD stated her expectation was for all residents who had an indwelling urine catheter to have a privacy bag on their urine catheter drainage bag to protect the resident's dignity. During an observation on 1/06/2026 at 9:30 a.m. in Resident 14's room, Resident 14 was observed in bed sleeping, wearing a gown, lying on her left side with foam wedges for positioning. A urine bag was observed hanging on the left side of Resident 14's bed, uncovered, on the lower rail. Resident 14 had a second urine bag, uncovered, hanging on the right side of the bed on the upper bedside rail. During a review of Resident 14's AR, dated 1/7/26, the AR indicated Resident 14 was admitted to the facility from an acute care hospital on [DATE] with diagnoses of sepsis (life-threatening blood infection), obstructive and reflux uropathy (when urine cannot drain through the urinary tract. Urine backs up into the kidneys and may cause them to become swollen), and dementia (a progressive state of decline in mental abilities). During a review of Resident 14's MDS, dated [DATE], the MDS section C indicated Resident 14 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 8 (a score of 0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired, 13-15 suggests cognitively intact), which suggested Resident 14 was moderately cognitively impaired. During an interview on 1/7/2026 at 4:10 p.m. with CNA 2, a photo of Resident 14's urine bag was reviewed. CNA 2 stated Resident 14's urine bag should have had a cover over the bag as well as over the nephrostomy urine bag (a tube your healthcare provider places to take pee directly from your kidney and channel it into a bag), to protect Resident 14's privacy and dignity. CNA 2 stated Resident 14 did not need people seeing their urine. During an interview on 1/7/26 at 4:20 p.m. with the DSD, the DSD stated her expectation was for all residents who had an indwelling urine catheter to have a privacy bag on their urine catheter drainage bag to protect the resident's dignity. The DSD further stated the same dignity bag should have been provided for Resident 14's nephrostomy urine bag because it also collected urine. During a review of the facility's policy and procedure (P&P) titled, Quality of Life – Dignity, dated 8/2009, indicated, .each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality . Residents shall be treated with dignity and respect at all times . [treated with dignity] means the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth . staff shall promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures . demeaning practices and standards of care that compromise dignity are prohibited. Staff shall promote dignity and assist residents as needed by: . helping the resident to keep urinary catheter bags covered .

Based on interview and record review, the facility failed to prevent the elopement (when a resident leaves the facility's premises or a safe area without authorization, or necessary supervision) of one of seven residents (Resident 7) when staff did not respond promptly to a security elopement alarm when Resident 7 eloped from the facility. This failure had the potential for Resident 7 to experience injury such as falling or struck by traffic, becoming disoriented and lost due to his unsupervised time away from the facility, and also the potential for six other residents who were identified as elopement risks (Resident 1, Resident 2, Resident 3, Resident 4, Resident 5, and Resident 6) to elope. During a review of Resident 7's Progress Notes (PN), dated 11/1/25, at 8:23 p.m., the PN indicated he was admitted to the facility that evening with diagnoses that included acute encephalopathy (a rapid onset of altered brain function that can cause confusion and disorientation) and was noted to have episodes of. Severe impairment (affecting all areas of judgement). Walks frequently. During a review of Resident 7's Elopement Risk Assessment (ERA), dated 11/1/25, at 7:42 p.m., the ERA indicated he was independently mobile, had a history of recent elopements, exhibited purposeful exit-seeking and Aimless or goal-directed pacing or wandering, and was determined to be At Risk for Elopement. During a review of Resident 7's Morse Fall Risk Screen (MFRS), dated 11/1/25, at 8:06 p.m., the MFRS indicated he had fallen in the past, and Overestimates or forgets limits. The MFRS indicated Resident 7 was at High Risk for Falling. During a review of Resident 7's Order Summary Report (OSR), dated 11/1/25, the OSR indicated he had a physician's orders for a security bracelet (an electronic bracelet that activates a loud alarm at the facility's exit doors) secondary to . Aimless or goal-directed pacing or wandering, exited facility multiple times, multiple attempts to exit facility. The OSR indicated the security bracelet was to be placed on Resident 7's right ankle. During a review of Resident 7's Care Plan Report (CP), dated 11/1/25, the CP indicated he had a Focus of Risk for wandering related to . Aimless or goal-directed pacing or wandering, exited facility multiple times, multiple attempts to exit facility. At risk for elopement. Mobile ambulates around facility. Interventions included Apply wander-sensor monitoring device [security bracelet] as ordered [by physician]. Check [security bracelet] for proper functioning and placement per facility protocol. Check door alarm with Maintenance Supervisor. During a review of Resident 7's PN dated 11/1/25, at 11:41 p.m., the PN indicated Resident is [sic] wandered around the facility and anxious to get out of the facility, [Security bracelet] in place. Staff redirect resident attention to bring him back to his room. During a review of Resident 7's PN dated 11/2/25, at 2:55 p.m., the PN indicated that earlier that day, at 7:40 a.m., Resident 7 was seen by staff outside of his room. The PN indicated that at 7:50 a.m., while breakfast was being served, Resident 7 was not in his room and a search was begun inside and outside of the facility to find Resident 7. The PN indicated that at 8:10 a.m., Resident had not been located. The PN indicated that at 8:50 a.m., the facility received a call from Resident 7's family member, who stated he was at their home (located about one mile away); and his family returned him to the facility at 9:37 a.m. The PN indicated Resident 7 was then placed on one-to-one staff monitoring and an In-service given to all staff regarding respond to [security bracelet] alarm. During an interview on 11/4/25, at 10:35 a.m., with the Administrator, the Administrator stated Resident 7's family member lived about one mile away and Resident 7 knew exactly how to get there. The Administrator stated when Resident 7 returned to the facility, he still had his security bracelet on. The Administrator stated the only doors in the facility equipped with an alarm that detects the presence of the security bracelet are the front doors of the facility. During an interview on 11/4/25, at 10:40 a.m., with the Director of Nursing (DON), the DON stated Resident 7's security bracelet did work. It triggered the front door, the alarm went off, it was going off. The alarm at the front door was sounding. Nobody answered it immediately. Usually there is a receptionist at the front lobby [where the front doors are located], but she doesn't get in until 9 a.m., and this happened around breakfast, at 7:50 a.m. So, nobody responded to the alarm. We don't know how long it was sounding; we are still trying to determine how it got turned off. During a concurrent interview on 11/4/25, at 10:45 a.m., with the Administrator and DON, the Administrator and DON both stated the alarm at the front door was not responded to by staff timely when Resident 7 eloped from the facility on 11/2/25 at approximately 7:50 a.m. The Administrator stated the facility started in-services to educate the staff about the importance of responding to the front door alarm timely, beginning on 11/2/25. The Administrator stated the facility is fully staffed at 7:50 a.m., except for the receptionist who arrives on duty at 9 a.m. The Administrator stated there are also six other residents in the facility with security bracelets (Resident 1, Resident 2, Resident 3, Resident 4, Resident 5, and Resident 6) due to a high risk for elopement. During a review of Resident 1's OSR dated 9/10/21, the OSR indicated Resident 1 had a physician's order for a security bracelet placement secondary to: (walking aimlessly and exiting behavior). During a review of Resident 2's OSR dated 5/9/24, the OSR indicated Resident 2 had a physician's order for a security bracelet placement secondary to: (risk of elopement). During a review of Resident 3's OSR dated 9/3/25, the OSR indicated Resident 3 had a physician's order for a security bracelet placement secondary to: Exit seeking behavior, poor judgement. During a review of Resident 4's OSR dated 10/2/25, the OSR indicated Resident 4 had a physician's order for a security bracelet placement secondary to: High risk of wandering due to impaired cognition, resident likes to ambulate without asking for help. During a review of Resident 5's OSR dated 10/23/25, the OSR indicated Resident 5 had a physician's order for a security bracelet due to exit seeking behavior. During a review of Resident 6's OSR dated 10/17/25, the OSR indicated Resident 6 had a physician's order for a security bracelet placement secondary to: (risk of elopement). During a review of the facility's policy and procedure (P&P) titled, Elopement Prevention and Management, dated 9/25, the P&P indicated, Residents who exhibit wandering behavior and/or are at risk for elopement will receive adequate supervision to prevent accidents and receive care in accordance with their person-centered plan of care. When use of an electronic monitoring system [security bracelet] or door alarm device is deemed appropriate, maintain and utilize system and/or sensors in accordance with manufacturer recommendations. Monitor response to interventions and document accordingly. Evaluate effectiveness of interventions and make changes as needed. During a review of the facility's policy and procedure (P&P) titled, [Security Bracelet] System, dated 1/25, the P&P indicated, Purpose: To use a device that will alert the resident and staff of wandering or elopement tendency The nursing staff will check for the placement and alarming sound of the [security bracelet] during the shift.

Based on interview and record review, the facility failed to administer an antibiotic (a medicine that inhibits the growth of or destroys disease causing microorganisms such as bacteria) as prescribed by a physician for one of three sampled residents (Resident 1). This failure resulted in Resident 1 not receiving antibiotics for an infected left ankle, potentially resulting in worsening infection. Findings: During a review of Resident 1's Admission Record (AR) , dated 4/21/25, the AR indicated Resident 1 was admitted to the facility with diagnoses that included aftercare for a fractured left ankle. During a review of Resident 1's Progress Note (PN) , dated 3/4/25, by Surgeon 1, the PN indicated, Surgeon 1 had performed surgery on Resident 1's fractured left ankle on 1/4/25. The PN indicated Resident 1 was seen for a follow up visit by Surgeon 1 on 3/3/25. The PN indicated, concern for surgical site infection. Bactrim [an antibiotic] ordered today. The PN indicated Bactrim DS 800-160 milligrams (a unit of measurement) per tablet take one tablet by mouth two times per day for 10 days to begin on 3/3/25 and end on 3/13/25. During a concurrent interview and record review on 4/16/25 at 1:43 p.m. with Director of Nursing (DON), Resident 1's clinical record was reviewed. The DON stated Surgeon 1's physician order for Bactrim to be given to Resident 1 starting on 3/3/25 Did not happen. The DON stated that a process is in place to start an antibiotic within four hours once the order is received. During a concurrent interview and record review on 4/21/25 at 10:21 a.m. with DON, the DON stated after Resident 1's appointment on 3/3/25 with Surgeon 1, Surgeon 1's PN was faxed to the facility and may have been placed in the medical records box and it should have been given to clinical staff, but it was not. During a concurrent interview and record review on 5/2/25 at 10: 40 a.m. with Medical Records (MR) staff, MR stated, the facility received Surgeon 1's PN on 3/4/25. MR stated that when faxes are received via fax, they are uploaded, given to the nurses, and put in the resident's chart. MR stated, Recently there was a hiccup with the nurse not getting it and now we have a follow up meeting the next day to discuss all previous appointments and follow up with paperwork. During an interview on 5/2/25 at 10:52 a.m. with DON, the DON stated, The risk of starting [Resident 1's] antibiotic late can lead to possible infection, which she did get. During a review of the facility's policy and procedure (P&P) titled, Medication and Treatment Orders , dated 7/16, the P&P indicated, Drug and biological orders must be recorded on the Physician's Order Sheet in the resident's chart.

Based on interview and record review, the facility failed to ensure one of three residents (Resident 1) was free from injury when he attempted to self-transfer out of his bed with the bed ' s wheels unlocked, resulting in a bedside fall and fracture to his left hip. This failure had the potential to contribute to the fall with fracture when the bed ' s unlocked wheels caused the bed to move when he attempted to transfer out of bed. Findings: During a review of Resident 1 ' s Admission Record (AR), dated 10/11/24, the AR indicated Resident was a [AGE] year old male admitted to the facility in 2021 with diagnosis that included neurocognitive disorder with Lewy bodies ( a type of progressive dementia that leads to a decline in thinking, reasoning and independent function); bipolar disorder (mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration, can make it difficult to carry out day-to-day tasks); and dementia (a chronic condition that causes a decline in mental abilities, such as thinking, remembering, and reasoning, that interferes with daily life). During a review of Resident 1 ' s Minimum Data Set (or MDS, a standardized, comprehensive assessment tool), dated 8/2/24, the MDS indicated at Question C0500 Brief Interview for Mental Status a score of 15 out of 15, which indicated Resident 1 was cognitively intact. The MDS indicated at Question GG0115 B, a score of 2, which indicated he had impairments on both sides of his lower extremities (hip, knee, ankle, foot). The MDS indicated at Question GG0120 that he was wheelchair bound. The MDS indicated at Questions GG0170: D, Sit to stand: The ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed a score of 2, which indicated Resident 1 needed Substantial/maximal assistance [from staff] - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort; E, Chair/bed-to-chair transfer: the ability to transfer to and from a bed to a chair (or wheelchair), a score of 2, which also indicated Resident 1 needed Substantial/maximal assistance [from staff] - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort; and I, Walk 10 feet: Once standing, the ability to walk at least 10 feet in a room, corridor, or similar space, a score of 9, which indicated a score of 9, which indicated this assessment question was Not Applicable - Not attempted and the resident did not perform this activity. During a review of Resident 1 ' s Physical Therapy Evaluation and Treatment (PTET), dated 9/17/24, the PTET indicated Resident 1 needed Max Assist for transfers, and that his Gross Motor Coordination = impaired. During a review of Resident 1 ' s Progress Notes (PN), dated 10/6/24, at 8:20 a.m., the PN indicated, .informed that resident [1] was laying on the floor. Upon entering room resident was laying on the floor in a prone position [face down] to the bed attempting to get up. Resident was asked what he was trying to do as per resident he was trying to transfer himself to the wheelchair. During a review of Resident 1 ' s Progress Notes (PN), dated 10/7/24, at 10:10 a.m., the PN indicated Resident 1 . needs supervision in transferring. [Resident 1] further stated that he thinks the bed had moved when he was transferring. ordered to obtain Xray, today Xray done, resulted [in a fracture of the thigh bone near the hip] . ordered to send resident out to a [General Acute Care Hospital, or GACH] for further evaluation. During a review of Resident 1 ' s Progress Notes (PN), dated 10/10/24, at 7:02 p.m., the PN indicated Resident 1 was readmitted to the facility from the GACH with a diagnosis of Left Femur fracture, s/p left hip hemiarthroplasty on 10/8/24 [a fracture of the left hip, with surgical repair]. During a review of Resident 1 ' s Progress Notes (PN), dated 10/21/24, at 9:01 p.m., the PN indicated, .stopped by to see [Resident 1] this afternoon to discuss concerns. regarding a recent fall he had. [Resident 1] stated the night he fell , a CNA [Certified Nursing Assistant] came in and asked him for permission to move his bed back in its original place to allow the CNA to be able to help [Resident 1 ' s roommate] with resident care. [Resident 1] stated that when the CNA left they must of forgot to lock the bed because he then got up to get out of bed and fell to the floor. During an interview on 10/22/24, at 9:30 a.m., with Resident 1, Resident 1 stated that before he fell on [DATE], at about 1 or 2 a.m., my roommate was on his call light, and the staff that came in asked me if it was ok to move my bed to tend to him. I said OK. After they left, they forgot to lock my bed wheels. There ' s red and green colored foot pedals, see? I fell out of bed that morning, I began to get out of bed, I pushed off the bed for a bit of leverage, and boom, I went face down on the left side. Resident 1 stated a male nurse came into the room and found him on the floor. Resident 1 stated, I explained to him the bed was unlocked. During an interview on 10/22/24, at 11:50 a.m., with CNA 1, CNA 1 stated when a resident is in bed, the wheel locks should be locked at all times. During an interview on 10/22/24, at 11:44 a.m., with CNA 2, CNA 2 stated, resident beds should be locked when they are in bed. During an interview on 10/22/24, at 5 p.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated she was on duty on 10/6/24 when Resident 1 fell to the floor. LVN 1 stated, When I went into the room, the bed was moved to the side and [Registered Nurse, or RN 1] was in there with me. The bed was moved to the side maybe like a foot and a half from its normal position. I don ' t know if somebody pushed it or if [RN 1] pushed it. During an interview on 10/24/24, at 2:45 p.m., with RN 1, RN 1 stated he recalled being the first staff person to find Resident 1 on the floor next to his bed on the morning of 10/6/24. RN 1 stated, I was walking down the hallway when I saw him on the floor. I was first staff who saw him on floor. He was face down, face was turned to the left, he was alert, he said he was trying to transfer to [his wheelchair] but he didn ' t make it. Yeah, the bed was not straight, a little bit to the side, like it was pushed. The bed was like that when I found it. About one foot from normal resting position. I don ' t recall checking if the brakes were locked. No, bed would not be able to move if brakes were locked, they are kind of heavy. [Resident 1] said the brakes were unlocked. The bed rolled easily when we moved it, we got him up into the wheelchair. This bed is the type with foot pedals to lock and unlock. When resident is in bed, it should be locked. During an interview on 11/1/24, at 4:45 p.m., with Registered Nurse Supervisor (RNS), RNS stated resident bed wheel locks should be locked when residents are in bed, of course. They should be locked all the time. During a review of the Federal Drug Administration (FDA) website page titled, A Guide to Bed Safety Bed Rails in Hospitals, Nursing Homes and Home Health Care: The Facts, dated 12/11/17, the FDA website page indicated, Meeting Patients ' Needs for Safety - Keep the bed in the lowest position with wheels locked.

Based on observation, interview and record review, the facility failed to ensure drugs and biologicals were stored and labeled in accordance with current accepted professional standards of practice when: 1. Two of four medication carts were found unlocked and unattended by Licensed nurses. This failure had the potential for residents, staff, and visitors to access the medication carts. 2. Polyethylene glycol 3350 was left on top of the medication cart 1 unattended in Station 1. This failure had the potential risk of other residents, staff and visitors walking by and gaining access to the medication and could lead to adverse effect when taken without a prescription. 3. An expired bottle of Lactulose ( a non-absorbable sugar used in the treatment of constipation), was observed in the medication cart. This failure had the potential for Resident to receive expired medication which could have undesired effects. Findings: 1. During a concurrent observation and interview on 9/25/24 at 8:50a.m. with Licensed Vocational Nurse (LVN) 1, the medication cart was observed unlocked and unattended in the hallway of station 1 outside of room [ROOM NUMBER], LVN 1 was inside a resident room and did not have direct sight of medication cart. LVN 1 stated the medication cart should always be locked when unattended. LVN 1 stated an unlocked medication cart was accessible to residents, staff and visitors walking by and they may grab medications from the medication cart and drink medication which could lead to adverse reactions. During a concurrent observation and interview on 9/25/24 at 3:35 p.m. with LVN 2 in Station 2 hallway outside of Resident 34's room. LVN 2 walked in resident 34's room and left her medication cart unlocked and unattended with residents, staff and visitors walking by. LVN 2 stated she should have made sure her medication cart was locked before she entered Resident 34's room. LVN 2 stated the unlocked medication cart was unattended and any residents, staff and visitors walking by could access the medications inside the medication cart and drink medication which could lead to adverse reaction. During a review of Resident 34's Admission Record, (AR-document containing resident personal information) dated 9/26/24, the AR indicated Resident 34 was admitted to the facility on [DATE] with diagnoses which included diabetes (high blood sugar level in the blood), hemiplegia and hemiparesis (weakness to one side of the body) and muscle spasm. During an interview on 9/26/24 at 10:20 a.m. with the Director of Staff Development (DSD), the DSD stated the practice was to never leave a medication cart unlocked and unattended. The DSD stated an unlocked medication carts was easily accessible by residents, staff and visitors walking by. The DSD stated licensed nurses should never leave their medication carts unlocked and unattended. During an interview on 9/27/24 at 2:40 p.m. with the Director of Nursing (DON), the DON stated her expectation was to make sure medication carts were locked when not within the licensed nurses sight. The DON stated licensed nurses should always make sure to lock their medication carts when they walked inside resident room. 2. During a concurrent observation and interview on 9/25/24 at 8:59 a.m. with LVN 1 in station 1 hallway outside of Resident 244. LVN 1 walked inside Resident 244's room and left a bottle of medication on top of his medication cart. LVN 1 did not have sight of the medication on top of the medication cart. LVN 1 stated it was his fault he left the medication unattended on top of the medication cart. LVN 1 stated the practice was to make sure no medications were left on top of the medication cart because any residents, staff or visitors walking by could grab and drink medication which could lead to drug reaction or overdose of medication. During a review of Resident 244's Admission Record, dated 9/26/24, the AR indicated, Resident 244 was admitted to the facility on [DATE] with diagnoses which included hypertension (high blood pressure), muscle spasm and muscle weakness. During an interview on 9/27/24 at 2:45 p.m. with the Director of Nursing (DON), the DON stated it was not acceptable to leave any medication on top of the medication cart unattended. DON stated, .Any medications left on top of the medication cart unattended is accessible to other residents, staff and visitors walking by . The DON stated any residents, staff and visitors could grab medication hide it and or distribute to other residents which could lead to serious health condition. During a review of facility's policy and procedure titled (P&P), Medication Administration-General Guidelines, dated 10/17, the P&P indicated, medications are administered as prescribed in accordance with good nursing principles and practices . During administration of medications, the medication cart is kept closed locked and secure. The medication cart needs to be secured and locked when unattended . 41608 3. During a concurrent interview and record review on 9/26/24 at 10:20 a.m. with Licensed Vocational Nurse (LVN) 5, in station two at medication cart (med cart) 2, a bottle of Lactulose was observed with the expiration date of 9/13/24. LVN 5 stated the medication carts should be checked every shift for expired medications. LVN 5 stated expired medications could no longer have the same effect or may have undesired side effects. During an interview on 9/26/24 at 11:07 a.m. with the Assistant Director of Nurses (ADON), in Medication Room two, the ADON stated, the lactulose should not have been in the med cart. Expired medication could not be as effective and could cause side effects that could be harmful to residents. During a review of the facilities policy and procedure (P&P) titled, Medication Storage in The Facility dated 1/2018, the P&P indicated, . E. The nurse will check the expiration date of each medication before administering it. F. No expired medication will be administered to a resident. G. All expired medication will be removed from the active supply and destroyed in the facility, regardless of amount remaining . I. Nursing staff should consult with dispensing pharmacist for any questions related to medication expiration dates . During a review of the facilities P&P titled, Specific Medication Administration Procedures (undated), indicated, To administer medications in a safe and effective manner . E. Check expiration date on package/container . During a review of the facilities P&P titled, HR Manual: Job Description . Licensed Vocational Nurse dated 10/19/2015, the P&P indicated, .Responsibilities/Accountabilities . 2. Care Planning: . 2.4. Evaluates effectiveness of interventions to achieve patient goals and minimize re-hospitalization s . 3. Provision of Direct Patient Care: 3.1. Administers medications and performs treatments per physician orders .

Based on observation, interview, and record review the facility failed to post the results of the most recent survey in a place readily accessible to 91 of 91 residents, families, and their legal representatives. This failure had the potential to violate the rights of residents and their representatives to be informed of previous survey deficiencies. Findings: During an observation on 9/24/24 at 10:30 a.m., a binder labeled CDPH Survey Results was located in a holder in the hallway east of the main entrance. During a review of the facility's, CDPH Survey Results binder, undated, the binder did not contain results for the facilities last recertification survey on 9/22. During an interview on 9/24/24 at 10:35 a.m. with the Director of Nursing (DON), the DON stated the facility had their last survey 9/22. The DON stated the results of that survey were not included in the CDPH Survey Results binder. During a concurrent interview and record review on 9/24/24 at 10:42 a.m. with the Administrator (ADM), the facility's CDPH Survey Results binder, undated, was reviewed. The CDPH Survey Results binder did not contain the facility's previous survey results from 9/22. The ADM stated the facility's last survey was in 2022 and the results of the survey were not in the binder. The ADM stated he thought only results from the previous year needed to be stored in the binder and since the survey was in 2022 it did not need to be included. During a review of the facility's policy and procedure (P&P) titled, Resident Rights, dated 8/22, the P&P indicated, .the resident has the right to be informed of his or her rights and of all rules and regulations . 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: . examine survey results .

Based on observation, interview, and record review the facility failed to ensure an infection prevention and control program was maintained for 91 of 91 sampled residents when: 1. A room containing five full sharps containers (a bin used to store needles which have been used on residents) was unlocked and accessible to 91 of 91 residents. The sharps containers were stacked on top of each other. One of those containers was full and did not have a lid covering it. This failure had the potential to cause residents to enter the room and hurt themselves if they touched the exposed sharps. 2. Resident 58's oxygen concentrator (a medical device which provides oxygen to a resident) filter was covered in dirt, dust, and lint like materials. This failure had the potential to introduce contaminants (materials which can make something dirty) into the oxygen supply and cause Resident 59 to breathe in dirty air. 3. Resident 61 and Resident 3's oxygen concentrator filters were covered with grayish white material. This failure could result in Resident 61 and Resident 3 to develop serious respiratory health problems. 4. Resident 345's oxygen tubing was not labeled with the date it was changed. This failure had the potential to put Resident 345 at risk for possible respiratory infection. Findings: 1. During a concurrent observation and interview on 9/26/24 at 11:52 a.m. with Licensed Vocational Nurse (LVN) 1 near nurses' station 1, a room containing five full sharps containers was accessible to residents. The sharps containers were stacked on top of each other. One of those containers was full and did not have a lid covering it. LVN 1 stated the room was used by the lab collection company contracted by the facility. The lab company's employees were using the room to store their equipment and sharps. LVN 1 stated the sharps containers should not have been stacked on top of each other and the open sharps container should have had a lid to prevent injuries. During a concurrent interview on 9/26/24 at 12:23 p.m. with the Director of Nursing (DON) and the Infection Preventionist (IP), the DON stated the room which contained the sharps containers was utilized by the outside contracted company who store their supplies. The DON stated the facility needed to incorporate the room in their infection control program since it was in their facility. The DON stated staff should have also reported to her if they noticed the sharps containers were in an unacceptable condition, like sharps containers being full and having no lid. The IP stated her expectation was for staff to have brought up the condition of the room to her because there was potential for residents to walk into the room and puncture themselves with supplies in the sharp's containers. The IP stated it was important for staff to monitor the room and keep it in an acceptable condition because it could have led to cross contamination (the physical movement or transfer of harmful bacteria from one person, object, or place to another) across the facility. During an interview on 9/26/24 at 2:31 p.m. with the Phlebotomist (PHL), the PHL stated the room containing all the sharps containers was used by the lab company to store all of their equipment. The PHL stated none of the sharp's containers should have been stacked on top of each other, the lab company's staff should have been disposing of the sharps containers as they got full. The PHL stated she was surprised by how the sharps containers were being stored in the room. The PHL stated it looked like the room had accumulated over a week's worth of sharps containers. The PHL stated there should not have been any containers without covers because they had the potential to fall and spill all of their contents on the floor. During an interview on 9/27/24 at 10:17 a.m. with the IP, the IP stated even though a separate company was storing sharps containers in the facility, it was still the responsibility of the facility staff to ensure their storage practices followed infection control standards. During a concurrent interview on 9/27/24 at 10:52 a.m. with the DON and the Administrator (ADM), the ADM stated it was not acceptable to have the sharps containers stacked on top of each other or with missing lids. The ADM stated even if the storage was left by an outside company, it was still the responsibility of the facility and the staff to ensure everything was stored appropriately. The DON stated it was the responsibility of staff to notify their supervisor if they identified any issue with the room. During a review of the facility's policy and procedure (P&P) titled, Infection Prevention and Control Program, dated 2018, the P&P indicated An infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections . important facets of infection prevention include: .Educating staff and ensuring that they adhere to proper techniques and procedures .instituting measures to avoid complications or dissemination (spread) . During a review of the facility's P&P titled, Sharps Disposal, dated 1/12, indicated, . contaminated sharps will be discarded into containers that are a. closeable . 3. During use, containers for contaminated sharps will be handled as follows .b. Nursing staff will ensure that the containers are maintained in an upright position throughout use; and c. Designated individuals will be responsible for sealing and replacing containers when they are 75% to 80% full to protect employees from punctures and/or needlesticks .7. Whoever observes incorrect disposal or handling of contaminated sharps should report the information to the Infection Preventionist . 51271 2. During a review of Resident 58's Admission Record (AR-a document that s) provides resident contact details, a brief medical history, level of functioning, preferences and wishes) dated 9/25/24, the AR indicated Resident 58 had a history of asthma (a chronic lung disease that makes breathing difficult by causing inflammation and narrowing of the airways) and dependence of supplemental oxygen (person requires continuous use of oxygen therapy to maintain adequate oxygen levels). During a concurrent observation and interview on 9/23/24 at 9:17 a.m. in Resident 58's room, Resident 58's oxygen concentrator filter was covered in dirt, dust and lint. Resident 58 stated she received continuous oxygen via nasal cannula (a thin, flexible tube that goes around the ears and into the nose). During a concurrent interview and record review on 9/26/24 at 3:11 p.m. with Certified Nursing Assistant (CNA) 2, CNA 2 stated she was not permitted to handle Resident 58's oxygen concentrator or cannula. It was the responsibility of the nurse to maintain resident oxygen devices and equipment at the facility. CNA 2 stated if there were any potential issues she noted, she would report them to the nurse. During a concurrent interview and record review on 9/26/24 at 3:30 p.m., with Licensed Vocational Nurse (LVN) 2, Resident 58's Physician Orders, dated 9/26/24, were reviewed. The Physician Orders indicated Resident 58 was ordered oxygen at 2 liters per minute (flow rate) from a nasal cannula, albuterol sulfate (medication used to prevent and treat difficulty breathing caused by lung disease) via nebulizer (machine which changes liquid medicine into droplets which are inhaled through a mouthpiece or mask) as needed, and budesonide (medication which treats a variety of conditions by reducing swelling in the body) via nebulizer every six hours. LVN 2 sated Resident 58 was receiving oxygen for her asthma. LVN2 stated Resident 58 had always received oxygen through her nasal cannula. LVN 2 stated she was not aware of where the oxygen concentrator filters were located on the oxygen concentrator or how to clean them. During an interview on 9/27/24 at 11:30 a.m. with Director of Staff Development (DSD), DSD stated it was the expectation of the facility for CNAs to escalate potential issues or concerns regarding the oxygen concentrator to a nurse. During an interview on 9/27/24 at 12:00 p.m. with the IP, the IP stated the expectation was for all oxygen concentrator filters to be changed every Friday. The IP stated this expectation was communicated to staff when they got hired. The IP stated the filters on the oxygen concentrator suck in air from the outside. The IP stated it was important to change out the oxygen concentrator filters because it ensured Resident 58 could breathe in clean air. During an interview on 9/27/24 at 11:04 a.m. with the DON, the DON stated the expectation was for the nurses to wash and clean the oxygen concentrator filters, they should have cleaned them every seven days or as needed. The DON stated if the filters were not clean, dust and lint could have been breathed in by Resident 58. During a review of the facility's policy and procedure (P&P) titled, Infection Prevention and Control Program, dated 2018, the P&P indicated An infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections . important facets of infection prevention include: .Educating staff and ensuring that they adhere to proper techniques and procedures .instituting measures to avoid complications or dissemination (spread) . During a review of facility's P&P titled, Respiratory Therapy - Prevention of Infection, dated 11/15/23, the P&P indicated, . Infection Control Considerations Related to Oxygen Administration . Wash filters from oxygen concentrators every seven days with soap and water. Rinse and squeeze dry . 40641 3. During observation on 9/23/24 at 7:45 a.m. in Resident 61's room during initial tour, Resident 61 was lying in bed, eyes closed and appeared comfortable. Resident 68 was noted with a oxygen cannula connected to the oxygen concentrator. Resident 68 did not answer questions when asked. Resident 68's oxygen concentrator filter was observed covered with grayish white materials. During a concurrent observation and interview on 9/23/24 at 8:30 a.m. during initial tour in Resident 3's room, Resident 3 was observed lying in bed watching Television. Resident 3 was observed using oxygen via nasal cannula connected to a oxygen concentrator. Resident 3's oxygen concentrator filter was found covered with grayish white lint like material. Resident 3 stated she did not have any concerns. During a concurrent observation and interview on 9/23/24 at 8:35 a.m. with Licensed Vocational Nurse (LVN) 3, LVN 3 stated the Resident's 3 and 61's oxygen concentrator filters were not clean, the filters were covered with white lint like material. LVN 3 stated the oxygen filters needed to be cleaned. LVN 3 stated dirty oxygen filters placed residents using oxygen at risk for respiratory illness and they are already compromised. LVN 3 stated she was not sure who was responsible in cleaning and replacing the oxygen filters. During an interview on 9/23/24 at 8:50 a.m. with Assistant Director of Nursing, the ADN stated housekeeping are responsible in changing and cleaning oxygen concentrator filters. During a concurrent observation and interview on 9/23/24 at 9:04 a.m. with Housekeeping Supervisor (HKS), HKS verified Residents' 61 and 3's oxygen concentrator filters are covered with lint like materials and stated, . the oxygen concentrator filters are dirty and should have been cleaned . The HKS stated housekeeping role was to clean oxygen concentrators after resident discharged . The HKS stated it was not housekeeping's job to clean or replace oxygen concentrator filters while a resident is in the facility. The HKS stated she did not know who was responsible in cleaning oxygen concentrator filters for current residents. During a concurrent observation and interview on 9/23/24 at 9:25 a.m. with Infection Preventionist (IP), Residents' 61 and 3's oxygen concentrator filters are observed and IP stated, . It does not look like they were cleaned at all . The IP stated licensed nurses are responsible in making sure to clean oxygen concentrator filters. The IP stated licensed nurses replaced nasal cannulas every week and should have been cleaning and/or replacing oxygen concentrator filters at the same time. The IP stated not cleaning oxygen concentrator filters could exacerbate respiratory condition which could result in more serious respiratory health problems. During an interview on 9/27/24 at 2:30 p.m. with the Director of Nursing (DON), the DON stated oxygen concentrator filters are cleaned and replaced every seven days and as needed. The DON stated there was a miscommunication about who was responsible in cleaning and replacing the oxygen concentrator filters. The DON stated licensed nurses will be cleaning and replacing oxygen concentrator filters every seven days when nasal cannulas are replaced. The DON stated dirty filters could further worsen respiratory problems of residents' using oxygen. During a review of facility's policy and procedure (P&P) titled, Respiratory Therapy - Prevention of Infection, dated 11/15/23, the P&P indicated, . Infection Control Considerations Related to Oxygen Administration . Wash filters from oxygen concentrators every seven days with soap and water. Rinse and squeeze dry . 49949 4. During a review of Resident 345's Admission Record (document containing resident demographic information and medical diagnosis) dated 9/26/24, the admission record indicated, Resident 345 was admitted to the facility on [DATE]. Resident 345's diagnosis included Covid 19 (infectious disease caused by the SARS-CoV-2 virus) chronic Obstructive Pulmonary Disease (COPD- a condition caused by damage to the airways or other parts of the lung that blocks airflow and makes it hard to breathe), Acute Respiratory Failure (occurs when the lungs and blood have impaired gas exchange, resulting in low oxygen levels in the body's tissues) and Depression. During a review of Resident 345's Minimum Data Set (MDS - a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment), dated 9/26/24, the MDS, indicated Resident 345 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 12 (a score of 0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired, 13-15 suggests cognitively intact) indicating Resident 345 was moderately cognitively intact. During an observation on 9/23/24 at 11:15 a.m. in Resident 345's room, Resident 345 had a nasal cannula (a device that delivers extra oxygen through a tube and into your nose) connected to an oxygen concentrator (medical device that separates nitrogen from the air around you so you can breathe up to 95% pure oxygen). The nasal cannula tube did not have the date written on it. During an interview on 9/23/24 at 11:15 a.m.in Resident 345's room, Resident 345 stated she was admitted to the facility for one week for covid-19. Resident 345 stated she was not sure when the nasal cannula tube was changed. During an interview on 9/23/24 at 11:25 a.m. with Registered Nurse (RN) 2, RN 2 stated, the nasal cannula tube should have had the date on it. RN 2 stated the nasal cannula tube should had been replaced every week. RN 2 stated the nurses and central supply person was responsible to change the nasal cannula tube weekly. RN 2 stated, the nasal cannula tube needed to be changed weekly to prevent clogging. RN 2 stated, the nasal cannula needed to have a date to make sure it was changed weekly. RN 2 stated, Resident 345 was at risk for respiratory failure with a clogged nasal cannula tube. During an interview on 9/26/24 at 12:23 p.m. with the Infection Preventionist (IP), the IP stated, the nasal cannula tube should have had a date on it. The IP stated, the nasal cannula tube should had been changed every seven days and as needed when the nasal cannula tube was clogged or dirty. The IP stated, it was important to date the nasal cannula tube, so staff knew when to changed it. The IP stated, When we date the [nasal cannula] tubing it is to make sure the residents had a clean tubing. The IP stated, the tubing had to be changed to prevent a respiratory infection. The IP stated, the nasal cannula tube had to be dated to changed timely. During an interview on 9/26/24 at 12:30 p.m. with the Director of Nursing (DON) the DON stated, My expectation is to make sure they [nasal cannula tube] are label and if they [nurses] see it on the floor, whatever the situation would be to make sure it is replaced and labeled. The DON stated the nasal cannula tube needed to be changed every seven days. The DON stated, the nasal cannula tube needed to have a written date on it every time it was removed from the package and used on Residents. During a review of the facility's policy and procedure (P&P) titled, Infection Prevention and Control Program, dated 2018, the P&P indicated An infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections . important facets of infection prevention include: .Educating staff and ensuring that they adhere to proper techniques and procedures .instituting measures to avoid complications or dissemination (spread) . During a review of professional reference retrieved from https://www.ucsfhealth.org/education/your-oxygen-equipment, titled, Patient Education Your Oxygen Equipment, dated 2022-2024 indicated, . the nasal cannula should be changed every week . if you are using a humidifier, empty it at least once a day .

Based on observation, interview, and record review, the facility failed to develop and implement a resident centered care plan for three of 11 sampled residents (Resident 1, Resident 31, and Resident 53) when: 1. Resident 31 did not have a care plan for the use of clotrimazole (brand name-used to treat fungal infection) medication. This failure placed Resident 31 at risk for complications from not having care needs planned by licensed nurses to determine if nursing intervention needed to be added, changed, or completed. 2. The padding on Resident 1's left bedrail was not fully intact, and the metal bar was exposed This failure had the potential to result in Resident 1 sustaining an injury during a seizure (uncontrolled bursts of electrical activities that change sensations behaviors, awareness and muscle movements) episode. 3. Resident 53 did not have a care plan in place for the change in condition for diarrhea on 9/14/24. This failure had the to result in Resident 53's medical needs not to be met. Findings: 1. During a concurrent observation and interview on 9/23/24 at 7:33 a.m. Resident 31's room, Resident 31 was lying in bed, feet were dangling off the bed while his body was covered with blanket. Observed toenails were thick and long, Resident 31 stated staff cut his nails, and the foot doctor had seen him recently. During a review of Resident 31's Admission Record, dated 9/26/24, the admission record indicated Resident 31 was admitted to the facility on [DATE] with diagnoses which included epilepsy (brain disease where nerve cells don't signal properly, which causes seizures[uncontrolled burst of electrical activities that changes sensations, behaviors and muscle weakness]), anemia (body does not produce enough healthy red blood cells) and dementia (loss of cognitive functioning, thinking, remembering and reasoning). During a review of Resident 31's Order Summary Report, dated 9/26/24, the Order Summary Report, indicated, . Clotrimazole External Cream one percent [1%] . Apply to toenails topically in the morning for onychomycosis [fungal infection that affects the nails, causing them to become discolored, thickened, and brittle] for four months . During a concurrent interview and record review on 9/25/24 at 2:16 p.m. with Licensed Vocational Nurse (LVN) 3, Resident 31's order summary was reviewed and LVN 3 stated Resident 31 was seen by podiatrist and was ordered ointment to be applied to his toenails for four months. LVN 3 stated she did not find a care plan for the new order and there should have been a care plan. LVN 3 stated a care plan should have been initiated by the licensed nurse who received the order. LVN 3 stated the care plan was very important to monitor the condition of residents whether there was progress or decline. LVN 3 stated care plan were the responsibility of all licensed nurses. During a concurrent interview and record review on 9/25/24 at 2:40 p.m. with Social Service Director (SSD), the SSD stated she arranged for podiatrist to come in the facility and they come in the facility to see residents every two months. The SSD stated the podiatrist saw Resident 31 on 7/17/24 and 9/17/24. During an interview on 9/27/24 at 2:25 p.m. with the Director of Nursing (DON), the DON stated Resident 31's care plan should have been initiated by the licensed nurse receiving the order. The DON stated care plans are important because it directs the staff on how to care and monitor progress of residents. Care plans are initiated immediately after an order was received. During a review of facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, dated 12/16, the P&P indicated, . The comprehensive, person-centered care plan will: a. Include measurable objectives and timeframes . Identifying problem areas and their causes, and developing interventions that are targeted and meaningful . Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions changes . 49949 3. During an observation on 9/23/24 at 11:50 a.m. in Resident 53's room, an enhanced barrier (infection control strategy to reduce the spread of bacteria) sign was next to the door. Resident 53 stated, he had diarrhea last week. During a review of Resident's 53 Admission Record dated 9/27/24, the admission record indicated, Resident 53 was admitted to the facility on [DATE] with diagnoses which included, Parkinson's Disease( a condition where a part of your brain deteriorates, causing more severe symptoms over time), Gastro-Esophageal Reflux Disease (GERD- condition in which stomach acid repeatedly flows back up into the tube connecting the mouth and stomach), Pain, Schizoaffective (chronic mental illness that causes a person to experience dramatic changes in their thoughts, moods, and behaviors). During a review of Resident 53's Minimum Data Set (MDS - a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment), dated 8/2/24, the MDS, indicated Resident 53 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 15 (a score of 0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired, 13-15 suggests cognitively intact) indicating Resident 53 was cognitively impaired. During a review of the facility's document titled, SBAR [ Situation, Background, Assessment, and Recommendation (or Request), is a structured communication framework that can help teams share information about the condition of a patient or team member or about another issue your team needs to address] Communication Form and Progress Note for RNs/LPN/LVNs (SBAR) for Resident 53, dated 9/14/24, the SBAR indicated .Situation .the change in condition, symptoms, or signs observed and evaluated is/are: Diarrhea .This started on 09/14/2024 .since this started it has gotten .(box checked] stayed the same .This condition, symptoms, or sign has occurred before: [box checked] unknown .Review and Notify .primary physician: Yes .Date:9/14/24 .Time:2:30 PM .Testing .[box checked] blood test .[box checked]other .C.diff [a bacterium that can cause diarrhea other intestinal conditions] and stool culture .[box checked] other n/a . During a review of Resident 53's, [Facility Name] Progress Notes *NEW* dated 9/14/24, the progress note indicated, .Situation: The Change in Condition/s report on this CIC evaluate are/were: Diarrhea . During an interview on 9/27/24 at 10: 17 a.m. with the Director of Nurses (DON), the DON stated Resident 53 had diarrhea on 9/14/24 and an SBAR was done. The DON stated, the physician ordered C-Diff and stool culture (a lab test that examines a stool sample for the presence of bacteria or other germs that can cause infection). The DON stated Resident 53's lab results were negative for c-diff. The DON stated, Resident 53 did not have a recent care plan developed for his diarrhea. The DON stated, Resident 53's diarrhea was considered a changed in condition and a care plan for diarrhea should have been done. During an interview on 9/27/24 at 2:58 p.m. with Registered Nurse (RN) 2, RN 2 stated, Resident 53 had a changed in condition when he had diarrhea. RN 2 stated, there was no care plan for the diarrhea on 9/14/24. RN 2 stated, a care plan should have been developed due to a change in condition related to this new problem. RN 2 stated it was important to create a care plan to ensure the residents were getting the proper care. RN 2 stated, the care plan notified other disciples about the change in condition. During an interview on 9/27/24 at 3:06 p.m. with the Minimum Data Set Coordinator (MDSC) 1, the MDSC 1 indicated Resident 53 had a changed in condition when he had diarrhea. MDSC 1 stated, the staff should have done a care plan to reflect the changed in condition. MDSC 1 stated Resident 53 short term care plan. MDSC 1 stated, nurses and the DON were responsible for the short-term care plans. During a review of facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, dated 12/16, the P&P indicated, . The comprehensive, person-centered care plan will: a. Include measurable objectives and timeframes . Identifying problem areas and their causes, and developing interventions that are targeted and meaningful . Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions changes . 51271 2. During a review of Resident 1's Admission Record (AR-a document that provides resident contact details, a brief medical history, level of functioning, preferences and wishes), dated 9/25/24, the AR indicated Resident 1 has a history of epilepsy (a brain disease where nerve cells don't signal properly, which causes seizures). During a review of Resident 1's Minimum Data Set (MDS-resident assessment tool which indicates physical and cognitive abilities), the MDS indicated a Brief Interview for Mental Status (BIMS-an assessment of cognitive function) score of 12 (0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, 13-15 no cognitive impairment) indicating Resident 1 had moderate cognitive impairment. During an observation on 9/23/24 at 9:15 a.m. in Resident 1's room, the padding on residents left bedrail was not fully intact, and the metal bar was exposed. During a concurrent observation and interview on 9/25/24 at 10:30 a.m. with Certified Nursing Assistant (CNA) 7 in Resident 1's room, the padding on Resident 1's left bedrail was not fully intact, and the metal bar was exposed. CNA 7 stated Resident 1's bed rails were to be padded for easier turning and for Resident 1's protection. CNA 7 stated she was unsure of Resident 1's medical history that would indicate the use of padded rails and the nurses were responsible for communicating to the CNAs During a concurrent observation and interview on 9/25/24 at 10:45 a.m. with CNA 8 in Resident 1's room, the padding on Resident 1's left bedrail was not fully intact, and the metal bar was exposed. CNA 8 stated Resident 1's bedrails should have been fully padded for Resident 1's protection. During a concurrent interview and record review on 9/25/24 at 11:00 a.m. with Registered Nurse (RN) 1, Resident 1's Care Plan, dated 5/24/24 was reviewed. The Care Plan indicated at risk for recurrent seizure episode . padded side rails on bed as indicated . RN 1 stated she did not know why Resident 1's bedrail padding was not intact and properly maintained. RN1 stated both of Resident 1's bedrails should have been padded as indicated on her care plan. RN 1 stated it was the responsibility of the nursing staff to ensure the care plans were being followed. RN 1 stated Resident 1 had a diagnosis of seizures, and she could hurt herself if she hits her limbs on the unpadded rail. During an interview on 9/25/24 at 11:30 a.m. with House Keeping Supervisor (HKS), the HKS stated it was the expectation of nursing staff to log items that need repair in the maintenance log located at nurse's station. During a review of the facility's Maintenance Log dated 9/24, the maintenance log indicated no entries for bed rail padding repair was present for Resident 1's bed. During an interview on 9/27/24 at 9:32 a.m. with the Director of Staff Development (DSD), the DSD stated if a CNA was unsure whether Resident 1's torn siderail padding needed to be replaced, they could have asked the nurses. The DSD stated it was the nurse's responsibility to check the care plan to see if the side rail needed to be padded and then place a work order in the maintenance log. The DSD stated the nurses failed to communicate and implement the care plan's intervention for padded side rails for Resident 1. The DSD stated if Resident 1's siderails were not padded, Resident 1 may have injured herself if she hit the rail. During an interview on 9/27/24 at 11:15 a.m. with the Director of Nursing (DON), the DON stated she expected her staff to report damaged padding to the side rails and write the work order in the maintenance log to be fixed. During a review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, dated 12/17, the P&P indicated, .comprehensive, person centered care plan that includes measurable objectives and timetables to meet the residents physical, psychosocial and functional needs is developed and implemented for each resident . the comprehensive, person centered care plan will: .g. Incorporate identified problem areas h. Incorporate risk factors associated with identified problems . 13. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents condition change .

Based on observation, interview, and record review, the facility failed to ensure residents were treated with respect and dignity in an environment that promotes and enhances quality of life for five of 21 sampled residents (Residents 68, 81, 245, 246, and 350,) when Residents 68, 81, 245, 246 and 350 waited up to 20 minutes for their lunch tray while watching other residents eat their meal while in the dining room. This failure violated Residents' 68, 81, 245, 246 and 350 the right to be offered a dignified dining experience. Findings: During an observation on 9/23/24 at 12:21 p.m. in the dining room, nursing staff passed out lunch trays to residents in the dining room except two residents, Resident 68 and Resident 81. Resident 68 and Resident 81 did not receive a lunch tray and watched other residents eat sitting at the same table. Resident 68 and Resident 81 were observed looking at other residents eating around them. Resident 68 and Resident 81 were served their lunch 15-20 minutes after other residents were served their lunch. During a concurrent observation and interview on 9/24/24 at 12:30 p.m., in the dining room, nursing staff was observed passing out lunch trays to residents in the dining room except for four residents, Residents 68, 245, 246 and 350. Residents 68, 245, 246 and 350 sat on the same table and did not receive their lunch trays and watched other residents eat in the dining room. Residents 68, 245, 246 and 350 were observed looking around and looking at other residents eat around them. Residents 68, 245, 246 and 350 were served their lunch 25-30 minutes after other residents were served their lunch. Family Member (FM) 1 was seated next to Resident 350 stated, it was not the first time Resident 350 ate in the dining room, and she did not understand why staff send Resident 350's lunch tray to his room. FM 1 stated it was uncomfortable watching other residents eat while Residents 68, 245, 246 and 350 waited for their lunch tray. During a review of Resident 68's Admission Record [AR-document which contain patient personal information], dated 9/26/24, the AR indicated Resident 68 was admitted to the facility on [DATE] with diagnoses which included unspecified psychosis ( ), anemia (low red blood cell) and muscle weakness. During a review of Resident 68's Minimum Data Set (MDS-an assessment tool used to identify resident cognitive [pertaining to reasoning, memory and judgement] and physical function level), assessment dated [DATE], indicated Resident 68's Brief Interview for Mental Status (BIMS-screening tool used in nursing home to assess cognition) assessment score was six out of 15 (0-15 scale [0-6 severe cognitive deficit, 7-12 moderate cognitive deficit, 13-15 no cognitive deficit]) indicating Resident 68 had severe cognitive deficit. During a review of Resident 81's Admission Record dated 9/26/24, the AR indicated Resident 81 was admitted in the facility on 6/13/24 with diagnoses which included psychosis (mental health disorder) and fracture (break in bone). During a review of Resident 81's MDS assessment dated [DATE], indicated Resident 81's BIMS score was nine out of 15 indicating Resident 81 had moderate cognitive deficit. During a review of Resident 245's AR dated 9/26/24, the AR indicated Resident 245 was admitted to the facility on [DATE] with diagnoses which included embolism and thrombosis, muscle weakness. During a review of Resident 245's MDS dated [DATE], indicated Resident 245's BIMS was 14 out of 15 indicating Resident 245 had no cognitive deficit. During a review of Resident 246's AR, dated 9/26/24, the AR indicated Resident 246 was admitted to the facility on [DATE] with diagnoses which included urinary tract infection (bladder infection) and anemia. During a review of Resident 246's MDS dated [DATE], indicated Resident 246's BIMS was four out of 15, indicating Resident 246 had severe cognitive deficit. During a review of Resident 350's AR dated 9/26/24, the AR indicated Resident 350 was admitted to the facility on [DATE] with diagnoses which included urinary tract infection and heart failure. During a review of Resident 350's MDS dated [DATE], indicated Resident 350's BIMS was 14 out of 15, indicating resident 350 had no cognitive deficit. During an interview on 9/23/24, at 12:35 p.m. with Certified Nursing Assistant (CNA) 3 in the dining room, CNA 3 stated the practice was to serve one table at a time then move on to the next table. CNA 3 stated it was not right for Resident 68 and 81 to wait for their food while they watched other residents eat. During an interview on 9/24/24 at 12:46 p.m. with CNA 4 in the dining room, CNA 4 stated Residents' 68, 81, 245, 246 and 350 waited a long time for their meals because they did not usually eat in the dining room. CNA 4 stated, .Therapist brought residents in the dining room after they finished working with them CNA 4 stated, dietary staff sent Residents' 68, 81, 245, 246 and 350's lunch trays in their rooms. CNA 4 stated they should have let the kitchen staff know to send Residents' 68, 81, 245, 246 and 350's in the dining room so they did not have to watch other residents eat while they wait for their lunch trays. During an interview on 9/26/24 at 9:19 a.m. with Dietary Service Manager (DSM), the DSM stated the practice was to serve one table at a time then move on to the next table. The DSM stated it was not right for residents to wait a long time for their lunch tray to be served while they watched other residents eat around them eat; it was a dignity issue. The DSM stated the nursing staff in the dining room should have let dietary staff know when a resident who do not usually eat in the dining room decided to eat in the dining room. During an interview on 9/26/24 at 9:35 a.m. with Minimum Data Set Coordinator (MDSC) 1, MDSC 1 stated she usually helped in the dining room during meals. MDSC 1 stated she checked the food trays making sure residents received their diets as ordered. MDSC 1 stated Residents 68, 81, 245, 246 and 350's lunch trays were not served until later because their lunch trays were sent out to the floor. MDSC 1 stated they had to watch other residents eat while they waited for their lunch trays. MDSC 1 stated nursing staff working in the dining room should have communicated with the dietary staff of Residents' 68, 81, 245, 246 and 350 eating in the dining room. MDSC 1 stated the practice was to served everyone at the same table at a time. During an interview on 9/26/24 at 10:15 a.m. with Director of Staff Development (DSD), the DSD stated the practice was for the nurse to check the trays first then the CNAs distributes the trays. The DSD stated, . Staff needed to serve one table at a time before moving on to the next table . The DSD stated it was a dignity issue for residents watching other residents eat while they waited for their food. During an interview on 9/27/24 at 2:10 p.m. with the Director of Nursing (DON), the DON stated, .CNAs working in the dining room should have communicated with the dietary staff . The DON stated the expectation was for residents to be served their food one table at a time then moved on to the next table. During a review of facility's policy and procedure (P&P) titled, Quality of Life-Dignity dated 8/09, the P&P indicated, . Residents should be treated with dignity and respect at all times . During a review of the facility's policy and procedure (P&P) titled, Resident Rights, dated, 8/22, the P&P indicated, .be treated with respect, kindness and dignity . be free from corporal punishment or involuntary seclusions, and physical or chemical restraints not required to treat the resident's symptoms .

Based on observation, interview and record review, the facility failed to ensure residents received adequate supervision to prevent accident hazards (an unexpected injury or illness that occurred due to the resident ' s environment) for one of three sampled residents (Resident 1) when Resident 1 who had dementia (condition of progressive loss of memory, language and other thinking abilities which requires increased supervision of the individual) and had a known behavior of moving around in the facility in the wheelchair independently, exited unsupervised to the rose garden outside. Resident 1 was found in an area of the rose garden exposed to the sun for an unknown amount of time on a day temperatures reached up to 108 degree Fahrenheit (unit of temperature measurement). This failure resulted in Resident 1 sustaining second- degree burns (a burn that affects the outer and middle layers of skin which results in blistering, swelling, redness and pain) on top of his scalp, right ear, posterior (back side) neck, left shoulder and both knees and an acute kidney injury (a sudden episode of kidney damage), which required treatment at an acute care hospital. Findings: During record review of Resident 1 ' s Admission Record (AR- a document that provides resident contact details, a brief medical history), the AR indicated, Resident 1 had diagnoses which included .BURN OF SECOND DEGREE SCALP .CHRONIC KIDNEY DISEASE, STAGE 3 (CKD- a condition where the kidneys have moderate damage and are less able to filter waste and fluid from the blood) .TYPE 2 DIABETES MELLITUS (a problem in the way the body regulates and uses blood sugar) .ALZHEIMER ' S DISEASE (brain disorder which slowly destroys memory and thinking skills) .UNSPECIFIED DEMENTIA .BURN OF SECOND DEGREE OF NECK .BURN OF SECOND DEGREE OF RIGHT KNEE .BURN OF SECOND DEGREE OF LEFT SHOULDER .BURN OF SECOND DEGREE OF RIGHT EAR . During a review of Resident 1's Minimum Data Set (MDS- a standardized assessment and care screening tool), dated 7/22/24, the MDS indicated, Resident 1's Brief Interview for Mental Status (BIMS- an evaluation of attention, orientation and memory recall) indicated a score of 6 (0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, 13-15 no cognitive impairment), indicating Resident 1 had severe cognitive impairment (an intense inability to think, remember, use judgement and make decisions which requires frequent supervision of the individual). During an interview on 8/2/24 at 10:22 a.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated, staff would always have to supervise Resident 1 because he would wheel himself around the facility in his wheelchair and was always trying to go home. CNA 1 stated, Resident 1 was a fall risk and had alarms on his bed and wheelchair to alert the staff when he got up without assistance. CNA 1 stated, the staff should not have allowed Resident 1 to be outside alone without staff supervision due to the risk of being sunburned. During an interview on 8/2/24 at 10:31 a.m. with Social Services Director (SSD), SSD stated, Resident 1 was discharged from the facility on 7/22/24 with orders for nursing care to treat his wounds. SSD stated, Resident 1 had a right ear second degree burn, right knee second degree burn, left shoulder second degree burn, posterior neck second degree burn and a second degree burn to the top of Resident 1 ' s scalp. During an interview on 8/2/24 at 10:48 a.m. with Director of Nursing (DON), DON stated, Resident 1 had sundowners (a person with dementia who becomes increasingly irritable as the day progresses) behaviors and yelled out for his wife. DON stated, Resident 1 was in a wheelchair and liked to go outside. DON stated, Resident 1 was admitted to the hospital from 6/24/24 until 7/2/24 to be treated for the burns that were sustained while residing at the facility which required further evaluation and treatment. During an interview on 8/2/24 at 10:57 a.m. with Assistant Director of Nursing (ADON), ADON stated, Resident 1 opened the door and wheeled himself out into the sun-exposed area of the rose garden patio on 6/23/24 and was outside without staff supervision for an unknown amount of time. ADON stated, an AM (morning shift that works from 7 am to 3 pm) CNA saw Resident 1 outside, alerted a PM (night shift that works 3 pm to 11 pm) CNA of Resident 1 ' s location outside and the PM CNA brought Resident 1 inside. ADON stated, it was not known how long Resident 1 was outside for. ADON stated, blisters were found on Resident 1 ' s scalp and neck and treatments to the affected areas were completed. ADON stated, Resident 1 was found to have inflammation and swelling to the face, neck and scalp on 6/24/24. ADON stated, Resident 1 was sent to the hospital for evaluation due to the swelling and was gone from the facility for about a week. During an interview on 8/2/24 at 11:03 a.m. with DON, DON stated Resident 1 was originally admitted on [DATE] to the facility and the first blisters were observed during the NOC (overnight shift that works 11 pm to 7 am) shift by staff on 6/23/24. DON stated, Resident 1 had a popped blister to the posterior neck which was open and contained slough (material covering wound bed that is made of dead tissue, pus and other debris) when he came back from the hospital. DON stated, Resident 1 also had an open and popped blister to the scalp, a popped left shoulder blister, a popped right ear blister, a popped right knee blister and an intact left knee blister when Resident 1 returned back from the hospital. During an interview on 8/2/24 at 11:29 a.m. with DON, DON stated, staff interviews were completed regarding this incident and staff reported Resident 1 was at the sun-exposed, far end of the rose garden prior to being brought inside. During an observation on 8/2/24 at 11:46 a.m. outside in the rose garden, the rose garden was positioned in the center of facility. The rose garden contained concrete paths around the perimeter, a covered patio area and grass. The covered patio area was located on the side closest to the only door used to access this outdoor area. The farthest area of the rose garden had a concrete path and was unshaded. During an interview on 8/2/24 at 11:58 a.m. with CNA 2, CNA 2 stated, she worked the AM shift on 6/23/24 and saw Resident 1 sitting in the rose garden at the end of the shift. CNA 2 stated, CNA 2 went and told PM shift staff that Resident 1 was outside and needed to be brought back inside. CNA 2 stated, Resident 1 was a fall risk. CNA 2 stated, Resident 1 should have been supervised and not left unattended outside because it was the staff ' s responsibility to ensure safety and security for the residents. During a phone interview on 8/8/24 at 9:41 a.m. with CNA 4, CNA 4 stated, she was working the PM shift on 6/23/24 and at the start of the shift, another CNA was leaving, looked out to the rose garden and saw a resident sitting outside alone. CNA 4 stated, Resident 1 was in the rose garden on the sidewalk on the far side, which was unshaded. CNA 4 stated, Resident 1 was strong enough to open the door, get outside and wander in the rose garden. CNA 4 stated, the temperature outside was at least 110 degrees Fahrenheit. CNA 4 stated, she went outside, approached Resident 1 and said Resident 1 should come inside due to the excessive heat. CNA 4 stated, it was unknown how long Resident 1 had been outside and the skin on Resident 1 ' s arm was warm to touch. CNA 4 stated, CNA 4 brought Resident 1 inside to cool down. CNA stated, Resident 1 was provided with cold water and a popsicle in order to make Resident 1 ' s temperature lower. CNA 4 stated, Resident 1 was placed near his assigned nurse for the shift so the nurse could assess Resident 1. CNA 4 stated, facility staff did not pay attention where Resident 1 wandered to and should have supervised Resident 1 because it was so hot outside. CNA 4 stated, it was best to monitor the residents and residents should not be left unattended at any point. During a phone interview on 8/9/24 at 3:22 p.m. with Licensed Vocational Nurse (LVN) 1, LVN stated, Resident 1 had a diagnosis of dementia. LVN 1 stated, LVN 1 worked the 6/23/24 NOC shift which started at 11 pm. LVN 1 stated, a CNA alerted LVN 1 of a blister on the top of Resident 1 ' s head during that shift on 6/24/24. LVN 1 stated, the RN (registered nurse) supervisor was notified to assess Resident 1, notified the NP (Nurse Practitioner) and the wound was treated. LVN 1 stated, the treatment nurse and wound doctor came in the morning of 6/24/24 and were notified to treat and evaluate Resident 1. LVN 1 stated, Resident 1 also had multiple small and intact blisters to the back of his neck. LVN 1 stated, LVN 1 was notified by the NOC CNA that Resident 1 was outside earlier in the day and was wheeled into the facility by a CNA. LVN 1 stated, it was very hot the day this incident occurred. LVN 1 stated, Resident 1 should not have been left unattended and needed monitoring. LVN 1 stated, Resident 1 should have been closely monitored to prevent Resident 1 from getting dehydrated by being outside, getting lost or sustaining a fall. During a phone interview on 8/9/24 at 3:48 p.m. with LVN 2, LVN 2 stated, Resident 1 was alert and oriented to his name only and answered questions with one word only. LVN 2 stated, she worked the PM shift on 6/23/24. LVN 2 stated, Resident 1 had been outside and the PM CNA brought Resident 1 inside. LVN 2 stated, she observed Resident 1 after PM CNA gave him water, a popsicle and checked his vitals. LVN 2 stated, the CNAs requested LVN 2 to assess Resident 1 in the evening because swelling was noted to his face. LVN 2 stated, Resident 1 had swelling to the side of his face. LVN 2 stated, the NP was notified and orders obtained to send Resident 1 to the hospital. LVN 2 stated, Resident 1 was sent to the hospital on the evening of 6/24/24 was diagnosed with second-degree burns. LVN 2 stated, Resident 1 should have been supervised outside due to the possibility of wandering, not knowing what they were doing and potentially falling. During a phone interview on 8/9/24 at 4:14 p.m. with CNA 5, CNA 5 stated, Resident 1 was confused, not fully alert, dependent on staff and a fall risk. CNA 5 stated, CNA 5 worked the AM shift on 6/23/24. CNA 5 stated, Resident 1 was outside at the end of CNA 5 ' s shift. CNA 5 stated, another CNA saw Resident 1 outside and notified the other staff about his location. CNA 5 stated, Resident 1 should have been closely supervised because Resident 1 was not alert, didn ' t know what was going on and was also a fall risk. During a concurrent phone interview and record review on 8/13/24 at 4:00 p.m. with DON, Hospital 1 ' s SNF Packet (SP- Patient documentation provided by Hospital 1 to SNF facility), dated 7/1/24 was reviewed. The SP indicated, .Chief Complaint .Blister Pt [patient] brought in by ambulance for blisters to top of head and posterior neck secondary to being outside yesterday for unknown amount of time. Today blisters popped, facility would like skin sites evaluated .found to have second degree burn in the scalp and neck. Cr [Creatinine- a chemical waste product in the blood, urine and muscle where a high result can indicate a kidney problem] increased to 2.0 from 1.3. BUN [Blood Urea Nitrogen- a substance in the blood created when protein breaks down and a high level can indicate kidney problems] 52 from 37 .Acute kidney injury superimposed [a secondary diagnosis occurring during or immediately following the original diagnosis] on CKD .Likely due to dehydration from staying under the sun yesterday Associated with second degree burn in the scalp and neck .2nd degree (blister) burn of scalp and neck from contact with sunlight; probably related to underlying dementia; Total body surface area: <10% . DON stated, Resident 1 was sent to the hospital and it was reported to the hospital staff that Resident 1 was outside for an unknown amount of time. DON stated, the hospital diagnosed Resident 1 with second-degree burns and an acute kidney injury. DON stated, Resident 1 had a known diagnosis of dementia with behaviors of wandering in his wheelchair outside and because of this should have been supervised while outside in the rose garden. DON stated, due to the lack of supervision for Resident 1 while he was alone outside unprotected on a hot day, he sustained and was hospitalized for second-degree burns to the scalp, ear, neck, shoulder and knees as well as an acute kidney injury. DON stated, staff should have done frequent rounding and checking on Resident 1 while he was outside for safety purposes, to assess for pain and to make sure staff can monitor for anything Resident 1 could not have verbalized for himself. During a review of Resident 1 ' s Progress Notes (PN), dated 6/24/24, the PN indicated, .06/24/2024 04:57 .NOC cna reported to writer that pm cna reported to her that am cna found the resident outside (in between am and pm shift) AM cna quickly wheel in resident inside the facility. NOC cna reported to writer resident has big open blister on top of the head, multiple intact blister on the back of the neck w/ [with] redness discoloration and warm to touch. Writer assess, notified noc RN supervisor .Treatment applied as per NP order Cleanse w/ ns [normal saline], pat dry, apple triple ABX [antibiotic], covered xerofoam [a fine mesh gauze dressing that has medication within it to promote wound healing] dressing. To be evaluated by treatment nurse and wound doctor this morning . During a review of Resident 1 ' s PN, dated 6/24/24, the PN indicated, .06/24/2024 11:09 .Seen resident this morning as endorsed from previous shift, resident had blister to his head. Noted dressing on his off and open blister red in color, no bleeding, with 2 small intact fluid filled on surrounding area. Also noted scattered intact blister on posterior neck .treatment orders clarified .Monitor intact blisters for untoward signs of skin breakdown . During a review of Resident 1 ' s PN, dated 6/24/24, the PN indicated, .06/24/2024 11:16 .Report from nursing staff received that resident propels self towards lobby most of the time when he is up. Has Dx [diagnosis] of Dementia, verbally responsive .Spoke with resident, verbalizes wants to go home, resident in his room at this time. NP .made aware via phone, ordered to apply wander guard [an alarm system used to monitor residents who are at risk of leaving a safe area] due his exit seeking behavior . During a review of Resident 1 ' s PN, dated 6/24/24, the PN indicated, .06/24/2024 22:29 [10:29 p.m.] . Nurse was notified of swelling to resident ' s face, head and neck swelling with scattered large blisters .NP .notified with orders to send out for further evaluation. Patient sent out to [name of Hospital- Hospital 1] . During a review of Resident 1 ' s Hospital 1 ' s Emergency Department Timeline (EDT), dated 6/24/24, the EDT indicated, .ED [Emergency Department] Pt Care Timeline .Arrival .06/24/2024 21:28 [9:28 p.m.] .Chief Complaints .Blister (Pt brought in by ambulance for blisters to top of head and posterior neck secondary to being outside yesterday for unknown amount of time. Today blisters popped, facility would like skin sites evaluated) .IV fluid Indication .clinical dehydration .SW [Social Worker] Consult .SW called [ADON] .to ask if patient was locked out of the facility. Per [ADON], patient went out to the garden to sit .she is not sure how long patient sat outside. When patient came inside, they realized there were blisters on his head .Case Management Initial Screening .Contacted pt ' s spouse .Spouse reports she .was told pt was found outside and ended up getting blisters due to the heat .Contacted .admissions at [skilled nursing facility name] .Per .staff did not bring pt outside as it was over 100 degrees yesterday . During a review of Resident 1 ' s Admission Readmission Screen and Baseline Care Plan (RS), dated 7/2/24, the RS indicated, .07/02/2024 21:42 [9:42 p.m.] .admitted From .Acute Hospital .Admitting Diagnosis .Acute Kidney injury .Level of cognitive impairment .Severe impairment (affecting all areas of judgment) .With exit-seeking behavior .Amoxicillin [medication used to treat infections] Oral Tablet 500 MG [milligram- unit of weight measurement] .1 tablet by mouth every 8 hours for Partial thickness [second-degree] burn of scalp . Resident is a returning patient of this facility, prior to transfer to acute care, resident noted to have multiple areas of popped blisters, as per skin assessment upon arrived, popped blister to posterior neck- L [length] 6.5 cm (centimeter- unit of length measurement), W [width] 7 cm, D [depth] UTD [depth unknown] - wound bed 90% necrotic [death of normally living tissue] tissue, mild drainage noted, no mal [foul] odor .popped blister to left shoulder, wound bed pink in color, popped blister to top of head . The RS indicated, Resident 1 had a popped blister to the top of his head which measured 17 cm by 10 cm by 0.1 cm; a popped blister to the right ear which measured 2.5 cm by 2 cm by 0.1 cm; a popped blister to the right knee which measured 2.5 cm by 4 cm by 0.1 cm; a popped blister to the left shoulder which measured 3.5 cm by 5 cm by 0.1 cm; a popped blister to the posterior neck which measured 6.5 cm by 7 cm by an undetermined depth; an intact blister to the left knee. During a review of Resident 1 ' s PN, dated 7/2/24, the PN indicated, .resident readmitted with diagnosis of Acute Kidney Injury .Resident is a returning patient of this facility, prior to transfer to acute care, resident noted to have multiple areas of popped blisters . During a review of Resident 1 ' s Progress Note Details (PND), dated 7/8/24, the PND indicated, .complaints of increased Pain .initial exam- pt wound consulted and tx [treatment] in place. pt with stable wound with numerous complex medical conditions .patient high risk for medical complications, skin breakdown, infection, sepsis [life-threatening emergency when the body ' s response to an infection damages vital organs] and even death . Wound #1 Scalp is a Burn .measurements are 11cm x 10cm width x 0.2 cm depth . small amount of serous [clear, watery fluid] drainage .Wound bed has 71-80, bright red, granulation [development of new tissue and blood vessels], 11-20% slough . Wound #2 Posterior Neck .measurements are 4cm length x 7 cm width with no measurable depth Small amount of serous drainage .Wound bed has 41-50%, bright red, granulation, 41-50% slough .Wound #3 Left Shoulder is a Burn . measurements are 4cm length x 2cm width with no measurable depth .Small amount of serous drainage .Wound bed has 81-100% slough . During a review of Resident 1 ' s PND, dated 7/15/24, the PND indicated, .Wound #1 Scalp is a Burn .Subsequent wound encounter measurements are 11cm x 10 cm width x 0.2 cm depth .Small amount of serous drainage .Wound bed has 71-80%, bright red, granulation, 11-20% eschar [hardened, dry black or brown dead tissue] .Wound #2 Posterior Neck .Subsequent wound encounter measurements are 4cm length x 7cm width with no measurable depth .no drainage noted .Wound bed has 91-100% eschar .Wound #3 Left Shoulder is a Burn .Subsequent wound encounter measurements are 3cm length x 1cm width with no measurable depth .no drainage noted .wound bed has 91-100% eschar .Wound #4 Right Knee is a Burn .Initial wound encounter measurements are 1cm length x 1cm width with no measurable depth .no drainage noted .91-100% eschar . During a review of Resident 1 ' s PN, dated 7/22/24, the PN indicated, .Resident seen by Dr [doctor] .this morning. Burn (2nd degree burn) wound to Scalp, posterior neck, and shoulder .100% necrotic area .awaiting referral to wound clinic. To continue with present treatment orders . During a review of Order Summary Report (OSR), dated 8/2/24, the OSR indicated .Active Orders As Of: 07/21/2024 .Cleanse [clean] 2nd degree burn wound on top of scalp with NS [normal saline], pat dry and apply [Silver Sulfadiazine brand name- medication used to prevent and treat burn wound infection] cream and leave open to air in the morning for 14 Days . Cleanse 2nd degree burn wound on L [left] shoulder with NS, pat dry and apply Silvadene cream and leave open to air in the morning for 14 Days . Cleanse 2nd degree burn wound on Posterior neck with NS, pat dry and apply Silvadene cream and leave open to air in the morning for 14 Days . Cleanse R [right] ear 2nd degree burn with NS, pat dry and apply Silvadene cream and leave open to air in the morning for 14 Days . Cleanse R knee 2nddegree burn with NS, pat dry and apply Silvadene cream and leave open to air in the morning for 14 Days .Refer to Burn clinic for further evaluation and management of 2nd degree burn to scalp, neck shoulder .Resident may discharge to home on 7/21/24 with same medications .RN for wounds .Silver SulfaDIAZINE External [outer] Cream 1% .Apply to scalp, neck topically every day and evening shift for Burn . During a review of Resident 1 ' s Care Plan (CP), undated, the CP indicated, .Altered skin integrity r/t [related to] LEFT SHOULDER OPEN AREA .Date Initiated: 07/02/2024 .LEFT SHOULDER OPEN AREA will be free from signs and symptoms of redness, swelling and foul smelling drainage .Observe for s/s [signs and symptoms] of pain, redness, swelling and foul smelling drainage on site and notify MD [doctor of medicine] and responsible party as indicated .Check resident ' s skin condition for presence of skin breakdown during care, bathing and shower .Treatment as order .Monitor response to treatment During a review of Resident 1 ' s CP, undated, the CP indicated, .Altered skin integrity r/t OPEN AREA TO RIGHT EAR .Date Initiated: 07/02/2024 .OPEN AREA TO RIGHT EAR will be free from signs and symptoms of redness, swelling and foul smelling drainage .Observe for s/s of pain, redness, swelling and foul smelling drainage on site and notify MD and responsible party as indicated .Check resident ' s skin condition for presence of skin breakdown during care, bathing and shower .Treatment as order .Monitor response to treatment During a review of the AccuWeather website https://www.accuweather.com/en/us/fresno/93702/june-weather/327144, dated 6/24, the website indicated the temperature on 6/23/24 was a high of 108 degrees Fahrenheit. During a review of the facility ' s policy and procedure (P&P) titled, Safety and Supervision of Residents, 7/17, the P&P indicated, .Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities .The interdisciplinary care team shall analyze information obtained from assessments and observations to identify any specific accident hazards or risks for individual residents .The care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision .Resident supervision is a core component of the systems approach to safety. The type and frequency of resident supervision is determined by the individual resident ' s assessed needs and identified hazards in the environment .

Based on observation, interview and record review, the facility failed to ensure residents were free from physical abuse for one of three sampled residents (Resident 1) when Registered Nurse (RN) 1, in response to Resident 1's complaint of abdominal pain and possible constipation, instructed Licensed Vocational Nurse (LVN) 1 and Certified Nursing Assistant (CNA) 1 to physically restrain Resident 1 while RN 1 willfully continued to push her finger into Resident 1's rectum (lower part of the intestine that terminates at the anus [where waste matter leaves the body]) even after Resident 1 cried no and stop. Resident 1 did not agree and consent to RN 1 manually inserting her finger into the rectum to extract feces (waste matter discharged from the bowel). These failures resulted in Resident 1 feeling fearful of and threatened by RN 1 and LVN 1, experiencing avoidable physical harm, avoidable mental and emotional anguish and self-isolation as a result of the anguish and required administration of anti-anxiety medications to treat the anxiety produced by this experience. Findings: During a review of Resident 1's Face Sheet (FS - a document containing important resident information), the FS indicated, Resident 1 was an [AGE] year-old female, admitted to the facility on [DATE] with diagnoses including, . hemiplegia [paralysis affecting one side of the body] and hemiparesis [weakness or inability to move on one side of the body] following a cerebral infarction [stroke, resulting from disrupted blood flow to the brain] affecting right dominant side . The FS indicated, Resident 1 was her own Responsible Party (decision-maker) and was cognitively able to make medical decisions. During a review of Resident 1's Brief Interview for Mental Status (BIMS - a short performance-based cognitive screener for nursing home residents, scored 0 to 15), the BIMS score was 15, which indicated Resident 1 was cognitively intact. During a concurrent observation and interview on 1/12/23, at 9:59 a.m., with Resident 1, Resident 1 was sitting in a wheelchair in her room. Resident 1 stated, on the morning of 12/30/22, she told Licensed Vocational Nurse (LVN) 1 she felt constipated. Resident 1 stated, on 12/30/22, around 3:00 p.m., she asked a physical therapist to tell LVN 1 she still felt constipated and had abdominal pain. Resident 1 stated, LVN 1 and RN 1 came into her room and LVN 1 had her hands on her hips. Resident 1 stated, RN 1 and LVN 1 spoke to each other in another language. Resident 1 stated, RN 1 in an angry tone told Resident 1 they could call an ambulance to take her to the hospital for constipation and pain or they could take care of the constipation and pain at the facility. Resident 1 stated, she told RN 1 and LVN 1 she did not think she needed to go to the hospital. Resident 1 stated, RN 1 and LVN 1 put gloves on and rolled Resident 1 to her side. Resident 1 stated, LVN 1 was facing her and holding her shoulder and arms, while RN 1 was on Resident 1's back side. Resident 1 stated, Certified Nursing Assistant (CNA) 1 came into the room. Resident 1 stated, LVN 1 and RN 1 told CNA 1 they needed her hands to hold Resident 1's legs. Resident 1 stated, she asked RN 1 and LVN 1 what they were doing. Resident 1 stated, RN 1 said we are going to get that out of there and put her finger in Resident 1's rectum. Resident 1 stated, she screamed for RN 1 to stop. Resident 1 stated, RN 1 said, . you have hemorrhoids [swollen veins in the anus and lower rectum] . and according to Resident 1, RN 1 shoved her finger up Resident 1's anus. Resident 1 stated, she cried for her to stop, and RN 1 shoved her finger in Resident 1's anus again and turned her finger around inside. Resident 1 stated, CNA 1 left the room after the third time RN 1 put her finger in Resident 1's anus. During a concurrent observation and interview on 1/12/23, at 10:20 a.m., with Resident 1, Resident 1 became tearful and stated, . I cried and cried . I kept telling them no, no, no . Resident 1 stated, she was upset, and later a nurse gave her alprazolam (a medication to treat anxiety and panic disorders). Resident 1 stated, she stayed in bed for five days because she was so upset about the incident. Resident 1 stated, the event was very painful and very emotional. Resident 1 stated, she thought of the event every time she had a bowel movement (BM). Resident 1 stated, a nurse came into her room that looked like LVN 1 and she yelled at her to get out. Resident 1 stated, Medical Doctor (MD) 1 took a picture of her anus when he examined her on 1/4/23 and showed her the picture. Resident 1 stated, the picture indicated her anus was red. During a review of Resident 1's Nursing Progress Notes (NPN), dated 12/30/22, at 4:30 p.m., the NPN indicated, . [alprazolam] Oral Tablet . Give 1 tablet by mouth every 12 hours as needed for . emotional Outburst . During a review of Resident 1's NPN, dated 12/30/22, at 5:30 p.m., the NPN indicated, . PRN [as needed] Administration of [alprazolam] was Ineffective . During a review of Resident 1's NPN, dated 12/31/22 to 1/2/23, the NPN indicated, . 12/31/2022 19:43 [7:43 p.m.] . Restlessness 12/31/20222 23:15 [11:15 p.m.] . PRN Administration [of alprazolam] was: Effective . 1/1/2023 22:07 [10:07 p.m.] . meds [alprazolam] administered d/t [due to] anxiety . 1/2/2023 00:30 [12:30 a.m.] . PRN Administration [of alprazolam] was: Effective . During an interview on 1/12/23, at 11:14 a.m., with the Director of Nursing (DON), physician progress notes for Resident 1 on 1/4/23, including photos taken of Resident 1's anal area were requested. The DON stated, there were no pictures of Resident 1's anal area in Resident 1's medical record taken by the physician. During an interview on 1/12/23, at 11:25 a.m., with LVN 1, LVN 1 stated, on 12/30/22, at the end of her shift, Resident 1 was complaining of abdomen cramping . so I called my supervisor, [RN 1] . LVN 1 stated, Resident 1 asked RN 1 to check her for hemorrhoids and consented to let RN 1 check for hemorrhoids. LVN 1 stated, RN 1 found no hemorrhoids, but a hard stool at the tip of the rectum. LVN 1 stated, RN 1 asked Resident 1 if she wanted the stool removed and Resident 1 said yes. LVN 1 stated, RN 1 flicked the stool out with her finger. LVN 1 stated, Resident 1 was not crying or screaming. LVN stated, after Resident 1 said no, RN 1 stopped. LVN 1 stated, RN 1 gave a suppository (method of delivering medication inserted in the rectum) to soften Resident 1's stool. LVN 1 stated nursing staff was not allowed to remove a stool impaction (a result when stool backs up in the intestine) by digital/finger extraction. During an interview on 1/12/23, at 11:36 a.m., with RN 1, RN 1 stated, Resident 1 complained of abdomen cramping and constipation and consented to let RN 1 look for hemorrhoids. RN 1 stated, she saw a black hard stool at the rectum and asked Resident 1 . if she wanted me to scrape the stool out . RN 1 stated, Resident 1 consented and . I asked Resident 1 to help push . RN 1 stated, she used her finger to push it out. RN 1 stated, she could see more stool and asked the resident if she wanted a suppository to soften the stool. RN 1 stated, nursing staff are not allowed to remove a stool impaction. RN 1 stated, Resident 1 was not crying or screaming. RN 1 stated, she and LVN 1 spoke in a foreign language when positioning Resident 1. During a review of Resident 1's Physician Progress Notes (PPN) by MD 1, dated 1/4/23, the PPN indicated, . Chief Complaint: Follow up visit . [Resident 1] requested help and according to her she had a painful manual disimpaction [use of fingers to remove stool from the rectum] of the stool . Patient and daughter would like to examine the area for injuries / wound . no new injury noted and no active bleeding . During an interview on 1/12/23, at 11:55 a.m., with MD 1, MD 1 stated, the facility did not initially contact him regarding Resident 1's allegation of RN 1 performing a painful digital disimpaction. MD 1 stated, he had a call from the Assistant Director of Nursing (ADON) regarding Resident 1's constipation. MD 1 stated, MD 1 was asked by Resident 1 and Resident 1's daughter to examine Resident 1 during his visit on 1/4/23. MD 1 stated, Resident 1's anal area appeared with non-specific (general) redness. MD 1 stated, he took a picture of Resident 1's anal area on 1/4/23. MD 1 provided a copy of the picture, titled, Media Information (MI), dated 1/4/23, at 10:52 a.m. The MI indicated, Resident 1's name and medical record number. During a review of Resident 1's NPN, dated 1/3/23, at 3:05 p.m., the NPN by the ADON, indicated, . Resident visited in her room, this writer asked her about her bowel movement, she said its [sic] still difficult for her, currently on docusate sodium [a stool softener] 250 mg [milligram, a unit of measure] once daily. [MD 1] made aware via phone and ordered [polyethylene glycol, a laxative and stool softener] 17 grams [unit of measure] 1 packet once daily . During a review of Resident 1's NPN, dated 1/4/23, at 11:51 a.m., the NPN indicated, . Resident is complaining of itchiness to perianal [around anus] area while [MD 1] was examining her. With slight redness noted. order to apply zinc oxide cream [medication to treat skin irritation] for ski [sic, skin] protection and maintenance . During an interview on 1/12/23, at 12:04, with the ADON, the ADON stated, on 12/30/22, in the afternoon, CNA 1 told her she was uncomfortable about Resident 1 who was in pain. The ADON stated, she went into Resident1's room and saw LVN 1 and RN 1 and asked them what happened. The ADON stated, the nurses said they were giving a suppository. The ADON stated, she told CNA 1 the nurses were helping her. The ADON stated she heard Resident 1 straining in constipation, not screaming. During an interview on 1/12/23, at 12:17 p.m., with CNA 1, CNA 1 stated, RN 1 and LVN 1 were in Resident 1's room and asked CNA 1 to help hold Resident 1 down while RN 1 gave a suppository. CNA 1 stated, RN 1 and LVN 1 did not need a third person to give a suppository. CNA 1 stated, she could see RN 1 was digging in Resident 1's rectum with her index finger far up Resident 1's anus. CNA 1 stated, Resident 1 was screaming . no ., . stop . and . ow . over and over, but LVN 1 kept getting new gloves for RN 1 and RN 1 kept digging far up Resident 1's rectum for what seemed like more than five minutes. CNA 1 stated, RN 1 said, . I can feel it up there . CNA 1 stated, after RN 1 probed Resident 1's rectum twice, CNA 1 left the room. CNA 1 stated, as she was leaving, RN 1 said, .it's okay, like having a baby . During an interview on 1/12/23, at 12:20 p.m., with CNA 1, CNA 1 stated, the Assistant Director of Nursing (ADON) came down the hallway outside Resident 1's room and asked who was screaming. CNA 1 stated, she told the ADON Resident 1 was screaming, and RN 1 was sticking her finger in Resident 1's rectum while LVN 1 was holding her down. CNA 1 stated, the ADON looked in Resident 1's room immediately came back out and told CNA 1 the nurses knew what they were doing. CNA 1 stated the ADON did not intervene with the nurses. During an interview on 1/12/23, at 12:25 p.m., with CNA 1, CNA 1 stated, the Director of Nursing (DON) told CNA 1, not to put anything in writing about the event because the state could take legal action. CNA 1 stated, the DON tried to convince her it was okay and told me if we sent her to the hospital, the state would be called on the facility because they did not deal with the impaction at the facility. During an interview on 1/12/23, at 12:25 p.m., with CNA 1, CNA 1 stated, after RN 1 and LVN 1 left Resident 1's room, CNA 1 went to clean up Resident 1 and she could tell there had not been a hard stool as there was soft stool smeared on the linens. CNA 1 stated, she did not think resident was constipated because she remembered changing Resident 1 two days before on 12/28/22 after a BM. CNA 1 stated, she had looked in the electronic medical record and saw Resident 1 also had a stool on 12/29/22, one day before the incident. During a review of Resident 1's Activities of Daily Living (ADLs), dated 12/28/22 to 1/10/23, the ADLs indicated, Resident 1 had a large hard stool on 12/28/22, at 6:35 p.m. The ADLs indicated Resident 1 had a medium-sized normal stool on 12/29/22, at 9:07 p.m. During an interview on 1/12/23, at 12:39 p.m., with LVN 2, LVN 2 stated, on 12/30/22, sometime after 3:30 p.m., she was eleven rooms away and she heard a resident down the hall screaming . no . and . stop . LVN 2 stated, the ADON came out into the hallway and asked who was screaming. LVN 2 stated, CNA 1 told her RN 1 was sticking fingers inside Resident 1's rectum. LVN 2 stated, she told CNA 1 removing impactions was out of the nurse's scope of practice (activities a licensed person is allowed to practice as a health professional). LVN 2 stated, she told CNA 1 the ADON, RN 1 and LVN 1 are all friends, and they will not tell on each other. During an interview on 1/12/23, at 1:47 p.m., with the Activities Assistant (AA), the AA stated, Resident 1 did not want to get up for activities the week of 1/4/23 to 1/11/23. The AA stated, Resident 1 did not want any activities in her room during the same time frame. During a review of Resident 1's Activity Attendance Record (AAR), dated December 2022, the AAR indicated, Resident 1 participated in activities in her room on 12/2, 12/6, 12/9, 12/13, 12/16, 12/20, 12/23, 12/27 and 12/30. During an interview on 1/12/23, at 3:20 p.m., with the ADM, the ADM stated, there was no documentation of activities for Resident 1 for January 2023. The ADM stated, the Activities Director was contacted on the phone and stated Resident 1 refused all activities in January of 2023. During a review of Resident 1's Progress Notes (PN), dated 1/4/23, at 4:38 p.m., the PN by the Social Services Director (SSD), indicated, . SSD stopped by res [resident's] room this afternoon regarding a recent incident on 12/30/22 . Res stated the incident was a traumatic and painful experience, res stated she does not wish to speak about the incident in detail . Res request to no longer have either nurse assigned to her. Admin, DON, ADON made aware . Writer encouraged res to go to the dining room for meals and participate in activities, res declined . Writer offered to have her seen by [name], Psychologist, res agreed and stated it would be helpful, psych eval [psychiatric evaluation] was sent to [psychologist] via fax. No concerns regarding isolative or withdrawn behavior . SS [Social Service] to follow up as needed . During a concurrent interview and record review on 1/12/23, at 3:26 p.m., with the DON, the DON reviewed the facility's Clinical Protocol (CP), titled Bowel Disorders, dated 9/2017. The DON stated, the CP did not instruct nurses to remove bowel impactions. The DON stated, RN 1 and LVN 1 did nothing wrong because they only pushed out a BM at the end of the anus. The CP indicated, . Assessment and Recognition . the nurse shall assess and document/report the following . Presence of fecal impaction . Abdominal assessment . Digital rectal examination . Treatment/Management . The physician will help identify the possible need for hospitalization to manage a gastrointestinal disorder . During a concurrent interview and record review on 1/12/23, at 3:28 p.m., with the DON, the DON reviewed RN 1's Counseling/Disciplinary Notice, dated 1/4/23, and LVN 1's Counseling/Disciplinary Notice, dated 1/4/23. The DON stated, RN 1 and LVN 1 were counseled on the bowel protocol. When asked why RN 1 and LVN 1 were counseled if they did nothing wrong, the DON stated, RN 1 and LVN 1 were counseled to make sure in the future they do not go further than the anus. During an interview on 1/25/23, at 9:47 a.m., with Resident 1, Resident 1 stated, on 12/30/22, she never told RN1 or LVN 1 she thought she had hemorrhoids, nor did she ask RN 1 or LVN 1 to check her for hemorrhoids. Resident 1 stated she had not had hemorrhoids since she had hemorrhoid removal after her children were born. Resident 1 stated on 12/30/22, around 3:00 p.m. when LVN 1 was about to go home, LVN 1 came into her room with her hands on her hips and said, Well, now what do you want? Resident stated she told LVN 1 she was constipated and needed get some medication. Resident 1 stated LVN said, I guess we can call an ambulance. LVN 1 stated she would take care of it and left the room. Resident 1 stated, LVN 1 returned with RN 1. Resident 1 stated, she did not consent to the digital extraction of stool. Resident 1 stated, RN 1 showed her RN 1's pinky finger and LVN 1 stated they were going to stick RN 1's little finger in up her anus. Resident 1 stated, she said No, I'm sore and the nurses rolled her over and pulled down her pants. Resident 1 stated she felt her put her finger in her anus and then . jammed it up Resident 1 stated, she told RN 1 it hurt and screamed for her to stop. Resident 1 stated, RN 1 said, you're full of hemorrhoids. Resident 1 stated, RN 1 . jammed her finger in again and I screamed . Resident 1 stated, later several CNAs told her they could hear her down the hall. Resident 1 stated, she did not feel threatened or afraid until after this incident happened. Resident 1 stated, she asked for RN 1 and LVN 1 not to care for her because she felt threatened by them and fearful of them. During an interview on 1/25/23, at 11:02 a.m., with RN 1, RN 1 stated, LVN 1 called her to assist because Resident 1 complained of abdomen pain and LVN suspected Resident 1 had hemorrhoids. RN 1 stated, she asked Resident 1 if she wanted her to check her rectum for hemorrhoids and Resident 1 said yes. RN 1 stated she used her fore finger to remove the crowning stool (stool emerging at the anus) and ask Resident 1 to push like having a baby because RN 1 had small hands. RN 1 stated, when Resident 1 said to stop, RN 1 stopped. And asked if she wanted to go to the hospital and resident 1 said no. RN 1 stated she did not consider calling the physician regarding abdomen pain and Resident was offered an ambulance before the procedure. During an interview on 1/25/23, at 12:00 p.m., with the ADON, the ADON stated, on Friday, 12/30/23, in the afternoon she came out . to the nursing station to check on something. I overheard a CNA saying she is not comfortable with a resident . Surveyor informed the ADON witnesses stated she came out to the nursing station and asked who was screaming. The ADON stated, . Hold on . let me recollect . I was hearing all kinds of noises . I heard someone crying. A CNA said she was uncomfortable with a resident moaning. I can't remember what else she said . The ADON stated, she went to Resident 1's room and saw RN 1 standing at the side of the bed and LVN 1 standing at the foot of the bed, facing the bathroom. The ADON stated, RN 1 told her they had been giving a suppository. The ADON stated, she went back to console CNA 1 and told her the nurses were helping Resident 1. During an interview on 1/25/23, at 12:28 p.m., with the DON, the DON stated there is no policy and procedure for rectal exams or digital extraction because the nurses do not do them. The DON stated, the nurses only check for hemorrhoids if a resident complains about it and only an external visualization is allowed. The DON stated, for a resident complaint of constipation, first action would be to assess, listen for bowel sounds (abdominal sounds made by the intestines as they push food through), assess for bowel obstruction, use orders for fleets enema or suppository for softening and call the doctor. The DON stated taking the resident to the hospital would be the last resort. During a review of Resident 1's Medication Administration Record (MAR), dated 12/1/22 to 12/31/22, the MAR indicated, magnesium hydroxide (a chemical used to treat constipation)was administered to Resident 1 on 12/30/22, at 10:18 a.m. During an interview on 1/26/23, at 8:41 a.m., with LVN 1, LVN 1 stated, on the morning of 12/30/22, Resident 1 stated she could not have a BM and she gave Resident 1 magnesium hydroxide. LVN 1 stated in the afternoon someone called her again about Resident 1. LVN 1 stated, Resident 1 complained of abdominal pain and mentioned she might have hemorrhoids. LVN 1 stated, RN 1 asked Resident 1 if she wanted to go to the hospital for the pain and Resident 1 said no. LVN 1 stated, . we offered going to the hospital first because I was focused on abdomen pain first . LVN 1 stated, they did not call the doctor because RN 1 performed a nursing intervention by removing stool. LVN 1 stated, she does not know if the abdominal pain stopped. LVN 1 stated, after the nurses asked going to the hospital, Resident 1 did not talk about the pain again. LVN 1 stated, the nurses did not give Resident 1 any pain medication on 12/30/22. Regarding Resident 1 screaming for at least five minutes. LVN 1 stated, . I don't think so. I know she probably screamed during the stool removal . During a review of the facility's Policy and Procedure (P&P), titled Abuse Prevention Program, dated 12/1/22, the P&P indicated, . to promote an environment free from any form of resident abuse . mistreatment . Abuse- willful infliction of injury . intimidation, or punishment with resulting physical harm, pain, or mental anguish . Type of Abuse . 'Mental Abuse' - is the use of verbal or nonverbal conduct which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation, or degradation . During a review of a professional reference titled, Digital Rectal Exam (DRE), dated 9/26/22, retrieved from https://my.clevelandclinic.org/health/diagnostics/24212-digital-rectal-exam, the DRE indicated, . Several healthcare providers [physicians] may perform a DRE [digital rectal exam] . During a review of a professional reference titled, Digital Disimpaction and How It's Done (DDHIT), dated 1/11/22, retrieved from https://www.verywellhealth.com/digital-evacuation-1945037, the DDHIT indicated, . Digital disimpaction is not a recommended treatment for constipation unless the condition cannot be relieved by other methods . risk of injury, including anal fissures [tear of the moist tissue around the anus] or rectal perforation [hole formed by piercing] , as well as hemorrhoids and infection . During the review of a professional reference titled, American Nurses Association Code of Ethics for Nurses (ANACEN), dated 2015, retrieved from https://nursing.[NAME].edu/wp-content/uploads/2019/06/ANA-Code-of-Ethics-for-Nurses.pdf, the ANACEN indicated, . The nurse practices with compassion and respect for the inherent dignity, worth, and unique attributes of every person . The nurse promotes, advocates for, and protects the rights, health, and safety of the patient .

Based on observation, interview, record review, the facility failed to ensure the Certified Dietary Manager (CDM) fulfilled her job responsibilities of daily kitchen oversight when: 1. The CDM failed to monitor daily kitchen operations to ensure a) food safety guidelines and standards of practice were followed; b) effective supervision of kitchen employees was conducted; c) proper preparation of pureed items; d) meal palatability and food was prepared to conserve nutrients; e) resident food preferences and intolerances were followed, and f) kitchen equipment was in safe working order (Cross reference to F812, F802, F803, F804, F806, and F908). 2. The CDM delegated daily departmental oversight responsibilities to Cook 1, who was not trained or qualified to perform the duties of a CDM. Cook 1 performed the CDM's job duties 40 hours weekly which included but not limited to; ordering food, visitation of residents for food preferences, attending care plan meetings, and providing instruction and guidance to food service employees. 3. Cook 2, who was responsible for preparing two meals a day, five days a week, was not competent in adequate hand washing, preventing cross contamination of food, cleaning, sanitizing and storage of food preparation equipment, manual washing of cookware used for resident food preparation, proper testing of the kitchen sanitizing solution, preparing puree food items according to the recipe, ensuring the resident food was prepared in a manner which maintained the nutritional value of resident meals and resident meals were palatable (Cross reference to F802, F803, F804, and F812). 4. The Registered Dietitian (RD) did not provide effective oversight of the kitchen operations. 5. The facility Administrator was not aware that an unqualified, untrained employee was performing CDM's managerial duties on a fulltime basis and the CDM was not fulfilling her job responsibilities. These failures to ensure the CDM fulfilled her job responsibilities resulted in exposing 76 of 76 residents (17 sampled residents and 59 non-sampled residents), who received food prepared in the kitchen, to practices with the potential to result in food borne illness, bacterial cross contamination, poor meal quality, decreased meal satisfaction and compromised resident nutritional status including but not limited to weight loss. Due to the lack of daily oversight and monitoring of the food service operations by qualified personnel that could cause serious potential harm of food borne illnesses, an Immediate Jeopardy (IJ- a situation in which the facility's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death to a resident) situation was called on [DATE] at 5:24 p.m., under Code of Federal Regulations (CFR) S483.60 Staffing (F801) with the Administrator, (ADM) the Director of Nursing (DON), Assistant DON (ADON), Infection Preventionist (IP), Certified Dietary Manager (CDM), and the Staffing and Recourse Nurse in attendance. The IJ template was provided to the ADM. The facility submitted an acceptable IJ Plan of Removal (Version 3) on [DATE], at 5:42 p.m. The IJ Plan of Removal included but was not limited to the following: 1) As of [DATE] the current CDM will resume her role as outlined in the job description to include, but not limited to: planning, controlling, coordinating, directing, and evaluating all aspects of food service, along with data collection for clinical charting, MDS (Minimum Data Set - a comprehensive assessment used for screening, clinical and functional status elements for nursing home residents) participation, and care planning, as well as begin routine monitoring of the kitchen operations to ensure food safety guidelines are met. - Directing the food service operation following the facility and Dietary Policy and Procedure Manuals, - Developing and writing schedules for dietary staff, supervising the preparation of food and food service for the resident meals according to established menus and standardized recipes, ensuring food is prepared by methods that conserve nutritional value and is palatable and attractive to residents, purchasing food and supplies according to the facility menu and remains within the budgetary guidelines established by the facility and maintains all cost records as required by administration, - Participating in planning and conducting departmental meetings and in-service education, - Ensuring sanitation and safety standards are maintained according to State, Federal, and local regulations, maintains all dietary records, i.e.: temperature records, tray cards, profiles, nutritional assessments, MDS, care plans, etc., - Coordinates and gathers the information required by the Registered Dietitian i.e.: resident weights, skin report, facility admissions, dietary consults, enteral feedings, etc., - Participates in charting responsibilities as requested by facility and Registered Dietitian, - Ensures residents receive the proper food items to meet their dietary need and that food is served at the appropriate temperature for safety and palatability, - Participates in IDT (Interdisciplinary Team) meetings and conferences as requested by the facility, - Communicates with Registered Dietitian regularly and as requested by the Administrator or Director of Nursing, - Performs other duties assigned by the Administrator. The CDM will conduct daily Food Service Sanitation (FSS) Kitchen checks using the California Association of Healthcare Facilities (CAHF) Daily Supervisor Rounds Checklist and will include staff interviews which will be reviewed with the Administrator daily (Monday-Friday) to begin on [DATE] for 30 days. If any line item(s) are not met, item(s) will be reviewed, and corrective action implemented for continued monitoring. At the completion of 30 days, if threshold of 90% is not met, additional daily FSS Kitchen checks will continue for 30 days and then be re-evaluated. A Performance Evaluation of the CDM utilizing the facility form will be conducted by the Regional Administrator, on [DATE] and at the completion of the 30 days referenced above to include duties as written in the job description (Threshold: Meets Standards). The Registered Dietitian will conduct a bi-monthly sanitation inspection and review with the Administrator. The Administrator will conduct a bi-monthly Administrator Kitchen Inspection Checklist and review findings with the Registered Dietitian. The Registered Dietitian using the Competency Checklist for Food Service Workers, will complete competencies of all kitchen staff beginning today, [DATE], through [DATE]. Any areas identified requiring improvement will result in 1:1 in-service with staff member with return demonstration to ensure competency is met. By [DATE], all food service workers will be reevaluated by the Registered Dietitian using the Competency Checklist for Food Service Workers. The findings from the daily FSS Kitchen checks and the bi-weekly Dietary Manager Kitchen Inspection Checklist will be discussed at the monthly QA meeting for three months or until substantial compliance is met (Threshold: 90%). 2) As of [DATE] Cook 2 was replaced with a qualified dietary cook (Cook 1). Cook 1 will prepare breakfast and lunch 5 days per week. Cook 1 was an experienced cook when hired on [DATE]. Cook 1's last competency evaluation was [DATE]. 3) The fulltime a.m. Cook (Cook 2) was removed from her duties effective immediately and did not cook breakfast on [DATE]. Cook 2 verbally resigned from her position on [DATE] at 11:00 am. 4) Upon investigation, it was determined that Cook 1's recent duties had evolved over several years, but her job description was not updated to reflect changes or additions to her role. The Administrator reviewed the Dietary Department Job Descriptions/Duties, and it has been determined that the assigned role of Cook 1 was never reclassified to reflect her recent duties. As of [DATE], the Cook 1 has resumed her designated role as cook. All duties defined in her job description upon hire have been reviewed and acknowledged. Systemic problems that occurred resulting in the employment of a cook who did not perform to sanitary standards/expectations are as follows: COVID-19 Pandemic, staffing shortages, failure of Dietary Manager to conduct timely competencies, and failure of the Dietary Manager to provide direct oversight/supervision. The components of the IJ Plan of Removal were validated through observations, interviews, and record review. The IJ was removed on [DATE] at 5:53 p.m. with the ADM in attendance. Findings: During a review of the professional reference obtained from https://www.foodsafety.gov/food-poisoning, downloaded [DATE], indicated, food poisoning or foodborne illnesses can affect anyone who eats food contaminated by bacteria, viruses, parasites, toxins, or other substances. During a review of the professional reference obtained from https://www.foodsafety.gov/people-at-risk/older-adults downloaded [DATE], indicated certain groups of people are more susceptible to foodborne illness. This means they are more likely to get sick from contaminated food and, if they do get sick, the effects are much more serious. Older adults residing in nursing homes are ten times more likely to die from bacterial gastroenteritis than the general population. This increased risk of foodborne illness is because organs and body systems go through changes during aging. These changes include: the gastrointestinal tract holds on to food for a longer period, allowing bacteria to grow; the liver and kidneys may not properly rid bodies of foreign bacteria and toxins; the stomach may not produce enough acid. The acidity helps to reduce the number of bacteria in our intestinal tract. Without proper amounts of acid, there is an increased risk of bacterial growth; underlying chronic conditions, such as diabetes and cancer, may also increase a person's risk of foodborne illnesses. 1. During the tour of the kitchen between [DATE] at 8:22 a.m. and [DATE] at 4:24 p.m. the following was observed: a. Proper hand washing was not performed by Cook 2 after a trash can was touched, b. Cross contamination was not prevented when a measuring scoop was stored inside a food bin, c. Expired food items (three bags of cabbage and five bags of corn tortillas) were available for use and not discarded, d. Leftover potatoes were observed in the walk-in refrigerator and not cooled down safely, e. More than five steam table pans, two small and one large frying pans had thick dark brown residue on the insides of the pans, four cutting boards were heavily marred, the can opener blade was brown and worn, f. The meat slicer, mixer, can opener and a weighing scale were visibly dirty and not clean, g. Three food items in plastic bins were not labeled and did not have open dates, h. Milk was stored in crates on the floor of the walk-in refrigerator, i. Cook 2 stored more than five steam table pans wet and not inverted, j. The walk-in refrigerator door, knife rack and a plastic container with clean divided plates were visibly dirty and not clean, k. Two kitchen brooms were stored on the floor, l. A beverage that belonged to an employee was stored in the walk-in freezer, m. Puree recipes were not followed, n. Kitchen equipment was not in safe working order when the walk-in freezer had excessive ice build-up, the walk-in refrigerator door was not flush with the door jamb exposing a gap, and the temperatures on the oven dial were worn off and not legible, o. Resident 80's food preferences and intolerances were not followed, and p. Resident food was not prepared to provide palatability and conserve nutritive value. a. During an observation on [DATE], at 8:25 a.m., in the kitchen, Cook 2 was washing steamtable pans and placing them in the rinse sink. Cook 2 touched the trash can then grabbed a rag out of the sanitation bucket and started sanitizing the counter tops. Cook 2 then returned to the rinse sink and started removing the steam trays from the rinse sink. During an interview on [DATE], at 8:38 a.m., with Cook 2, Cook 2 stated, touching the trash can and then sanitizing counters was not the facility's process. Cook 2 stated, You need to wash your hands after touching the trash can. During an interview on [DATE], at 4:29 p.m., with Certified Dietary Manager (CDM), CDM stated, that if kitchen staff touched a trash can, they would need to wash their hands after. CDM stated, staff must wash hands anytime the hands become contaminated (having been made impure by exposure to something) to prevent cross contamination (the process by which bacteria or other microorganisms are unintentionally transferred from one thing to another with harmful effect). CDM stated her last in-service on handwashing was in 2021. CDM stated, she did not have an in-service on handwashing for 2022. During a review of the facility's Policy and Procedure (P&P) titled, SANITATION AND INFECTION CONTROL SUBJECT: DISHWASHING PROCEDURES (DISHMACHINE), dated 2018, the P&P indicated, . the employee must wash hands thoroughly before handling clean dishes, trays and carts . During a review of the professional reference titled, USFDA [United States Food and Drug Administration] Food Code, dated 2017, the USFDA Food Code indicated, . Section ,d+[DATE] . When to Wash, food employees shall clean their hands . after engaging in other activities that contaminate the hands . b. During an interview on [DATE], at 8:24 a.m., with CDM, CDM stated, it was the facility's practice to not store scoops inside bins. During an observation on [DATE], at 10:19 a.m., in the kitchen, Cook 2 was preparing to puree (a smooth creamy substance made of liquidized food) food items for the lunch meal on top of a cart. Cook 2 had a plastic bin that contained thickener (a substance added to a liquid to make it firmer) on the top of the cart. Cook 2 used a metal measuring scoop stored inside the plastic bin to scoop up the thickener. Cook 2 added thickener to the food multiple times. Cook 2 placed the measuring scoop on the top of the cart more than two times before placing it back into the plastic bin. During a concurrent observation and interview on [DATE], at 3:10 p.m., with Cook 3, in the kitchen, there was a plastic bin containing thickener and a measuring scoop stored inside of it. Cook 3 stated, measuring cups should not be stored inside of the plastic bin. During a review of the facility's policy and procedure (P&P) titled, SANITATION AND INFECTION CONTROL SUBJECT: CLEANING SMALL APPLIANCES/EQUIPMENT, dated 2018, the P&P indicated, . Food Storage Bins . The scoop should be stored outside the bins in a designated area . c. During an observation on [DATE], at 8:24 a.m., in the kitchen, the walk-in refrigerator and the dry storage room were observed. The walk-in refrigerator had three bags of cabbage with expiration dates of [DATE]. The dry storage room was 82 degrees Fahrenheit (F) and had five bags of corn tortillas with manufactures date of [DATE]. The tortillas had no received date or expiration date on them. During an interview on [DATE], at 8:24 a.m., with CDM, CDM stated, she did not know when the tortillas were received. During an interview on [DATE], at 10:27 a.m., with CDM, CDM stated, the cabbage should have been discarded. During a concurrent observation and interview on [DATE], at 9:35 a.m., with Cook 1, in the dry storage room, the five bags of tortillas were stored with a verified received date sticker of [DATE]. Cook 1 stated, the process at the facility was food needed to be dated if it was removed from the original box it came in. Cook 1 stated, five bags of tortillas had received date of [DATE]. Cook 1 stated, if tortillas were not dated, she would look at the facility's shelf-life (the length of time for which an item remains fit for consumption) list. Cook 1 stated, tortillas were not listed on the facility's shelf-life list. During an interview on [DATE], at 10:44 a.m., with CDM, CDM stated, the shelf life for corn tortillas was 45 days from the manufactures date per [brand name] website. CDM stated that the tortillas were expired. d. During a concurrent observation and interview on [DATE], at 8:22 a.m., with CDM, in the walk-in refrigerator, there was a zip lock bag with sliced potatoes with a date that was not legible. CDM stated, the zip lock bag contained leftover cooked potatoes from [DATE]. CDM stated, a resident requested cooked potatoes twice a day. During an interview on [DATE], at 3:10 p.m., with Cook 3, Cook 3 stated, the facility did not save leftovers. Cook 3 stated, the facility's process was not to re-heat food for safety reasons. During an interview on [DATE], at 9:36 a.m., with Cook 1, Cook 1 stated, the facility's practice was to prepare food same day the resident was eating it and not keep leftovers. Cook 1 stated, if facility was to keep leftovers a record of that food should be documented on the facility's cooling log. During an interview on [DATE], at 1:04 p.m., with CDM, CDM stated, the cook made a batch of potatoes for three days. The leftover portion of potatoes would be refrigerated and used for the next meal. The CDM stated she has not kept a record of pre-made potatoes on the cooling log. During an interview on [DATE], at 2:15 p.m., with Registered Dietician (RD) 1, RD 1 stated, she had not seen any leftovers kept at the facility. RD 1 stated, she was not aware facility was keeping leftovers. RD 1 stated, if facility was keeping leftovers the leftovers would need to be cool downed properly. During a review of the facility's COOLING/CHILLING TEMPERATURE CONTROL LOG, dated [DATE] through [DATE], the COOLING/CHILLING TEMPERATURE CONTROL LOG indicated, no record of sliced potatoes. During a review of the facility's (P&P) titled, FOOD PREPARATION SUBJECT: FOOD PREPARATION, dated 2018, the P&P indicated, . Leftovers must be refrigerated immediately utilizing cool down log, covered labeled and dated . e. During a concurrent observation and interview on [DATE], at 8:22 a.m., with CDM, there were more than five steam table pans with thick dark brown residue (amount of something that remains after the main part has gone or been used) on the inside and outside of the pans. Two small and one large frying pans had thick dark brown residue on the insides of the pans. Four cutting boards were heavily marred. The can opener blade was brown and worn. CDM stated, the pans with the dark brown residue were not acceptable to cook with and should be replaced. CDM stated, the cutting boards needed to be replaced. CDM stated, the can opener blade was worn. During a concurrent observation and interview on [DATE], at 10:35 a.m., with CDM, in the kitchen, there was one rubber spatula with a chip in the rubber area. CDM stated, the spatulas needed to be discarded. During a review of the professional reference titled, USFDA Food Code, dated 2017, the USFDA Food Code indicated, . ,d+[DATE].11 Food-Contact Surfaces. (A) Multiuse FOOD- shall be: CONTACT SURFACES (1) SMOOTH; (2) Free of breaks, open seams, cracks, chips, inclusions, pits, and similar imperfections . During a review of the professional reference titled, USFDA Food Code, dated 2017, the USFDA Food Code indicated, . Section ,d+[DATE].12 Cutting Surfaces, surfaces such as cutting blocks that are subject to scratching and scoring [cut or scratch] shall be resurfaced if they can no longer be effectively cleaned and sanitized, or discarded if they are not capable of being resurfaced . f. During a concurrent observation and interview on [DATE], at 8:24 a.m., with CDM, in the kitchen, the meat slicer was covered with a plastic bag. CDM stated, if equipment was clean then it would be covered with a plastic bag. The bag covering the meat slicer was removed. The meat slicers' blade and grip had a brown sticky substance. CDM stated, the brown substance should not be on the meat slicer. CDM stated, the meat slicer was not cleaned appropriately. CDM stated, the meat slicer should be disassembled and sanitized. During a concurrent observation and interview on [DATE], at 8:24 a.m., with CDM, in the kitchen, the can opener blade was worn and brown. The can opener and can opener base had a brown sticky residue that transferred to the hand when touched. CDM stated, the can opener and can opener base was not clean. During a review of [DATE] DAILY CLEANING SCHEDULE SAMPLE FORM dated [DATE] through [DATE], the [DATE] DAILY CLEANING SCHEDULE SAMPLE FORM indicated, . ITEM . Slicer . RESPONSIBLE PARTY . Cooks . INITIALS AND DATE . Form was dated and signed off (documentation by staff that something was completed) for days [DATE] through [DATE]. During a review of the facility's P&P titled, CONTROL SUBJECT: SANITIZING EQUIPMENT, FOOD AND UTILITY CARTS, dated 2018, the P&P indicated, . All kitchen equipment and surfaces, which come in contact with food, will be cleaned and sanitized after each use . During a review of the professional reference titled, USFDA 2017 Food Code, dated 2017, the USDA Food Code indicated, Section ,d+[DATE].11 Equipment, Food-Contact Surfaces, Nonfood Contact Surfaces, and Utensils (A): Equipment food-contact surfaces and utensils shall be clean to sight and touch. During a concurrent observation and interview on [DATE], at 8:55 a.m., with CDM, in the kitchen, the mixer was on the counter with a plastic bag covering it. CDM stated, clean equipment was covered with a plastic bag. The plastic bag was removed. The mixer had a white flakey residue on it. CDM stated the mixer was not clean. During a review of [DATE] DAILY CLEANING SCHEDULE SAMPLE FORM dated [DATE] through [DATE], the [DATE] DAILY CLEANING SCHEDULE SAMPLE FORM indicated, . ITEM . Mixer . RESPONSIBLE PARTY . Cooks . INITIALS AND DATE . Form was dated and signed off for days [DATE] through [DATE]. During a review of the facility's P&P titled, SANITATION AND INFECTION CONTROL SUBJECT: CLEANING SMALL APPLIANCES/EQUIPMENT, dated 2018, indicated, . Mixers will be cleaned and sanitized after each use . During a concurrent observation and interview on [DATE], at 10:15 a.m., with CDM, in the kitchen, a rubber spatula with food residue was seen with a melted handle. The CDM stated the rubber spatula was dirty and handle not cleanable and would be discarded. During a review of the professional reference titled, USFDA 2017 Food Code, dated 2017, the USFDA Food Code indicated, Section ,d+[DATE].11 Equipment, Food-Contact Surfaces, Nonfood Contact Surfaces, and Utensils (A): Equipment food-contact surfaces and utensils shall be clean to sight and touch. During a concurrent observation and interview on [DATE], at 8:34 a.m., with Dietary Aid (DA) 2, in the kitchen, a plate was seen on the plate warmer with an orange residue. DA 2 stated, the plate warmer was an area for clean plates. DA 2 stated, the plate with the orange residue was not clean and removed it from the plate warmer. During an interview on [DATE], at 4:29 p.m., with CDM, CDM stated, dishware with food debris would not be clean and should be washed again. CDM stated, dirty dishware should not be placed with clean dishware. During a review of the facility's P&P titled, SANITATION AND INFECTION CONTROL SUBJECT DISHWASHING PROCEDURES (DISHMACHINE), dated 2018, indicated, . All the dishes should be inspected after coming out of dish-machine and if the dishes are not clean then they should be washed again in the dish-machine . During a concurrent observation and interview on [DATE], at 10:15 a.m., with Cook 2, in the kitchen, Cook 2 was slicing meat on the meat slicer. Cook 2 then weighed the slice of meat on a scale. Cook 2 stated that she was slicing turkey for the lunch meal. During a concurrent observation and interview on [DATE], at 9:33 a.m., with Cook 2, in the kitchen, Cook 2 opened a drawer attached to the counter. Cook 2 stated, the drawer contained the scale she used the day before to weigh meat. The weigh scale in the drawer had a sticky residue. During a concurrent observation and interview on [DATE], at 9:35 a.m., with Cook 1, in the kitchen, a weigh scale had sticky residue on it. Cook 1 stated, when the scale is stored in the drawer it should be stored clean. Cook 1 stated, the scale was not clean and was sticky. Cook 1 removed the weigh scale from the drawer and started cleaning it. During a review of the facility's P&P titled, FOOD PREPARATION SUBJECT: FOOD PREPARATION, dated 2018, the P&P indicated, . utensils and equipment will be cleaned and sanitized after each use . During a review of the professional reference titled, USFDA Food Code, dated 2017, the USFDA Food Code indicated, . Section ,d+[DATE].11 Equipment, Food-Contact Surfaces, Nonfood Contact Surfaces, and Utensils (A): Equipment food-contact surfaces and utensils shall be clean to sight and touch . During a review of the professional reference titled, USFDA Food Code, dated 2017, the USFDA Food Code indicated, . ,d+[DATE].13 Non-FOOD CONTACT SURFACES of EQUIPMENT shall be cleaned at a frequency necessary to preclude accumulation of soil residues . g. During a concurrent observation and interview on [DATE], at 8:22 a.m., with CDM, in the dry storeroom, a plastic bin of brown rice was not labeled or date listed. A plastic bin of dried potato was not labeled or dated. CDM stated she was unable to find a label or date for the brown rice or dried potato. During a concurrent observation and interview on [DATE], at 10:37 a.m., with CDM, in the kitchen, a clear plastic bin was seen with a white substance inside. The bin had no label or date on it. CDM stated, the white substance inside the bin was thickener. CDM stated, the bin should have been labeled and dated. During a review of the professional reference titled, USFDA Food code, dated 2017, the USFDA Food Code indicated, . Commercially processed food . Marking the date or day the original container is opened in a FOOD ESTABLISHMENT, with a procedure to discard the FOOD on or before the last date or day by which the FOOD must be consumed on the premises, sold, or discarded . h. During a concurrent observation and interview on [DATE], at 8:24 a.m., with CDM, in the walk-in refrigerator, crates used to store milk were on the floor. CDM stated, it was the facility's practice to store the milk in crates on the floor. During a review of the professional reference titled, USDA Food Code, dated 2017, the USDA Food Code indicated, . Section ,d+[DATE].11, Foods should be stored six inches above the floor . i. During an observation on [DATE], at 8:25 a.m., in the kitchen, Cook 2 was washing steam table pans and placing them in the rinse side of the sink. During a concurrent observation and interview on [DATE], at 8:57 a.m., with Cook 2, in the kitchen, Cook 2 placed a stack of washed stacked steam table pans on a clean rack. The seven steam table pans were wet, stacked together and not inverted. One of the seven pans had food debris. Cook 2 stated, the practice was to air dry the steam table pans and store them inverted once they were dry. Cook 2 stated, the steam table pans were not stored correctly. Cook 2 stated, she usually stored them inverted. Cook 2 stated, one of the steam table pans was not clean. Cook 2 removed the seven pans from the clean rack. During a review of the facility's P&P titled, SANITATION AND INFECTION CONTROL SUBJECT: DISHWASHING PROCEDURES (DISHMACHINE), dated 2018, indicated, . All dishes should be inspected after coming out of the dish-machine and if the dishes are not clean then they should be washed again in the dish-machine. Allow racks of dishes . to air dry . Do not rack and stack wet dishes . allow dishes to drain thoroughly and air dry after washing . During a review of the professional reference titled, USFDA Food Code, dated 2017, the USFDA Food Code indicated, . Section ,d+[DATE].11 Equipment, Food- Contact Surfaces, Nonfood Contact Surface, and Utensils, the food- contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations; Nonfood- contact surface of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris . During a review of the professional reference titled, USFDA Food Code, dated 2017, the USFDA Food Code indicated, . Section ,d+[DATE].11, Equipment and Utensils, Air Drying Required, after cleaning and sanitizing, equipment and utensils: (A) Shall be air-dried . j. During a concurrent observation and interview on [DATE], at 8:24 a.m., with CDM, in the kitchen, there was a black sticky substance on the walk-in refrigerator door. The black sticky substance obscured (keep from being seen) the color and texture of the door. The black sticky substance when touched with a hand would transfer onto the hand. CDM stated, the walk-in door was not clean. CDM state,d the walk-in door should be cleaned. The walk-in refrigerator had food debris, a package of (brand name) snacks and food wrappers on the floor under the racks. CDM stated, the floor should be free of trash and food. During a concurrent observation and interview on [DATE], at 8:36 a.m., with DA 1, in the kitchen, a plastic container containing clean divided plates had food debris and white/yellowish dried substance at the bottom of the container. DA 1 stated, the container was used to store clean divided plates. DA 1 stated, the container was not clean. DA 1, stated the facility's practice was to clean the plastic container every couple of days. DA 1 removed the plastic container. During a concurrent observation and interview on [DATE], at 9:33 a.m., with Cook 1, in the kitchen, the knife rack had white, beige and brown particles on the top of it. Knives were stored on the rack. Cook 1 stated, the knife rack was used to store clean knives. Cook 1 stated, the rack was not clean. Cook 1 stated, it should have been wiped and sanitized. During an interview on [DATE], at 4:29 p.m., with the CDM, the CDM stated, dishware with food debris was not be clean and should have been washed again. CDM stated, dirty items should not be placed with clean dishware. During a review the professional reference titled, USDA Food Code, dated 2017, the USDA food Code indicated, . ,d+[DATE].13 Non-FOOD CONTACT SURFACES of EQUIPMENT shall be cleaned at a frequency necessary to preclude accumulation of soil residues . k. During a concurrent observation and interview on [DATE], at 8:22 a.m., with CDM, in the sanitation closet, two brooms were touching the floor. CDM stated, the brooms should not be on the floor. CDM stated, the brooms should be hung up so they do not touch the floor. During a review of the professional reference titled, USFDA Food Code, dated 2017, the USFDA Food Code indicated, . 501.113 Storing Maintenance Tools . Maintenance tools such as brooms, mops, vacuum cleaners, and similar items shall be: (A)Stored so they do not contaminate FOOD, EQUIPMENT,UTENSILS, LINENS, and SINGLE-SERVICE and SINGLE-USE ARTICLES; and (B) Stored in an orderly manner that facilitates cleaning the area used for storing the maintenance tools . l. During a concurrent observation and interview on [DATE], at 8:22 a.m., with CDM, in the walk-in freezer, a white foam cup containing a beverage without a date was on a shelf. CDM stated, the cup belonged to an employee and should not have been stored in the walk-in freezer. During a review of the professional reference titled, USFDA Food Code, dated 2017, the USFDA Food Code indicated, . Section ,d+[DATE].11 Designated Areas, (B) - lockers or suitable facilities are to be located in a designated area where co [TRUNCATED]

Based on observations, interviews and record review, the facility failed to implement a comprehensive systematic approach to ensure effective monitoring and maintenance of acceptable parameters of nutritional status for three of three sampled Residents (Residents 6, 34, and 79) when: 1. Resident 6 experienced a severe unplanned weight loss of 21 pounds (lbs.) equivalent to 11.8% of total body weight according to weights obtained from 5/13/22 to 8/8/22. Certified Nursing Assistant (CNA) staff obtained weights, but Nursing Staff did not communicate the weight loss to the Physician or Registered Dietitian (RD) until 8/7/22. On 8/7/22, RD 1 noted a nine-pound weight loss (5.4%) for one month but did not note the 21 pound loss over 3 months. RD 1 did not communicate the weight loss or her recommendations to the Interdisciplinary Team (IDT, a healthcare approach that integrates multiple disciplines through collaboration). On 8/16/22, the IDT team noted an 11-pound weight loss from weights obtained from 7/6/22 to 8/8/22 and recommended a referral to RD 1. Nursing staff did not implement the RD's written recommendations for 8/7/22. Nursing staff did not report the recommended RD interventions to the physician. 2. Resident 34 experienced a severe unplanned weight loss of 22 pounds (13.5%) from weights obtained from 2/1/22 to 8/2/22. RD 3 noted weight loss of 15 pounds (8.4%) over 3 months on 2/6/22 and did not recommend individualized interventions to address the weight loss. RD 4 noted continued weight loss on 4/15/22 and made recommendations. The IDT did not implement RD 4's recommendations. 3. Resident 79 experienced a severe unplanned weight loss of 13.2 pounds (10%) over three months, from 5/10/22 to 8/16/22 and weight loss of 12.2 pounds (11%) over six months, from 3/3/22 to 8/16/22 and no RD consult or recommendations were made. These failures resulted in Residents 6, 34 and 79's decline in nutritional status leading to severe weight loss and the potential for compromised clinical status, fatigue, loss of muscle mass, susceptibility for infection and possibly death. Findings: 1. During a record review of the document titled, Admission Record (AR) dated 6/7/22, for Resident 6, the AR indicated, Resident 6 was a [AGE] year old male with diagnoses of Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements), muscle weakness, embolism (obstruction of an artery) and thrombosis (clotting of blood) of deep veins of left lower extremity (leg), anxiety, gastro-esophageal reflux disease (GERD, a condition in which acidic gastric fluid flows backward into the esophagus), depression, anxiety, and heartburn. During a record review of Resident 6's Minimum Data Set (MDS, a resident assessment tool used to identify resident cognitive and physical function), dated 8/5/22, the MDS assessment indicated, Resident 6's Brief Interview for Mental Status (BIMS, an assessment used to identify a resident's current cognition) score was 14 out of 15, which indicated Resident 6 was cognitively intact. During a record review, of Resident 6's MDS Section G Functional Status (Section G), dated 8/5/22, indicated Resident 6 ate with . supervision-oversight, encouragement, and cueing . and need assistance . setup help only . During an interview on 8/23/22, at 9:20 a.m., with Resident 6, Resident 6 stated he had lived at the facility for one year, five weeks and 2 days. Resident 6 stated the facility's food is not good. During concurrent interview and record review on 8/26/22, at 12:03 p.m., with Registered Dietitian (RD) 1, RD 1 reviewed the document titled, Weights and Vital Summary (WVS) for Resident 6, dated 1/1/22 to 8/31/22. RD 1 verified the following weights and dates for Resident 6: 5/13/22 178 lbs. 6/8/22 171 lbs. 6/13/22 171 lbs. 6/18/22 171 lbs. 7/6/22 168 lbs. 8/1/22 159 lbs. 8/8/22 157 lbs. RD 1 verified the weight loss from 5/13/22 to 8/8/22 was 21 pounds, indicating an 11.8% weight loss over 3 months. During a concurrent interview and record review on 8/26/22, at 12:03 p.m., with RD 1, RD 1 reviewed Resident 6's Progress Notes Dietary Note (PNDN), dated 8/7/22. RD 1 verified the PNDN indicated, . Res [Resident] was tested positive for covid [COVID-19, a respiratory virus caused by the SARS-CoV-2] on 7/29. Res is a/o [alert and oriented] x3 [to person, place, and time] and is able to make needs known. Res average po [oral] intake ~ [approximate] 75%. Res has improved po intake from last week . Per snf [Skilled Nursing Facility] progress note on 8/2, res had mildly diminished appetite last week. Suspect last week weight loss dt [due to] decreased po intake dt covid + [positive]. Current po meets > 75% of estimated needs for weight maintenance. Weight: 8/1/22 159 lbs 7/6/22 168 lbs Weight change: -9 [pounds] (-5.4% 0 weight change in a month . Nutrition dx [diagnosis]: Unintentional weight loss RT [sic] decreased appetite dt covid + AEB [abnormal Eating Behaviors] -9# (-5.4%) weight change in a month. I [Intervention]: continue poc [plan of care]- If res weight continues to be downward trending, consider a fortified diet and whole milk 4 oz [ounces, a unit of measure] TID [three times a day] with meals . RD 1 stated, she did not know why she did not address a three month weight loss of 21 pounds (11.8%) in her note. RD 1 stated she noticed the one-month weight loss. RD stated, she did not do look back at previous weight loss for a trend. RD 1 stated, she sometimes attended IDT meetings. RD 1 stated, she was only at the facility 2 days per week. RD 1 stated, the nurses notified the physician of weight loss and RD recommendations. During an interview on 8/26/22, at 1:38 p.m., with RD 2, RD 2 stated, she was the Director of Operations of [consulting nutrition company] and RD 1 reported to RD 2. RD 2 stated, if a resident had weight loss in a week, RD 2 would review the weekly weight loss, but review trends in the total weight loss over time to determine contributing factors. RD 2 stated, a RD needed to look at short-term and long-term weight loss when the resident was evaluated. RD 2 stated, there were triggers to evaluate for weekly, monthly, three month and six-month weight loss that had not been performed. During a record review of Resident 6's Care Plan (CP), dated 4/12/21, the CP indicated . Monitor and record food intake at each meal . Monitor and evaluate any weight loss. Determine percentage lost and follow the facility protocol for weight loss . Alert dietitian if consumption is poor for more than 48 hours . If weight decline persist [sic], contact Physician and Dietitian immediately . Inform resident representative/surrogate decision maker of resident's significant weight loss . During a record review of Resident 6's Documentation Survey Report v2 (Intake), dated 5/1/22 to 8/26/22, the Intake indicated, intake was blank for three mealtimes in May, intake was blank for 14 mealtimes in June, and intake was blank for four mealtimes in August. During a concurrent interview and record review on 8/26/22, at 11:41 a.m., with CNA 2, CNA 2 reviewed Resident 79's Intake, dated 7/1/22 to 8/26/22. CNA 2 stated, blank spaces on mealtimes meant the CNA did not record intake. CNA 2 stated, if there was no intake, it should have been marked 0. During a review of the facility's policy and procedure (P&P) titled, Weight Monitoring and Management, dated 1/2019, the P&P indicated, . a Weight Variance Committee . will: -Be responsible for the weight monitoring system. - Ensure that intervention(s) to manage the unplanned and significant weight loss/gain of the resident is appropriate and implemented in a timely manner . RNA [Restorative Nursing Assistant] will provide a copy of the weekly and monthly weight to the Director of Nursing, Dietary supervisor/RD, MDS Coordinator, Administrator and DSD [Director of Staff Development] to monitor weight management . any resident who weighs 100 lbs. or more and with a weight change of 5 lbs. in a week will be evaluated by the Weight Variance Committee to determine causative factors for significant weight change. Intervention will be provided to residents with significant weight loss . Any resident weight that varies reporting period by 5% in 30 days, 7.5% in 90 days and 10% in 180 days will be evaluated by the Interdisciplinary Team to determine the cause of weight loss . Assessment of risk factors for weight change and intervention required . Physician and responsible party will be notified by licensed nurse regarding weight loss . notification will be documented in the medical record . A plan of care addressing the significant weight variance . will be initiated by the Licensed Nurse/Dietary Supervisor/RD upon identification . Registered Dietician or Designee will be responsible for reviewing weight report, recommending any additional nutritional interventions, documenting progress . updating the resident care plan . discussing the weight changes with the Weight Variance Committee . Licensed Nurse will communicate and follow up with attending physician dietary recommendation to manage identified significant weight loss . Residents meeting criteria for significant weight loss . will be weighed weekly . Weekly weight will be reviewed by the Weight Variance Committee to address intervention [sic] that will manage significant weight loss . Director of Nursing Services and the Weight Variance Committee will determine the need to initiate the Weight Risk Note with the Attending Physician to address contributing factors . and intervention to manage . The Interdisciplinary Team will address significant weight change identified during initial, quarterly, and annual assessment . to ensure appropriate intervention . During an interview and record review on 8/26/22, at 4:35 p.m., with Director of Nursing (DON), DON stated, the Weight Variance Committee's (WVC) notes were documented in the medical record in the IDT Notes. DON stated, the WVC consisted of DON, ADON, RD, Administrator, and Director of Activities. During a concurrent interview and record review on 8/26/22, at 5:24 p.m., with Director of Nursing (DON) and Assistant Director of Nursing (ADON), the Progress Note IDT Notes (IDT Note), dated 8/16/22, for Resident 6 was reviewed. DON stated, the IDT Note indicated, Regarding his monthly weight loss of 11 lbs [pounds-unit of measure] from 168 to 157 lbs, IDT reviewed the chart he recent [recently] covid recovered [from covid], recommended Dietitian referral. Resident and MD [Medical Doctor] notified . ADON stated, the DON or ADON notify the physician if there was a significant weight loss or a RD recommendation. DON stated, that he notified the physician and family. The Progress Note Dietary Note (Dietary Note), dated 8/7/22, for Resident 6 was reviewed. DON stated the Dietary Note indicated a nine-pound weight loss (5.4%) in one month from 7/6/22 to 8/1/22. ADON stated, We did not notify the physician on 8/7/22 because we were not aware of the RD note. DON stated the IDT did not review the RD's Dietary Note, but rather utilized the paper the RD provided weekly listing residents with weight loss and RD recommendations. The document, titled RD Recommendations (RDR), dated 8/7/22 was reviewed. DON stated, the RDR listed all the residents with weight variance for the week along with RD recommendations. DON stated, Resident 6 was not listed on the RDR for 8/7/22. ADON stated, the list was given to the Certified Dietary Manager (CDM) who brought it to the IDT meeting. The WVS, dated 1/1/22 to 8/31/22 for Resident 6 was reviewed. DON stated, Resident 6 lost 21 pounds (-11.8%) from 5/13/22 to 8/8/22. DON stated, the WVS was not reviewed at the IDT meeting. During a concurrent interview and record review on 9/6/22, at 2:11 p.m., with DON, the facility policy titled Calculating percentages at Meal Times, dated 2018, was reviewed. DON stated, the policy indicated, . The Food and Nutrition Services department provides the meal percentage charts . for the CNA's [Certified Nursing Assistants] to record the meal intake of each resident . DON stated, the CNAs were to document each meal intake. ADON stated, if staff did not document every meal then there was no documentation. ADON stated, If they don't [document], they don't. During a concurrent interview and record review on 9/6/22, at 2:37 p.m., with RD 1, the Nutrition Screen and Assessment (NSA), dated 2/1/21 for Resident 6 was reviewed. RD 1 stated, the NSA type was indicated as Admission and the query for weight was left blank. RD 1 stated, the NSA indicated, . no weight available to assess BMI [Body Mass Index, a measure of body fat calculated with weight and height], will request from nursing . RD 1 stated, Resident 6's weight was available in the medical record and recorded on 1/22/21. RD stated, the weight was important to complete a NSA. RD 1 stated, if no weight had been available, she used the weight from the hospital or other resources. During a review of the facility's policy and procedure titled, Nutritional Assessment, dated 10/2017, the Nutritional Assessment indicated, . The nutritional assessment will be conducted by the multidisciplinary team and shall identify at least the following components . Usual body weight . Current height and weight . During a review of a professional reference, titled, Weight loss and Parkinson's disease retrieved from https://www.apdaparkinson.org/article/weight-loss-parkinsons-disease/, dated 2022, indicated, . Weight loss has been linked to a poorer quality of life and more rapid progression of PD [Parkinson's Disease] . Inadequate food intake can contribute to malnutrition . malnutrition can subsequently be the cause of increased susceptibility to infection, increased fatigue and increased frailty . During a review of a professional reference titled, Early weight loss in parkinsonism predicts poor outcomes, dated 11/28/17, indicated, monitoring weight and timely dietary interventions to counteract weight loss may significantly improve the outcome of Parkinson's disease patients .,weight loss .,was associated with higher risk of dependency, dementia, and death . During a review of a professional reference, retrieved from https://www.michaeljfox.org/news/ask-md-weight-loss-and-parkinsons-disease, titled, Ask the MD: Weight loss and Parkinson's Disease, dated 11/9/17, indicated, . weight loss in Parkinson's is common, but it's usually mild or, at most, moderate . 2. During a review of Resident 34's Admission Record(AR), dated 1/5/22, indicated, Resident 34 was a [AGE] year old male with diagnoses of hemiplegia (severe or complete loss of strength or paralysis on one side of the body) and hemiparesis (weakness on one side of the body) following a cerebrovascular disease (a group of conditions that affect blood flow to the brain) affecting the right dominant side, chronic obstructive pulmonary disease (COPD, a group of diseases that cause airflow blockage and breathing-related problems), hyperlipidemia (when the blood has too many lipids or fats, such as cholesterol), dementia, epilepsy (a disorder of the brain characterized by repeated seizures), depression, anxiety, atrial fibrillation (irregular and often very rapid heart rhythm that can lead to blood clots in the heart), gastro-esophageal reflux [GERD- when stomach contents and acid rise up into the esophagus], and dysphagia (swallowing difficulties). During a review of Resident 34's MDS, dated [DATE], Section C Cognitive Patterns (Section C), indicated Resident 34's BIMS score was 3 out of 15, which indicated Resident 34 was severely cognitively impaired. During a review of Resident 34's MDS, dated [DATE], Section G Functional Status (Section G), indicated, for eating, Resident 34 needed . Limited assistance-resident highly involved in activity; staff provide guided maneuvering of limbs or other non-weight-bearing assistance . one person physical assist . During a concurrent observation and interview on 8/23/22, at 8:39 a.m., Resident 34 was observed sitting up in bed and fed himself with gray handled weighted utensils (provide additional weight in the handles to help stabilize hand and arm movements for those who experience shaking while eating). Resident 34 stated, he was eating well. During a concurrent interview and record review on 8/26/22, at 11:52 a.m., with RD 1, the WVS, dated 1/6/22 to 8/8/22, for Resident 34 was reviewed. RD 1 verified that the WVS indicated, the following weights and dates for Resident 34: 1/06/22 167 lbs. 1/17/22 171 lbs. 1/24/22 166 lbs. 2/01/22 163 lbs. 2/10/22 164 lbs. 2/14/22 164 lbs. 3/03/22 157 lbs. 3/09/22 157 lbs. 4/08/22 150 lbs. 4/12/22 150 lbs. 4/20/22 148 lbs. 4/25/22 144 lbs. 5/02/22 144 lbs. 5/09/22 148 lbs. 5/17/22 152 lbs. 5/23/22 151 lbs. 5/30/22 151 lbs. 6/06/22 149 lbs. 6/13/22 144 lbs. 6/20/22 144 lbs. 6/27/22 147 lbs. 7/05/22 146 lbs. 7/13/22 145 lbs. 7/19/22 147 lbs. 7/27/22 144 lbs. 8/02/22 141 lbs. 8/08/22 146 lbs. During a review of Resident 34's Progress Notes Dietary Note (Dietary Note), dated 1/29/22, indicated RD 3 noted, . Res with weight loss X 1 week. Eating 25-100% of a mechanical soft, NAS [No added salt], NTL [thickened liquid] diet. Also receives [high calorie, high protein] shakes 4 oz TID [three times a day] with meals. Built up utensils provided to encourage self-feeding, assistance also required . At risk for weight loss d/t varied po intake, dementia, COPD, depression, GERD . Involuntary weight loss r/t varied po intake AEB 5 [pound] (2.9%) weight loss x 1 week . Recommend add [fortified nutritional drink] 4 oz BID . During a review of Resident 34's Order Summary (OS), dated 3/1/22, the OS indicated, (fortified nutritional drink) 4 oz (ounces- unit of measure) two times a day with meals was ordered for Resident 34 on 2/6/22. During a review of Resident 34's Dietary Note, dated 2/6/22, indicated, RD 3 noted, . Wts [weights]: 163# [#-pounds] (2/1), 178# (11/9) . Involuntary weight loss r/t varied po intake AEB 15# (8.4%) weight loss x 3 months . continue plan of care . During a review of Resident 34's IDT Note, dated 3/10/22, indicated, . Monthly weights reviewed. Noted 7 lbs weight loss in a month. Eating between 0-50% of . most meals with occasional refusal at times . No s/sx [signs or symptoms] of dehydration . Resident at nutritional risk . NP informed verbally of resident's weight loss. Will continue to monitor weight . During a review of Resident 34's Dietary Note, dated 4/15/22, indicated RD 4 noted, . Wt [weight] trend: 150 lbs (4/8), 157 lbs (3/9), 167 lbs (1/6),191.2 lbs (10/5) significant wt change: -7 lbs X 1 month, -17 lbs (10%) X 3 months, -41 lbs (21.5%) X 6 months . RD wt review complete d/t sig [significant] wt change . Res continues to tolerate diet as ordered. Averages 50% PO intake and consumes ONS [outside nutritional source, food from outside facility] as ordered . Res is begging to eat in dining room where CNAs and RNAs [Restorative Nursing Assistant] can cue resident and encourage resident to eat more. RD recommends weekly wts to monitor resident more closely . I [interventions]: Increase [fortified nutritional drink] to 120 ml [4 oz] to TID, Offer mech [mechanical] soft snacks TID between meals, Weekly wts monitoring, Resident to eat in dining room with cueing and encouragement from staff . During a review of Resident 34's Order Summary (OS), dated 5/1/22, the OS indicated, [fortified nutritional drink] 4 oz. three times a day was ordered on 4/26/22. The OS indicated, Mech (mechanical) soft snack TID between meals was ordered on 4/26/22. During a review of Resident 34's Dietary Note, dated 4/21/22, the Dietary Note indicated RD 4 noted . RNA reports . res has benefited from RNA dining and having cues to eat and consume ONS. RNA reports that res has begun to verbalize swallowing difficulty. RD recommends SLP [Speech Language Pathologist] evaluation for swallowing and choose safest most upgraded diet texture . During a review of Resident 34's Dietary Note, dated 4/29/22, the Dietary Note indicated RD 4 noted . Wt: 144 lbs . Wt trend: 144 lbs (4/25), 148 lbs (4/20), 150 lbs (3/9), 167 lbs 91/6), 191.2 lbs (10/5) . Significant wt change: -4 lbs X 1 week . PO intake: 50% avg [average] . Res has reported to RNA that he is not tolerating current diet texture. SLP eval [evaluation] is in place to downgrade diet to puree . RD recommends increasing [fortified nutritional drink] to 240 ml [8 oz.] TID . During a review of Resident 34's Order Summary (OS), dated 6/1/22, the OS indicated, [fortified nutritional drink] 8 oz. three times a day was ordered on 5/8/22. During a review of Resident 34's Dietary Note, dated 5/16/22, the Dietary Note indicated RD 3 noted, . usually requires extensive assist with meals . Res with 4# weight gain X 1 week . Involuntary weight loss . 15# (9.2%) weight loss x 3 months and 30#(16.9%) weight loss x 6 months . Continue plan of care . During a review of Resident 34'sDietary note, dated 6/17/22, the Dietary Note indicated RD 4 noted, . Significant weight change: -21 lbs (12.4%) x 6 months . Res maintains PO intake 50% avg with several meal refusals, res may not be tolerating diet as ordered. Refer to SLP for evaluation for proper diet texture . decline in condition . During a review of Resident 34's Dietary note, dated 7/1/22, the Dietary Note indicated RD 4 noted, . Significant wt change: -5 lbs x 1 week, -20 lbs (12%) x 6 months . Res maintains PO intake 50% avg, multiple high calorie ONS ordered to facilitate increased energy intake and minimize risk for wt loss SLP order to evaluate and potentially modify diet texture is in place . Continues downward trend. Consider appetite stimulating medication . Fortify diet . During a review of Resident 34's Order Summary (OS), dated 8/1/22, the OS indicated, Resident 34's diet and dietary supplements remain unchanged from 5/8/22. During a concurrent interview and record review on 8/26/22, at 11:52 a.m., with RD 1, RD 1 reviewed Resident 34's WVS, dated 1/6/22 to 8/8/22. RD 1 stated, Resident 34 lost 21 pounds (12.6%) from 1/6/22 (167 lbs.) to 7/5/22 (146 lbs.). RD 1 reviewed Resident 34's Dietary Note, dated 8/7/22. RD 1 stated, the Dietary Note indicated, . trending downward x 1 month . -3# (-2.1%) weight change in a week; -5# (-3.4%) weight change in a month; -7# (-4.7%) weight change in 3 months . please offer snacks 2 x daily . RD 1 stated, she did not evaluate Resident 34 for overall long-term weight loss because her visit with Resident 34 was triggered by weekly weight loss. RD 1 stated, she did not notify the physician of weight loss. RD 1 stated she wrote the residents weight loss and recommendations on a sheet and gave it to the DON or ADON at the end of the day. During a concurrent interview and record review on 8/26/22, at 11:53 a.m., with RD 1, RD 1 reviewed Resident 34's Dietary Note, dated 7/1/22. RD 1 stated, she did not follow up on the 7/1/22 recommendation for fortified diet and appetite stimulant because that was a different RD's recommendation. The Dietary Note, dated 8/11/22 was reviewed. RD 1 stated, the Dietary Note indicated RD 1 noted, .+5# (+3.5%) weight change in a week . no new nutrition dx [diagnosis] at this time . RD 1 stated, she did not look back at Resident 34's long-term weight loss, as a visit was triggered by weekly weight gain. During a review of Resident 34's Documentation Survey Report v2 (Intake), dated 10/1/21 to 8/31/22, Intake indicated, for the month of January 2022, record of meal intake was blank for 40 mealtimes. Intake indicated, February 2022 had five blank mealtimes; March 2022 had one blank mealtime; April 2022 had five blank mealtimes; May 2022 had six blank mealtimes; June 2022 had eight blank mealtimes; July 2022 had nine blank mealtimes; and August 2022 had 17 blank mealtimes. During a review of Resident 34's Care Plan (CP), initiated on 1/5/22, the CP indicated, . offer snack between meals . was entered on 4/26/22. The CP indicated, . [fortified nutritional drink] 8 oz TID . was entered on 5/8/22. During a concurrent interview and record review on 8/26/22, at 5:24 p.m., with DON and ADON, the WVS, dated 1/6/22 to 8/8/22, for Resident 34 was reviewed. DON stated, the WVS indicated on 7/5/22, Resident 34 had weight loss of 21 pounds (12.6%) for a six-month period. The Dietary Note for Resident 34, dated 7/1/22, was reviewed. DON stated, the Dietary Note indicated, the RD 4 recommended an appetite stimulant and fortified diet. The Registered Dietitian Nutritionist Intervention (RDNI) sheet, dated 7/1/22 was reviewed. DON stated, Resident 34 was not on the RDNI and therefore the IDT was not aware of the recommendation. DON stated, The RDNI is document we use. DON stated, the IDT did not look at the Dietary Notes. ADON stated, Resident 34's name and recommendation were on the RDNI, dated 7/1/22. The RDNI indicated for Resident 34, . Consider appetite stimulating medication . Fortify diet . ADON stated, the IDT did not address the RD recommendation of 7/1/22. During a concurrent interview and record review on 9/6/22, at 3:30 p.m., with DON, DON stated, there was no order for a SLP (Speech-Language Pathologist) evaluation, nor a SLP note in Resident 34's medical record. DON reviewed a document titled, Progress Note, dated 7/4/22 to 7/7/22, indicated, . 7/4/22 . Nurses Notes . Spoke ST [Speech Therapist], resident will be placed on 3 days trial of Pureed NAS [no added salt] diet . [ADON] . e-SIGNED . 7/7/22 . Resident reviewed due to 3 days trial of pureed diet related to wt loss, per nursing staff resident dislikes the food, eats even a little. ST made aware. Previous diet resumed. Dietary informed . [ADON] . e-SIGNED . During a review of a professional reference retrieved from https://www.escardio.org/The-ESC/Press-Office/Press-releases/Loss-of-muscle-and-weight-associated-with-disability-after-stroke titled, Loss of muscle and weight associated with disability after stroke, dated 1/25/19, indicated, . older patients with moderately sever stroke were particularly prone to developing cachexia [weakness and wasting of the body] after stroke, so it is very important to monitor their body weight, appetite and nutritional status . During a review of a professional reference retrieved from https://www.pulmonologyadvisor.com/home/topics/copd/unintended-weight-loss-in-outpatients-with-copd/ titled, Unintended weight loss in outpatients with Chronic Obstructive Pulmonary Disease, dated 6/9/22, indicated, . findings from this study demonstrate the importance of nutritional screening . for patients with COPD who are underweight . 3. During a review of Resident 79's Admission Record (AR), dated 6/27/21, the AR indicated, Resident 79 was a [AGE] year old female with diagnoses of dementia, osteoarthritis (OA- a degeneration of joint cartilage and the underlying bone), asthma (a respiratory condition marked by spasms of the bronchi of the lungs, causing difficulty breathing), anemia (a deficiency of red blood cells leading to lack of oxygen in the blood and fatigue), hyperlipidemia, hypertension (high blood pressure), and anxiety. During a review of Resident 79's MDS, dated [DATE], the MDS indicated, Resident 79's BIMS score was 5 out of 15, which indicated Resident 79 was severely cognitively impaired. During a review of Resident 79's MDS Section G Functional Status (Section G), dated 7/29/22, the Section G indicated, during eating, Resident 79 needed . supervision- oversight, encouragement or cueing . one person physical assist . During a concurrent observation and interview on 8/23/22, at 8:33 a.m., with Resident 79, Resident 79 was observed sitting up in bed with a CNA standing at the bedside. Resident 79 yelled, Don't touch me! Get out of here! I don't want to see you!. CNA respectfully told Resident 79, Okay and moved away. During an observation on 8/23/22, at 1:20 p.m., Resident 79 was sitting up in bed. A lunch tray was set-up by CNA in front of Resident 97. Resident 97 asked for orange juice. During an observation on 8/23/22, at 1:28 p.m., Resident 79 finished orange juice. No staff were at bedside. Lunch tray was uncovered and 100% of meal on tray was untouched. During a concurrent observation and interview on 8/23/22, at 1:41 p.m., Resident 97 was sitting up in bed with eyes closed. 100% of meal was on tray. LVN 9 stated, Resident 97 needed assistance while eating. During an observation on 8/24/22, at 1:15 p.m., Resident 97 was eating assisted by staff. During a concurrent observation and interview on 8/25/22, at 8:47 a.m., CNA 4 was putting away Resident 97's breakfast tray with 100% of meal uneaten. CNA 4 stated, Resident 97 did not want to eat. CNA 4 stated, Resident 97 started fighting CNA 4. CNA 4 stated, the nurse tried to get Resident 97 to eat, but Resident 97 fought with the nurse. During a concurrent interview and record review on 8/26/22, at 11:26 a.m., with CNA 2, CNA 2 reviewed Resident 79's Intake, dated 7/1/22 to 8/26/22. CNA 2 stated, blank spaces on mealtimes meant the CNA did not record intake. CNA 2 stated, if there was no intake, it should have been marked 0. CNA 2 stated, there were a lot of blanks for the resident to not be eating. The Intake nine mealtimes were blank for July 2022 and 14 mealtimes were blank for August 2022 at that time. Six of the 14 blank mealtimes for August 2022 were from 8/7/22 to 8/18/22. During a review of Resident 79's Care Plan, dated 8/10/22, indicated, . monitor meal intake . The Care Plan dated 8/16/22, indicated, . monitor and record food intake at each meal . alert dietitian if consumption is poor for more than 48 hours . During a concurrent interview and record review on 8/26/22, at 11:41 a.m., with RD 1, RD 1 reviewed Resident 79's WVS, dated 1/11/2021 to 8/22/2022. RD 1 stated, the WVS indicated the following weights and dates for Resident 79: 1/11/22 110 lbs. 1/18/22 110 lbs. 1/25/22 109 lbs. 3/09/22 109 lbs. 5/10/22 110 lbs. 6/13/22 108 lbs. 7/06/22 105 lbs. 8/8/22 99 lbs. 8/16/22 96.8 lbs. 8/18/22 97 lbs. 8/22/22 97 lbs. RD 1 stated, Resident 97 experienced a weight loss of 13.2 pounds (-10%) over three months, from 5/10/22 to 8/16/22 and weight loss of 12.2 pounds (-11%) over six months, from 3/3/22 to 8/16/22. During a review of Resident 97's IDT Note, dated 8/16/22, at 10:21 a.m., the IDT Note indicated, . recent weight loss 5.7% resident is COVID recovered, consuming 25-75%, family and MD notified, MD order BID [nutritional shake] . During a concurrent interview and record review on 8/26/22, at 11:42 a.m., with RD 1, RD 1 reviewed Resident 79's Dietary Note, dated 8/16/22, at 1:48 p.m. The Dietary Note indicated, RD 1 noted, . Res started taking [nutritional shake] with meals since 8/16 . weight: 8/8 . 99 . 7/6 . 105 . Weight change: -6# (-5.7%) weight change in a week . BMI: 20.7 low for age . unintentional weight loss rt poor PO intake dt covid and altered mental status . RD 1 stated, the Dietary Note was triggered by the weekly weight loss. RD 1 stated, she addressed monthly weight changes at the end of the month. RD 1 stated, she did not address the long-term weight loss for Resident 97. RD 1 stated, she did not recommend any intervention on 8/16/22 because the physician ordered the [nutritional shake] on that day. RD 1 stated, she wrote any recommendations on the RDNI and gave to the DON and ADON at the end of the day. RD 1 stated, she sometimes attended the weekly IDT meeting, but she was only at the facility two days a week. RD 1 reviewed Resident 79's OS. The OS indicated, [nutritio[TRUNCATED]

Based on observation, interview, and record review, the facility failed to develop and implement policies and procedures to prohibit misappropriation of resident property for one of 19 sampled residents (Resident 19) when the facility Social Services Director (SSD) withdrew funds from Resident 19's bank account without Resident 19's permission and in violation of facility policy. As a result of this failure, Resident 19's personal funds were not protected by the facility and her bank account was debited $2,280.18 dollars without authorization. Resident 19 suffered a loss of trust in facility staff to care for her financial needs and expressed sadness and emotional distress as a direct result of the unauthorized withdrawal of funds. Findings: Review of Resident 19's clinical record titled, Admission Record (document containing resident personal information) indicated Resident 19 was [AGE] years old and was admitted to the skilled nursing facility (SNF) on 7/29/16 with [DIAGNOSES REDACTED]. ), and Generalized Anxiety Disorder (mental disorder resulting in feelings of dread, apprehension and uneasiness). Resident 19's clinical record titled, Minimum Data Set (MDS) (a resident assessment tool used to plan care) dated 10/26/16, indicated Resident 19's Brief Interview for Mental Status score was 15 points out of a possible 15 points which indicated Resident 19 was cognitively (pertaining to judgement, memory and reasoning ability) intact. On 11/22/16 at 9:42 a.m., during an observation and concurrent interview at the SNF, Resident 19 was sitting in a wheelchair. Resident 19 conversed freely and was alert and oriented to person, place and time. Resident 19 stated in early October 2016 she asked the SSD to take her to a nearby Automated Teller Machine (ATM) so that she could withdraw money from her account. Resident 19 stated the SSD had been holding her debit card in the SSD office for safe keeping and on 10/9/16 the SSD accompanied her to the ATM where she withdrew money. Resident 19 stated the SSD stood behind her while she withdrew $200 from the ATM. Resident 19 stated she gave her debit card back to the SSD for safe keeping, but she did not give the SSD her Personal Identification Number (PIN) or permission to use her debit card for purchases. Resident 19 produced three ATM receipts dated 10/9/16 as follows: Date: 10/9/16, Time: 10:46 a.m. Balance from checking: $1728.64 Date: 10/9/16, Time: 10:46 a.m. Balance from savings: $17.00 Date: 10/9/16, Time: 10:48 a.m. Withdrawal from checking Amount Requested: $200.00 Amount Dispensed: $200.00 Terminal fee: $3.50 Total Amount: $203.50 Resident 19 stated on 11/18/16 she received her bank statement dated 10/12/16 to 11/8/16. Resident 19 stated she noticed some withdrawals from her account on the statement that she had not made. Resident 19 stated at approximately 3 p.m. on 11/18/16, she presented her bank account statement for the period of 10/12/16 to 11/8/16 to the facility Administrator (ADM). Resident 19 stated she informed the ADM because she was worried about the many ATM charges that appeared on the bank statement. Resident 19 stated she was aware the SSD had kept her bank card for safekeeping and showed the ADM the many ATM charges on the bank statement that occurred after the withdrawal of money on 10/9/16. Resident 19 stated she had provided no one with the authority to withdraw money from her account and had not authorized anyone to use her bank card at any retailer. Resident 19 provided her bank statement dated 10/12/16 to 11/8/16 and stated the following ATM withdrawals were not done by her except for the recurring charges listed on 11/3/16 totaling $58.65 for insurance and the recurring charge listed on 11/7/16 of $71.34. Resident 19 stated she had not made or authorized the remaining charges on the bank statement indicating a total amount of $1769.68 (including ATM fees of $2.50 for each transaction). The bank statement dated 10/12/16 to 11/8/16 indicated: 10/14/16 303.00 (ATM) 10/17/16 203.00 (ATM) 10/20/16 202.95 (ATM) 10/20/16 22.25 (ATM) 10/21/16 62.00 (ATM) 10/24/16 2.00 (ATM balance inquiry fee) 10/24/16 20.79 (purchase at food and liquor store) 10/24/16 103.50 (ATM) 10/24/16 203.00 (ATM) 10/27/16 30.28 (purchase at clothing store) 10/27/16 14.18 (purchase at liquor store) 10/27/16 42.95 (ATM) 10/28/16 2.00 (ATM balance inquiry fee) 10/31/16 42.25 (ATM) 10/31/16 28.96 (purchase at grocery store) 11/1/16 2.00 (ATM balance inquiry fee) 11/1/16 42.50 (ATM) 11/2/16 15.98 (purchase at variety store) 11/2/16 16.18 (purchase at fast food restaurant) 11/2/16 55.92 (purchase at liquor store with $40 cash back) 11/2/16 10.24 (purchase at liquor store) 11/3/16 32.07 (purchase at fast food restaurant) 11/3/16 28.64 (purchase at food and liquor store) 11/3/16 9.20 (recurring insurance charge authorized by Resident 19) 11/3/16 49.45 (recurring insurance charge authorized by Resident 19) 11/4/16 11.64 (purchase at a convenience market) 11/4/16 41.34 (purchase at a variety store) 11/7/16 2.00 (ATM balance inquiry fee) 11/7/16 71.34 (recurring charge authorized by Resident 19) 11/7/16 103.00 (ATM) 11/8/16 12.81 (purchase at food and liquor store) 11/8/16 82.25 (ATM) Resident 19 stated she was very ill when she was admitted to the SNF on 7/29/16 and the facility Social Services Director (SSD) helped her with her personal affairs and held some of her cash, about $140, in the SSD office as well as her debit card. Resident 19 stated the SSD told her it was the usual practice to lock up a debit card in the SSD office and Resident 19 felt she could trust the SSD with her card. Resident 19 stated after she realized money was missing from her checking account the ADM called the fraud department at the bank and then placed a call to the SSD's home. Resident 19 stated together with the fraud department at the bank she (Resident 19) identified additional withdrawals from her checking account on dates that began before 10/12/16 and after 11/8/16. Resident 19 stated the following amounts withdrawn from her checking account were identified by her and the bank fraud department as unauthorized withdrawals: 10/11/16 - $204.50 11/9/16 - $ 42.25 11/14/16 - $ 143.50 11/14/16 - $ 42.50 11/17/16 - $ 62.75 Resident 19 stated on 11/18/16 the ADM left a message on the SSD's answering machine requesting a return call to discuss problems with Resident 19's bank account. Resident 19 stated the local police department (PD) was contacted on 11/18/16 and an officer contacted her at the facility the morning of 11/19/17. Resident 19 stated the officer took her statement, reviewed available evidence, provided a case number and filed a police report. Resident 19 stated the officer told her approximately $3,000 had been withdrawn from her account without her permission. Resident 19 stated she felt someone at the facility had withdrawn the money and she lost trust in the facility and the facility staff. Resident 19 stated she felt sad and upset that she could not trust the facility staff because she had always felt she had a good relationship with the staff; especially the SSD. Review of Resident 19's document titled, (Bank) Claims Assistance Center dated, 11/21/16, indicated, Subject: Temporary credit for your account ending in (number) .Dear (Resident 19): While we research your inquiry, as a courtesy, we have temporarily credited $2,227.18 to your account above . On 11/22/16 at 11:20 a.m., during an interview, the Assistant Social Services Director (ASSD) stated on 11/18/16 at approximately 4:45 p.m., she was informed by the ADM that Resident 19's bank account had unauthorized withdrawals. The ASSD stated she visited Resident 19 fifteen minutes later and found her to be tearful, emotional, and upset. The ASSD stated Resident 19 expressed that she was very upset because it seemed the SSD had used her debit card to take money from her bank account. The ASSD stated Resident 19 said she felt emotionally hurt because she thought she had a good relationship with the SSD. On 11/22/16 at 1:05 p.m., during an interview, the ADM stated on 11/18/16 at approximately 3 p.m., Resident 19 reported she had discovered withdrawals on her local bank account statement which she had not authorized or done. The ADM stated she and Resident 19 called the fraud department at the bank and the bank representative went over Resident 19's account and identified multiple unauthorized transactions. The ADM stated Resident 19 was very clear on which transactions were not authorized. The ADM stated, the bank canceled the debit card used to access the account, issued a new card to Resident 19, opened an investigation and issued an event identification number. The ADM stated the SSD called her on 11/18/16 and stated she did not have Resident 19's debit card. The ADM stated she contacted the PD on 11/19/16 in the afternoon and was given a case number. The ADM stated the PD came to the facility on [DATE], spoke with her (ADM) and Resident 19, made copies of Resident's 19's bank statement and the facility's policies and procedures for handling resident's funds. The ADM stated the PD returned to the facility on the morning of 11/21/16 with video from Resident 19's bank where unauthorized transactions had occurred. The ADM stated that she (ADM) and Resident 19 were able to positively identify the facility's SSD at the ATM window in two separate videos. The ADM stated, she received a telephone call on 11/21/16 from the SSD stating, she (SSD) had $1400 at her house that belonged to Resident 19. The ADM stated the SSD's family member arrived at the facility at approximately 2 p.m. and presented a sealed envelope to the ADM which contained $1400 and indicated the money belonged to Resident 19. On 11/23/16 at 11:15 a.m., during an interview Resident 19 stated, she had filed charges of fraud and identity theft against the SSD. On 11/23/16 at 12 p.m., The ADM stated Resident 19 received a letter from the bank indicating $2,227.18 had been credited to her account because of evidence of fraud. Review of a document titled, Law Enforcement Report Form dated approved on 11/29/16, indicated, On 11/23/16, at 0800 hours, I (Local Police Officer, LPO) assembled an arrest team and went to the residence of suspect (SSD) .I contacted (SSD) and arrested her at her home .Suspect (SSD) committed several crimes as outlined in this investigation. Those crimes include identity theft, the possession of another person's credit card/bank card account information with the intent to defraud, and multiple acts of theft committed through the fraudulent use of the victim's credit/bank card to obtain cash and through unlawful ATM withdrawals and merchandise through unlawful point of sale purchases .The victim (Resident 19) is out $2,280.18 after the suspect (SSD) committed 30 plus fraudulent cash withdrawals and purchases using the victims bank card. The report was completed by the LPO. On 12/8/16 at 2:46 p.m., during a telephone interview, the SSD stated, in October 2016, Resident 19 gave her debit card and wallet to her to keep in the SSD office. The SSD stated it was not unusual for residents to give her purses or wallets to store in her office. The SSD stated she had been doing this for years for many residents. The SSD stated that she had taken Resident 19 to a local bank ATM two times in the past to withdraw money from her account. The SSD stated she was involved with Resident's 19's financial transactions including a withdrawal of $1,400 in cash. The SSD stated, We have been doing this forever. The SSD stated that she had held wallets, purses and monies for other residents over the years. The SSD stated the business office would ask her to hold residents money and property. The SSD stated she currently had three residents' property locked up in her office. The SSD stated it was not unusual to run financial errands for residents. The SSD stated, she was unsure of the facility's policy and procedures and she had been doing business this way for years. On 12/9/16 at 4:40 p.m., during an interview, the ADM stated, there was no policy or procedure that permits facility staff to access residents' personal bank accounts. The ADM stated there was not a facility policy or procedure that permitted facility staff to access resident bank accounts without written permission. On 12/9/16 at 6:35 p.m., during a telephone interview with the LPO, the LPO stated the facility SSD had accessed Resident's 19's debit card and made multiple purchases for personal gain. The LPO stated a search of the SSD's office and car had resulted in six wallets and purses in the office and one wallet in the SSD's personal car. The LPO stated that the SSD had confessed to points of purchases identified using Resident 19's bank card. The LPO stated the SSD had been charged with Identity Theft, Credit Fraud, and three counts of Actual Use. The facility policy and procedure titled, INVENTORY OF PERSONAL PROPERTY dated 03/2010, indicated .7. Send money and valuables to business office for safe keeping. Give receipt to resident or relative. Use valuables envelope . The facility policy and procedure titled, ABUSE PREVENTION dated 03/2010, indicated Purpose: To ensure that resident's rights are protected through implementation of the Abuse Prevention policy and procedure. Policy: Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff .TRAINING .2. The Director of Staff Development will also provide twice a year and as needed in-services to review with facility staff the Abuse Prevention Policy and Procedure .DEFINITIONS .Misappropriation of resident property .is defined as, the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident's belongings or money without the resident's consent. The facility document titled, Course Completion History dated 08/09/16, indicated the SSD completed Abuse and Neglect of the Elderly-An Overview on 07/09/15 and Preventing, Recognizing and Reporting Abuse on 07/20/16. The facility document titled (Facility) EMPLOYEE HANDBOOK dated October 2015, indicated, Gross Misconduct: Gross Misconduct infractions are a direct violation of the Company's standards of conduct. These infractions include, but are not limited to: 1. Abuse .fiduciary .abuse of a resident. 2. Theft: Theft, attempted theft, fiduciary malfeasance or abuse .ELDER ABUSE .The residents of this facility each have the right to be free from .fiduciary abuse .Definitions: Fiduciary Abuse means misappropriation of a resident's private funds .

Based on observation, resident and staff interview, and administrative document review, the facility failed to implement its Resident Trust Fund policies and procedures when the facility failed to protect 2 of 7 sampled residents, (Resident 1 and Resident 2) from misappropriation of personal funds. This failure resulted in a successful unlawful withdrawal of funds from Resident 2's trust account, and a second unsuccessful attempt to withdraw from Resident 1's account. This failure placed all residents with trust fund accounts at risk for financial abuse and misappropriation of personal funds. Findings: 1. On [DATE] at 11:25 a.m., California Department of Public Health (CDPH) received telephone notification by the facility of allegations of resident financial abuse, which indicated, R 2 (Resident 2) passed away in [DATE] R 2's trust account with the facility was closed out on [DATE] .$465 on R 2's residence trust banking account was cashed by someone that by name, no one knows or ever heard of . On [DATE] at 12 p.m., during an interview, the Director of Social Services (DSS) stated Resident 2 expired in [DATE], and the facility was informed by authorities of an unauthorized withdrawal of funds from Resident 2's trust fund in the amount of $465. On [DATE] at 12:15 p.m. during an interview, the Administrator (ADM) stated during a facility investigation, he discovered an unauthorized withdrawal of Resident 2's funds from her trust account on [DATE] was made in the amount of $465. The ADM stated the Trust Account check was made payable to a person not known to the facility. On [DATE] at 1:45 p.m., during an interview, the ADM stated it had been facility practice for the Director Of Nursing (DON) or the DSS to sign checks on the resident's trust accounts. He further stated when the facility conducted its investigation several deficiencies in practice had been identified. Resident 2's clinical record indicated the resident's Responsible Party was the (local) Public Guardian (PG) office. Review of Resident 2's Trust Fund Authorization document, dated [DATE], indicated it was not current to Resident 2's change of status to indicate the PG responsibility. On [DATE] at 1:55 p.m., during an interview, the Deputy PG stated the PG office assumed Conservatorship (court appointed) responsibility for Resident 2 on [DATE]. Facility Trust account balances dated [DATE] through [DATE] indicated Resident 2 was listed as a client, with a balance of $465.07. The facility bank check #4197, dated [DATE], indicated it was made payable in the amount of $465.07 to Estate of (Resident 2). Under for, it indicated Close Trust Account. The check was signed by one signer, the DSS. The facility document titled, Resident Trust Fund Policies/Procedures, revised [DATE], indicated, If a resident chooses to establish a resident trust fund in his/her name, the resident, agent, or legal representative must authorize the facility to do so by signing the Resident Trust Fund Authorization form No monies for any resident are to be held in trust by the facility without a signed authorization on file .Under Closing Resident Trust Accounts it indicated, Upon expiration or discharge of a resident, funds held in the Resident Trust Account must be refunded to the individual or appropriate agency within the time frames as identified in Federal and State specific regulations. In the event of expiration time frame is generally 30 days .Verify time frames specific to per your state regulations. Under Authorized Signers it indicated, .The following cannot be a signer on the Resident Trust Account; Social Service .All checks written on the Resident Trust Fund account must be signed by two (2) authorized check signers. The facility policy and procedure titled, Abuse Prevention dated ,[DATE], indicated under Policy, Residents must not be subjected to abuse by anyone . Under Misappropriation of resident property it indicated, the deliberate .use of a resident's belongings or money without the resident's consent. 2. On [DATE] at 11:25 a.m., during an interview, the facility notified CDPH regarding allegations of resident financial abuse, which indicated, R2 (Resident 2) passed away in [DATE] On R 1, staff says there was an attempt to cash a personal check from her personal bank account for $5,526 .reported from the bank .on [DATE]. On [DATE] at 12 p.m., during an interview, the DON stated he and the DSS were authorized signers for the Resident Trust Accounts. He further stated when the facility investigated, Resident 1 had been asked to sign a blank check, and did so. The check was then made payable to an unknown party in the amount of $5,226, and taken to a local bank in an attempt to cash the check. On [DATE] at 12:10 p.m., during an interview, the DSS stated the facility was notified by Adult Protective Services (APS) of an attempt to withdraw funds from Resident 1's checking account using her personal check. The DSS stated the facility held her checkbook in trust, and it was stored with the Business Office Manager (BOM) 1. Resident 1's clinical record indicated Resident 1 was admitted to the facility on [DATE]. Her current [DIAGNOSES REDACTED]. Resident 1's most recent Resident Assessment Instrument (RAI),(an assessment of resident functional ability) dated [DATE], indicated a Brief Interview for Mental Status (BIMS) score of 13 out of 15, which indicated Res 1 had few cognitive deficits in recall and orientation. On [DATE] at 3:50 p.m., during an interview, Res 1 stated she recalled being asked to sign a blank check, but was unable to recall who asked her to do so. She stated when she was informed of the unauthorized attempt to cash her personal check, she stated, It was hard for me to sleep .nobody is supposed to do that I couldn't understand. When asked if she had signed a document giving the facility permission to hold her checkbook in trust, she stated, I did, and then I reneged .about a year later, and stated she informed the facility of her decision. Facility account balance statements dated [DATE] through [DATE] indicated Resident 1 was not listed on the facility's trust accounts. On [DATE] at 2:20 p.m., during an interview, the ADM was asked if facility staff requested Resident 1 sign a blank personal check, he stated, That's true. Resident 1's written trust fund authorization was requested. The ADM was unable to produce documentation of Resident 1's written authorization. The facility document titled, Resident Trust Fund Policies/Procedures, revised [DATE], indicated, No monies for any resident are to be held in trust by the facility without a signed authorization on file. Under Disbursements it indicated, It is the responsibility of the facility to protect and provide proper documentation on all disbursements from the trust account .There are to be no blank checks signed by the facility.

Based on observation, staff, resident, and agency interviews, and administrative document review, the facility failed to provide services which met professional standards of quality when it failed to follow its Resident Trust Fund policies and procedures in the following: 1. The facility did not have written authorization from Resident (Res) 1 to hold her checkbook funds in Trust. 2. The facility did not have written authorization from Res 2's Deputy Public Guardian (DPG) to hold funds in trust, and on her death, the fund balance was not refunded to her estate within 30 days. 3. The facility failed to utilize the appropriate number of signers for the resident trust accounts and designated the Social Services Director (SSD), contrary to facility policy. These failures contributed to an unlawful and unauthorized withdrawal of Res 1's funds; and a second unlawful unauthorized attempt was made to withdraw Res 2's funds. Findings: 1. On [DATE] at 11:25 a.m., California Department of Public Health (CDPH) was notified by telephone regarding allegations of resident financial abuse, which indicated, On R 1, staff says there was an attempt to cash a personal check from her personal bank account for $5,526 .reported from the bank .on [DATE]. On [DATE] at 12 p.m., during an interview, the Director of Social Services (DSS) stated the facility was notified by Adult Protective Services (APS) of an attempt to withdraw funds from Resident 1's checking account using her personal check. The DSS stated the facility held her checkbook in trust, and it was stored in the Business Office Manager's (BOM)1 office prior to the attempted withdrawal. On [DATE] at 12:15 p.m., during an interview, the Director of Nursing (DON) stated he and the Social Service Director (DSS) were authorized signers for the Resident's Trust Accounts. He further stated when the facility investigated, Res 1 had been asked to sign a blank check, and did so. The check was then made payable to an unknown party in the amount of $5,226, and taken to a local bank in an attempt to cash the check. Res 1's clinical record indicated she was admitted to the facility on [DATE]. Her current [DIAGNOSES REDACTED]. Res 1's most recent Resident Assessment Instrument (RAI), (an assessment of resident functional ability) dated [DATE], indicated a Brief Interview for Mental Status (BIMS) score of 13 of 15, which indicated Res 1 had few cognitive deficits in recall and orientation. On [DATE] at 3:50 p.m., during an interview, Res 1 stated she recalled being asked to sign a blank check, but was unable to recall who asked her to do so. Res 1 stated when she was informed of the unauthorized attempt to cash her personal check, she stated, It was hard for me to sleep .nobody is supposed to do that I couldn't understand. When asked if she had signed a document giving the facility permission to hold her checkbook in trust, she stated, I did, and then I reneged .about a year later, and stated she informed the facility of her decision. On [DATE] at 2:20 p.m., during an interview, the ADM was asked if facility staff requested Res 1 sign a blank personal check, he stated, That's true. Res 1's written trust fund authorization was requested. The ADM was unable to produce documentation of Resident 1's written authorization. The facility document titled, Resident Trust Fund Policies/Procedures, revised [DATE], indicated, No monies for any resident are to be held in trust by the facility without a signed authorization on file. Under Disbursements it indicated, It is the responsibility of the facility to protect and provide proper documentation on all disbursements from the trust account .There are to be no blank checks signed by the facility. 2. On [DATE] at 11:25 a.m., CDPH received telephone notification by the facility of allegations of resident financial abuse, which indicated, R2 (Resident 2) passed away in [DATE] R 2's trust account with the facility was closed out on [DATE] .$465 on R 2's residence trust banking account was cashed by someone that by name, no one knows or ever heard of . On [DATE] at 12 p.m., during an interview, the DSS stated Resident 2 expired in [DATE], and the facility was informed by authorities of an unauthorized withdrawal of funds from Resident 2's trust fund in the amount of $465. She further stated the BOM was terminated from employment during the investigation. Resident 2's clinical record indicated her Responsible Party was the (local) Public Guardian's office. On [DATE] at 12:15 p.m. during an interview, the Administrator (ADM) stated during a facility investigation, he discovered an unauthorized withdrawal of Resident 2's funds from her trust account on [DATE], in the amount of $465. The ADM stated the Trust Account check was made payable to a person not known to the facility. He further stated a facility check had been issued to the PG's office to restore the funds to Resident 2's estate. On [DATE] at 1:55 p.m., during an interview, the Deputy Public Guardian (DPG) stated the office assumed responsibility for Res 2's personal funds effective [DATE], and she expired on [DATE]. Review of Res 2's Trust Fund Authorization dated [DATE], indicated it was not current to Res 2's change of status to Public Guardian (PG) responsibility. A facility copy of Resident Trust account check #4197, dated [DATE], indicated it was made payable in the amount of $465.07 to Estate of (Resident 2). Under for, it indicated Close Trust Account. The check was signed by the SSD. The facility document titled, Resident Trust Fund Policies/Procedures, revised [DATE], indicated, If a resident chooses to establish a resident trust fund in his/her name, the resident, agent, or legal representative must authorize the facility to do so by signing the Resident Trust Fund Authorization form No monies for any resident are to be held in trust by the facility without a signed authorization on file .Under Closing Resident Trust Accounts it indicated, Upon expiration or discharge of a resident, funds held in the Resident Trust Account must be refunded to the individual or appropriate agency within the time frames as identified in Federal and State specific regulations. In the event of expiration time frame is generally 30 days .Verify time frames specific to per your state regulations. 3. On [DATE] at 11:25 a.m., during a telephone interview, the facility notified CDPH of allegations of resident financial abuse, which indicated, R2 (Resident 2) passed away in [DATE] R2's trust account with the facility was closed out on [DATE] . On [DATE] at 1:45 p.m., during an interview, the ADM stated it had been facility practice for the DON or the DSS to sign checks on the resident trust accounts. He further stated when the facility conducted its investigation several deficiencies in practice had been identified. Facility Trust account balances dated [DATE] through [DATE] indicated Resident 2 was still listed as a client, with a balance of $465.07. The facility bank check #4197, dated [DATE], indicated it was made payable in the amount of $465.07 to Estate of (Resident 2). Under for, it indicated, Close Trust Account. The check was signed by one signer, the SSD. The facility document titled, Resident Trust Fund Policies/Procedures, revised [DATE], indicated Under Authorized Signers, .The following cannot be a signer on the Resident Trust Account; Social Service .All checks written on the Resident Trust Fund account must be signed by two (2) authorized check signers.