Every finding on record at The Californian

Based on interview and record review, the facility failed to employ either a dietitian (a licensed health expert on food and nutrition), a qualified nutritional professional (a certified expert who completes specific college degrees, supervised clinical hours, and board exams to provide safe, science-based dietary care and medical nutrition therapy), or a director of food and nutrition services (a senior leader who manages meal programs and kitchen operations such as planning healthy menus, handling budgets, following safety laws, and managing kitchen staff) on a full-time basis (35 hours or more a week). This had the potential to result in the facility's inability to meet the nutritional needs of the residents.During an interview on 8/18/26 at 3:09 p.m. with Dietary Supervisor (DS), DS indicated that the facility has not had a Dietary Director since March 2025. DS acknowledged not possessing the required certifications to be a qualified nutritional professional but was in the process of completing the educational requirements. During an interview on 8/18/26 at 12:05 p.m. with Registered Dietician (RD), RD indicated only working part-time at the facility and being on-site on Tuesdays. RD stated that DS was acting in the role of dietary services manager/director. During an interview on 8/20/26 at 9:22 a.m. with Administrator (ADM), ADM acknowledged the registered dietician worked part-time (less than 35 hours per week) and that the facility did not currently have a full-time qualified nutritional professional. A copy of the facility's policy was requested but none was provided.

Based on interview and record review, the facility failed to ensure documentation establishing the legal authority of individuals identified as the Responsible Party (RP) (the person listed by the facility as the resident's representative or contact person who may assist with decisions, paperwork, or communication) and/or legally recognized decision-maker was maintained in the medical record for two of four residents reviewed for advance directives (a legal document in which a person states their healthcare wishes and/or identifies someone to make healthcare decisions for them if they become unable to do so) (Residents #3 and #38), when:Resident #3's medical record did not contain a Durable Power of Attorney (DPOA) (a legal document that names another person to make healthcare decisions for someone if that person is unable to make or communicate those decisions) or other documentation establishing the legal authority of the individual identified as the Legally Recognized Healthcare Decision Maker.Resident #38's medical record did not contain a DPOA or other signed legal document establishing the authority of the RP who signed admission and treatment consent forms. The record also did not contain a Physician Orders for Life-Sustaining Treatment (POLST) form or care plan documentation addressing the resident's DPOA or advance directives.1. During a concurrent interview and record review on [DATE] at 3:15 p.m. with the Director of Nursing (DON) and Social Services Director (SSD), Resident #3's medical record was reviewed. The record did not contain a DPOA for Resident #3. admission and other consent forms were signed by the RP with documentation indicating that the consents were obtained by telephone. However, designation as the RP alone did not establish that the individual had legal authority to make healthcare decisions on behalf of Resident #3.During a review of Resident #3's Physician Orders for Life-Sustaining Treatment (POLST) (a medical order that tells healthcare staff which life-sustaining treatments a seriously ill or frail person wants or does not want, such as cardiopulmonary resuscitation [CPR] or other emergency treatments), the POLST identified the signer under the Information and Signature section as the Legally Recognized Decision Maker. The Social Services Director (SSD) confirmed that the POLST had been completed at the hospital prior to Resident #3's admission to the facility.The medical record did not contain documentation showing that the facility reviewed or updated the POLST following admission or verified the legal authority of the individual identified on the POLST as the Legally Recognized Decision Maker. The Director of Nursing (DON) and SSD acknowledged that documentation establishing the individual's legal authority, including a Durable Power of Attorney (DPOA), was not present in Resident #3's medical record. 2. During a concurrent interview and record review on [DATE] at 11 a.m. with the Social Services Director (SSD) and Social Services Assistant (SSA), Resident #38's medical record was reviewed. admission and treatment consent forms were signed by the Responsible Party (RP); however, the record did not contain a Durable Power of Attorney (DPOA) or other signed legal document establishing that the RP was legally authorized to make healthcare decisions on behalf of Resident #38. Review of Resident #38's progress notes dated [DATE] showed that the assessing physician documented that Resident #38 cannot make his own medical decisions and was only variably aware of his medical condition. Despite this documented inability to make his own medical decisions, the record did not contain documentation establishing the legal authority of the RP who signed admission and treatment consent forms on Resident #38's behalf. The record also did not contain a Physician Orders for Life-Sustaining Treatment (POLST) form or documentation in the resident's care plan addressing a DPOA, legally authorized decision-maker, or advance directives. The SSD and SSA acknowledged that a signed DPOA document should have been present in Resident #38's medical record and verified upon admission. During a review of the facility's Policy and Procedure (P&P) titled, Durable Power of Attorney for Health Care, the P&P indicated that during the admission process or shortly after admission, the admission Coordinator was responsible for informing the resident and significant other of the Durable/Medical Power of Attorney for Health Care. The P&P further indicated that a Statement of Request for a Durable/Medical Power of Attorney for Health Care form was to be completed and signed during admission and forwarded to Social Services staff. In addition, the P&P stipulated, The Social Service Department will obtain completed copies of the Durable Power of Attorney for Health Care for the Resident's medical record and for the family. During a review of the facility's Policy and Procedure (P&P) titled, Advance Directives, the P&P indicated that written information regarding advance directives was to be provided at the time of admission and documentation regarding the provision of advance directive information was to be included in the resident's clinical record. The P&P further indicated the admission Coordinator was responsible for inquiring whether the resident and/or Responsible Party (RP) had completed an advance directive, documenting acknowledgment of an advance directive in the admission Agreement, and obtaining completed copies of advance directives for placement in the resident's chart. The P&P further indicated that when an advance directive had not been executed, nursing staff, the admission Coordinator, or Social Services staff would assist the resident or RP to execute the Preferred Intensity of Care or Physician Orders for Life-Sustaining Treatment (POLST) form and Advance Directive orders shall be reconfirmed monthly with the physician's orders.

Based on interview and record review the facility failed to ensure the Preadmission Screening and Resident Review (PASSR - a federally required screening of all individuals for Intellectual Disability (ID) or Related Condition and a Serious Mental Illness (SMI) prior to admission) Level 1 was accurate in 1 of 13 sampled residents (Resident 65).This failure had the potential to place Resident 65 at risk for unidentified health care needs, lack of services and diminished quality of life.During review of Resident 65's electronic medical record (EMR), the admission Record (AR), dated 8/13/26, indicated Resident #65 was admitted with a diagnosis of unspecified psychosis (loss of touch with reality-such as hallucinations or delusions). The Order Summary Report (OSR), dated 8/18/26, indicates Resident 65 takes Seroquel (medication used to treat mental health conditions) every day for psychosis manifested by aggressive behavior. Review of the PASRR, dated 8/13/26, indicates a level II mental health evaluation was not required. However, further review of the PASRR shows that Section III - Serious Mental Illness questionnaire for question 11 Does the individual have a diagnosed Serious Mental Illness disorder such as Depressive Disorder, Anxiety Disorder, Panic Disorder, Schizophrenia/Schizoaffective Disorder, or symptoms of Psychosis, Delusions, and/or Mood Disturbance? was answered no. During a concurrent interview and review 8/19/26 at 10:11 a.m. with Minimum Data Set Coordinator (MDS), Resident 65's electronic medical record was reviewed. MDS confirmed the PASRR's received from the hospital is reviewed for accuracy during the admission process and if discrepancies are noted, the PASRR is resubmitted with the correct resident information. MDS acknowledged resident 65's OSR indicates resident is taking Seroquel for psychosis and the AR indicates the resident has a diagnosis of psychosis. MDS reviewed Resident 65's PASRR and acknowledged question 11 was not accurate. MDS stated I must have missed that when I reviewed it. During review of facility's policy and procedure (P&P) titled Preadmission Screening and Resident Review (PASRR), dated July 2026, the P&P indicates in part, The purpose of this policy is to ensure that residents/patients being considered for admission to this Skilled Nursing Facility (SNF) are evaluated for evidence of possible PASSR conditions, i.e., serious mental illness (SMI) .PASRR grants special protections to individuals with SMI .to ensure they receive services or supports that address their PASRR condition, including services linked to that condition, i.e., specialized services. 2. Prior to an individual being admitted to this facility from the hospital a PASRR must be obtained. The PASRR will be reviewed by the facility's Director of Nursing (DON) or designee for its accuracy.

Based on observation, interview, and review, facility staff failed to ensure food temperatures for alternate food items were taken, recorded, and at an acceptable temperature prior to meal service. This failure had the potential to spread foodborne illness to the entire resident population at the facility that receives meals prepared in the kitchen.During a concurrent observation, interview, and record review on 8/17/26 at 11:45 a.m. with Dietary Aide (DA), observed DA getting a chicken breast from the oven (not from the steam table) and placing it on a resident's tray during tray line. DA stated that Resident 52 did not eat pork or beef and the chicken breast was served as an alternative protein. During review of the facility's food temperature log (untitled), the alternative food items (chicken breast and white rice) were not listed and temperatures for these food items were not documented. DA acknowledged the temperatures were not documented on the temperature log. During an interview on 8/18/26 at 3:09 p.m. with Dietary Supervisor (DS), DS stated kitchen staff do not record the temperature of alternative food options because the temperature logs are pre-printed with the day's menu for breakfast, lunch, and dinner and there was no designated area on the form for alternative food items served to residents. DS acknowledged the temperatures for alternative food items were not documented and could be documented in any blank space on the temperature log. During review of the facility's policy and procedure (P&P) titled, Monitoring Trayline/Meal Service Temperatures, undated, indicates in part, Food temperatures will be recorded when meal service starts, and if possible, every 30 minutes during the service.1. Employees of the Food & Nutrition Services Department will be assigned to take and record the temperature of all hot and cold food items designated for service at each meal.6. Temperatures will be recorded prior to tray service.

Based on observation, interview and record review, the facility failed to maintain an infection prevention and control program when:Resident meal trays were placed on a Personal Protective Equipment (PPE) carts while staff put on PPE creating a direct pathway of cross contamination by exposing the resident's food to pathogens, body fluids, and/or contaminated surfaces. 2. Deep cleaning of a room was not completed following discontinuation of residents Contact Isolation for one of two sampled residents (Resident 62) These deficient practices had the potential to spread infection to residents in the facility. 1.During lunch tray pass observation on 8/17/26 at 12:12 p.m. Certified Nursing Assistant (CNA 1) was observed placing a resident's meal tray on a personal protective equipment (PPE) cart while donning (putting on) PPE (gloves, gown) prior to entering resident room [ROOM NUMBER] to deliver meal tray. During a concurrent observation and interview on 8/17/26 at 12:14 p.m. with Minimum Data Set Coordinator (MDS), MDS acknowledged observing CNA 1 placing meal tray on a PPE cart while donning PPE prior to entering resident room [ROOM NUMBER]. MDS acknowledged staff should not be placing food on the PPE cart. During review of facility's P&P titled General Infection Control Nursing Policies, undated, the P&P indicates in part, It is the policy of this facility that all nursing activities will be performed in a manner to minimize the potential for infection in residents, staff, and visitors. 2. During a review of Resident 62's Physician Order, dated 7/28/26, the order indicated Contact Isolation for the diagnosis of C. Diff. (Contact isolation is a set of infection control practices used in healthcare settings to prevent the spread of the bacteria from an infected patient to others) During a review of Resident 62's Progress Note,dated 8/17/2026, the Progress Note indicated a Dr's order of discontinuation of contact isolation precaution. Order noted and carried out. During a concurrent interview and record review on 8/19/26 at 11:46 a.m. with the Maintenance Director (MD). MD stated when a resident is no longer on contact isolation, either the Nurses or the Infection Preventionist (IP) let's housekeeping know so that they remove the isolation cart and perform a deep clean of the room immediately. MD provided Housekeeping Daily Room Cleaning Log and stated a deep cleaning was not performed for room [ROOM NUMBER] where resident 62 has remained during and after contact isolation. The last deep clean of this room was performed on 8/10/26 and the next scheduled deep clean is for 8/23/26. MD was not sure why it wasn't deep cleaned on the date of 8/17/26 but he does remember the isolation cart was removed (An isolation cart holds personal protective equipment (PPE) and infection control supplies such as gloves and gown, outside a patient's room to prevent the spread of germs) During an interview on 8/19/26 at 11:57 a.m. with Licensed Nurse (LN 2), LN 2 confirmed a room should be deep cleaned immediately following contact isolation. During an interview on 8/19/26 at 12:10 p.m. with Infection Preventionist (IP), IP stated a deep cleaning of the room is expected to be done right away following a discontinuation of contact isolation. During a review of the facility's policy and procedure (P&P) titled, Terminal Room Cleaning (Deep Cleaning), dated March 2020, the P&P indicated, The Infection Preventionist or their designee will notify the housekeeping supervisor or their designee of the isolation termination immediately or as soon as practicable. Following this notification, the housekeeping department will initiate a Terminal Room Cleaning (Deep Clean) in accordance with the Terminal Room Cleaning Guidelines.

Based on interview and record review, the facility failed to develop a care plan for the use of the anticoagulant medication Apixaban (a medication that helps prevent blood clots) for one of two sampled residents (Resident 39). This failure could result in medication related adverse events and poor management of anticoagulation therapy for Resident 39. Findings: During a review of Resident 39's Admission Record (AR), the AR indicated, Resident 39 was admitted on [DATE] with diagnoses that included congestive heart failure (heart muscle doesn't pump blood as well as it should) and presence of cardiac pacemaker (a device implanted in the body to deliver electrical pulses to your heart). During a concurrent interview and record review on 3/28/25 at 9:36 a.m. with the Minimum Data Set Coordinator (MDSC), Resident 39's electronic clinical record was reviewed. Review of Resident 39's Order Summary Report (OSR), dated 3/2025, the OSR indicated, a physician order for the medication Apixaban oral tablet 5mg (milligrams) two times a day for PPX (prophylaxis) DVT (deep vein thrombosis - a condition where a blood clot forms in a deep vein, typically in the lower legs). Further review of Resident 39's clinical record failed to indicate that a care plan was developed for the resident's use of this medication. The MDSC was unable to locate and produce a documented care plan for the resident's use of the said medication and stated, there is no care plan and there should be. During a review of the facility's policy and procedures (P&P) titled, Care Planning and Care Plans, dated 4/2024, the P&P indicated in part, Guidelines: 3. Patient care plans are to be initiated on admission of a patient and based on the physician's orders and assessments made of the patient . 4. The care plans are to be updated as the resident condition change and as revision is needed.

Based on observation, interview, and record review, the facility failed to ensure physician orders were followed for two of two unsampled residents (Residents 29 and 14) when: 1. Resident 29's apical pulse (AP - heartbeat that is felt or heard at the apex [top] of the heart, located on the left side of the chest) rate was not checked, as ordered, prior to receiving a blood pressure medication. 2. Resident 14's medical record had no documented intervention, as ordered, during two episodes when the resident had alarmingly low blood sugar readings. These failures had the potential to result in Resident 29 and 14 not receiving the appropriate care and services which can affect their health and safety. Findings: 1. During a review of Resident 29's, Admission Record (AR), dated 4/28/23, the AR indicated in part, Resident 29 is a [AGE] year-old male who was admitted to the facility on [DATE] with admission diagnoses including essential hypertension (high blood pressure), paroxysmal atrial fibrillation (fluttering of the heart) and peripheral venous insufficiency (a condition where the veins in the legs or arms become damaged, leading to poor blood flow back to the heart). During a medication pass observation on 3/26/25 at 8:40 a.m., with licensed nurse (LN) 1, LN 1 was observed measuring Resident 29's blood pressure and radial pulse rate (heart rate and rhythm felt on the thumb side of the wrist) prior to administering a blood pressure medication. The blood pressure medication blister package read, Propanolol Hydrochloride .10 mg (milligram), give one tablet by mouth two times a day . hold if SBP (systolic blood pressure) < (less than) 110 or AP < 55. During a review of Resident 29's Order Summary (OS), dated 3/26/25, the OS indicated the physician order, Propanolol Hydrochloride oral tablet 10 mg, give one tablet by mouth two times a day .hold if SBP < 110 or AP < 55, dated 2/19/25. During a concurrent interview and record review, on 3/26/25 at 10:10 a.m., with LN 1, Resident 29's OS, dated 3/26/25 was reviewed. LN 1 was informed that the resident's Propanolol . order indicated a parameter to check the AP. LN 1 verified the order and verbalized that she usually checked the radial pulse. LN 1 acknowledged that she should have been measuring Resident 29's AP instead of his radial pulse rates. 2. During a review of Resident 14's AR, dated 4/1/22, the AR indicated Resident 14 is an [AGE] year-old female who was admitted to the facility on [DATE] with admission diagnoses including Type 2 Diabetes Mellitus (a chronic disorder characterized by high blood sugar levels), essential hypertension and chronic kidney disease (a condition in which the kidneys gradually lose their function to filter the blood). During a review of Resident 14's Medication Administration Record (MAR), for the month of March 2025, the MAR indicated the physician order, Novolog Flexpen Insulin (a medication that helps regulate blood sugar levels) .inject as per sliding scale (amount of insulin to be administered based on a person's blood sugar level): if 0 - 70 = 0 unit; if responsive give milk or (OJ) orange juice; if unresponsive, give glucagon (a medication that can treat severe low blood sugar) . The MAR indicated further that on 3/23/25 at 11:30 a.m., Resident 14's blood sugar level was 11, documented by licensed nurse (LN) 2, and on 3/25/25 at 6:30 a.m., the blood sugar level was 60, documented by licensed nurse (LN) 3. During a concurrent interview and record review on 3/26/25 at 10:40 a.m., with the Director of Nursing (DON) and LN 2, Resident 14's medical record was reviewed. DON and LN 2 were informed that a review of Resident 14's MAR, for March 2025, under the medication order Novolog Flexpen Insulin sliding scale ., Resident 14's blood sugar level on 3/23/25 at 11:30 a.m., was 11 as documented by LN 2. A review of Resident 14's, e-MAR Progress Notes, for 3/23/35 failed to indicate documentation of any ordered interventions done to address the low blood sugar level. LN 2 acknowledged the finding but verbalized that the documented result was an error and should have documented the blood sugar level as 118. There was no documentation found in the medical record to correct the error. During a concurrent interview and record review on 3/26/25 at 2:09 p.m., with the DON, DON verbalized speaking to LN 3 regarding Resident 14's low blood sugar level taken on 3/25/25 at 6:30 a.m. LN 3 apparently notified the resident's physician of the low blood sugar reading, and the resident was given orange juice but failed to document the interventions in the resident's medical record. DON acknowledged LN 3 should have documented these interventions. During a review of the facility's policy and procedures (P&P), titled Medication Administration General Guidelines, dated 5/2016, the P&P indicated in part, Medication Administration .1) Medications are administered in accordance with written orders of the prescriber . 2) Obtain and record any vital signs necessary prior to medication administration . The P&P indicated further, Documentation .1) The individual who administers the medication dose, records the administration on the resident's MAR immediately following the medication being given . During a review of the facility's P&P titled, Resident Care Vital Signs, dated 6/2024, the P&P indicated in part, Vital signs upon which the administration of medications or treatments are conditioned shall be performed as required and the results recorded, i.e. digoxin (medication used to treat heart failure) based on apical pulse rate, antihypertensive agents based on blood pressure .

Based on observation, interview, and record review, the facility failed to ensure oxygen tubing for one of two sampled residents (Resident 98) was labeled and dated. This failure had the potential to result in cross-contamination (the transfer of harmful bacteria) for residents in an already compromised condition. Findings: During review of Resident 98's Admission Record (AD), the AD indicated Resident 98 was admitted on [DATE] with diagnoses that included, chronic obstructive pulmonary disease (COPD - a chronic lung disease causing difficulty in breathing) and dependence on supplemental oxygen. During a concurrent observation and interview on 3/25/25 at 11:45 a.m., with the Infection Preventionist (IP) in Resident 98's room, Resident 98 was observed wearing a nasal cannula (a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen) connected to an oxygen concentrator (a medical device used to deliver oxygen) without a label on the nasal cannula tubing. IP stated Resident 98's nasal cannula tubing was not labeled or dated and it should be. During a review of the facility's Policy and Procedure (P&P) titled Nasal Cannula, Nebulizer, and Humidifier Change and Usage, dated 2/2024, the P&P indicated, Procedure: 1. Ensure that all nasal cannula/nebulizer tubing are changed /replaced in a timely manner .4. Timely manner means to be changed weekly on Sunday 11-7 shifts. 5. Nasal Cannulas/nebulizer tubings are to be labeled with date of placement as well as patients room number.

Based on observation, interview, record review, the facility failed to ensure kitchen and food storage sanitation was maintained when: 1. Kitchen staff personal belongings (i.e., jacket and purse) were found inside the dry food storage room. 2. The low-temperature dish machine was operating without proper chemical sanitation. These failures increased the risk of food-borne illnesses to its vulnerable residents as a result of potential food contamination and improperly sanitized dishware. Findings: 1. During a concurrent observation and interview on [DATE] at 9:34 a.m., inside the facility's dry food storage room, with dietary staff (DS) 1, staff personal belongings including a jacket and a purse, were found inside a bin located in one of the lower storage racks. DS 1 verbalized that staff personal belongings should not be stored in any of the food storage areas. During a review of the facility's policy and procedures (P&P) titled, Section F: Safety and Sanitation .1. Employee Responsibility for Safety, undated, the P&P indicated in part, Procedure .22) Employees are not allowed to bring personal items including but not limited to cell phones, purses, make-up bags, etc., into food service production areas. 2. During a concurrent observation and interview on [DATE] at 9:45 a.m., with DS 1, the facility kitchen's low-temperature dish machine was observed during its operation. DS 1 explained that a chemical solution (i.e., chlorine) was used during the dish machine's final rinse phase to ensure the effective sanitation of dishes, cups and eating utensils used by residents. After the dish machine's normal wash and rinse cycle, DS 1 proceeded to check for the chemical solution's concentration on the dishware using a test strip. DS 1 compared the test strip color with the color chart on the test strip container. The result of the color comparison indicated the chemical solution concentration was measured at 10 ppm (parts per million - a unit of measurement that describes the concentration of a substance in a solution or mixture). DS 1 verbalized that the minimum chemical solution concentration should be at 50 ppm. DS 1 ran the dish machine for another wash and rinse cycle to retest the chemical solution's concentration. The test strip result measured the same at 10 ppm. The test strip was verified not to be expired. DS 1 acknowledged that the chemical solution's concentration was low. During an interview on [DATE] at 10:55 a.m., with the facility Administrator (ADM), ADM was informed of the issue with the dish machine. ADM acknowledged the issue with the dish machine. During a review of the facility's P&P titled, Section F: Safety and Sanitation .10. Ware Washing, undated, the P&P indicated in part, Policy .Utensils, dishes, beverage containers, pots and pans, flatware used for the preparation, service or storage of food will be cleaned and sanitized after each use. The P&P indicated further, Procedure .A. Mechanical Washing .Low temp machine XXX,d+[DATE] degrees Fahrenheit (F) with chemical sanitizer . Rinse must provide 50 to 100 ppm hypochlorite (chlorine) on the dish surface. Verify with a test strip prior to washing dishes for each meal.

Based on record review and interview, the facility failed to ensure the completed MDS (Minimum Data Set - a federally mandated health status screening and assessment tool used for all residents of long-term care health facilities) discharge assessments for two of two sampled residents (Residents 11 and 33) were submitted in a timely manner. This failure had the potential to result in resident data inaccuracies which could affect the facility's improvement efforts to provide high quality care to its residents. Findings: During a review of the Long-Term Care Survey Process (LTCSP - a computer application that supports the survey process for long-term care facilities) final sampling process, the non-mandatory facility task, Resident Assessment, was triggered. Residents 11 and 33 were triggered under this task for investigation of MDS records over 120 days old. During a review of Resident 11's Electronic Health Record (EHR), the Admission Record (AR), dated 1/11/24, indicate in part, Resident 11 was an [AGE] year-old female resident who was admitted to the facility on [DATE], with admitting diagnoses including, non-traumatic intracerebral hemorrhage (brain bleed), hypertension (high blood pressure), and cerebral edema (swelling of the brain). The AR further indicated, Resident 11 was discharged to an acute care hospital on 9/4/23. Review of Resident 11's EHR under MDS Summary, indicated no discharge assessment was initiated. During a review of Resident 33's, EHR the AR dated 1/11/24, indicated in part, Resident 33 was an [AGE] year-old male resident who was admitted to the facility on [DATE], with admitting diagnoses including, liver cell carcinoma (liver cancer), hepatomegaly (enlarged liver), and Type 2 Diabetes Mellitus (a chronic condition that affects the way the body processes blood sugar). The AR indicated, Resident 33 was discharged on [DATE]. Review of Resident 33's EHR under MDS Summary, indicated no discharge assessment was initiated. During a concurrent interview and record review of Residents 11 and 33's, EHR under MDS Summary, on 1/11/24 at 10:24 a.m. with Assistant MDS Coordinator (AMDS), Residents 11 and 33's, EHR under MDS Summary, were reviewed. AMDS verified the discharge date s and confirmed that no MDS discharge assessments were initiated for both residents. AMDS verbalized the facility is required to complete the resident's discharge assessment from the date of the resident's discharge from the facility up to 14 days and also to electronically submit the discharge assessment from the date the assessment was completed up to 14 days. AMDS acknowledged the discharge assessments for Residents 11 and 33 should have been completed and submitted in a timely manner and it was not . During a review of the, Centers for Medicare and Medicaid Services (CMS - a federal agency that provides effective health care coverage and promote quality care for people with Medicare) Resident Assessment Instrument (RAI - a tool which helps the nursing home staff gather information on the residents' strengths and needs so it can be addressed through a care plan) Version 3.0 Manual, Chapter 2: Assessments for the RAI, dated 10/2023, indicated in part, For unplanned discharges, the facility should complete the OBRA (Omnibus Budget Reconciliation Act of 1987 also known as the Nursing Home Reform Act - sets federal standards of care for nursing homes) discharge assessment to the best of its abilities. An unplanned discharge includes, for example: Acute care transfer of the resident to a hospital or emergency department in order to stabilize a condition . Resident unexpectedly deciding to go home or to another setting (e.g., due to the resident deciding to complete treatment in an alternate setting. The RAI manual further indicated, . 09. Discharge Assessment - Return Not Anticipated (A0310F = 10) . Must be completed when the resident is discharged from the facility and the resident is not expected to return to the facility within 30 days . Must be completed (item Z0500B) within 14 days after the discharge date (A2000 + 14 calendar days) . Must be submitted within 14 days after the MDS completion date (Z0500B + 14 calendar days).

Based on observation, interview, and record review, the facility failed to: 1. Develop a person-centered interdisciplinary team nutrition care plan (IDTNCP - detailed plans of care created by representatives from several medical disciplines or specialties) for one of 16 sampled residents (Resident 37) to include the resident's goals and desired outcomes. In addition, the IDTNCP lacked clear and specific measurable objectives and physician input, related to a planned weight gain for Resident 37. This failure resulted in unclear measurable weight gain goal and impedes the IDT from effectively monitoring, evaluating and revising the care plan, as appropriate, to ensure care needs would not go unrecognized and unmet. 2. Develop a care plan for one of 16 sampled residents (Resident 35) receiving blood thinners. This failure had the potential to result in medication adverse consequences to not be monitored. Findings: 1. During a concurrent interview and record review on 1/10/24 at 11 a.m. with Registered Dietitian (RD), Resident 37's Admission Nutrition Assessment (NA), dated 12/4/23, was reviewed. The NA indicated, Resident 37's admit weight was 98 pounds (lbs) and his usual body weight (UBW) was 108 lbs. RD stated she assessed Resident 37's nutritional needs at 30-35 calories per kg (kilogram) to promote weight gain because his BMI was low and because he had already lost weight from a previous admission to the facility. RD stated she wanted Resident 37 to gain weight. The NA also contained a check mark next to maintain weight. RD stated in her mind when she marked a goal of maintain weight it meant that weight loss was not the goal, and the goal was at a minimum to maintain weight with the desire for weight gain. RD stated she did not specifically document what the weight goal was but in my mind I would want him to re-gain weight to his UBW (usual body weight) of 108 lbs. RD verified the weight goal was not clearly documented in the NA. During a concurrent interview and record review on 1/10/24 at 11:30 a.m., with RD, RD stated she had not discussed that she assessed Resident 37's daily nutritional needs to promote weight gain with the resident or what his weight gain goal would be to ensure resident centered care. During a review of Resident 37's Weight Variance Progress Notes (WV), dated 1/10/24, the WV indicated, Resident 37 currently weighed 112 lbs, and the recommendation/plan was Continue POC (plan of care) - diet, fluids, nutritional supplements, monitoring po intake, wts [weights], and all other nutritional parameters. Dc [discontinue] from weekly weight monitoring. During a concurrent interview and record review on 1/10/24 at 11:35 a.m. with RD, Resident 37's IDT Nutrition Care Plan (IDTNCP), initiated by RD on 12/06/23, was reviewed. The IDTNCP included, Problem: . 12/20/23 gain of 3 lbs x 1 wk r/t [related to] po [by mouth] intake w/ [with] augmentation of nutritional supplement, 12/29/2023: + desirable 4 lbs or 3.7% weight gain x 1 week. + Good meal intakes and SF [sugar free] house shake daily, 1/10/24 Sig [significant] wt [weight] gain at 1 mon [month] r/t good po intake w/augmentation of nutritional supplement, Revision on: 1/10/24 .Goal: .Maintain weight +/-5% q [every] month x 3 months .Target Date: 03/03/2024 . RD stated, the goal indicated, Maintain weight +/-5% q month x 3 months. RD stated, the goal was not for weight loss, so the -5% of weight as part of the goal would not be applicable and was not accurate. RD verified the goal in her mind was for the resident to gain weight to UBW of 108 lbs. RD verified without a measurable goal the IDT would not know when the rate of weight gain or amount of weight gain might be of concern. RD verified without a specific measurable goal weight listed, the IDT would not be able to effectively monitor the POC, nor know when to revise when appropriate. During a concurrent interview and record review on 1/10/24 at 11:38 a.m., with Director of Nursing (DON), Resident 37's IDT nutrition care plan (IDTNCP), initiated by RD on 12/06/23, was reviewed. DON stated, the documented goal was, Maintain weight +/-5% q month x 3 months. DON verified the goal was not for the resident to lose weight, therefore the care plan goal was not accurate when it included -5% as being part of the goal. DON stated the goal is for weight maintenance or +5% weight gain. DON verified the IDT nutrition care plan had not contained clear, measurable goals when DON was unable to answer what the maintenance weight was, and was not aware RD assessment was for a planned weight gain, and was unable to state how much weight gain was planned, based on the IDT nutrition care plan, since the measurable goal was not clear. In addition, DON confirmed the expectation was for the IDT care plans to be developed with the participation of the physician, and with the resident's goals for outcomes which would include a planned weight gain. 48380 2. During a review of Resident 35's History and Physical (H&P), dated 11/9/23, the H&P indicated Resident 35 was admitted on [DATE] with a history of atrial fibrillation (when the heart beats irregularly which can produce blood clots leading to stroke or heart related death) and taking Eliquis (a blood thinning medication that controls blood clots). During a concurrent observation and interview on 1/9/24 at 2:57 p.m. with Resident 35, in the room, Resident 35 was observed sitting up in wheelchair and stated, I have heart disease and take Eliquis. During a concurrent interview and record review on 1/11/23 at 3:35 p.m. with a licensed nurse (LN 3), Resident 35's clinical record was reviewed. LN 3 verified Resident 35 was taking Eliquis but unable to find documentation of a nursing care plan for monitoring. During a concurrent interview and record review on 1/12/23 at 8:27 a.m. with the DON, Resident 35's clinical record was reviewed. Resident 35's, Order Summary Report (OSR), dated 11/8/23, indicated in part, . Eliquis tablet, give10 milligrams (mg), by mouth, twice a day for seven days ending 11/15/23 .and Eliquis tablet, give 5 mg, twice a day . Resident 35's, Medication Administration Record (MAR), dated 12/1/23 - 1/11/24, was also reviewed and indicated the same Eliquis order. The DON stated the Eliquis order was current. When asked if a care plan was developed in conjuction with Resident 35 taking Eliquis, DON was unable to find a documented care plan and acknowledged one should have been developed as it was the facility's policy. During a review of the facility's policy and procedure (P&P) titled,Care Planning And Care Plans, dated April 2013, the P&P indicated, Purpose: To ensure that this facility is in compliance with the regulations by ensuring that the resident is provided with appropriate and individualized care; To provide a communication tool to the Interdisciplinary Team who is responsible for giving care on an individualized [NAME] .Guidelines: 1. The Comprehensive Care Plan is developed and revised by the IDT, with the participation of the resident and/or resident representative ., 2 .it includes measurable objectives and timetables to meet the resident's . needs that are identified in the comprehensive assessment ., 3. Patient care plans are to be initiated on admission of a patient and based on the physician's orders and assessments made of the patient ., 4. The care plans are updated as the resident conditions change and as revision is needed .

Based on observation, interview, and record review, the facility failed to obtain and provide a prescribed, routine antihypertensive medication (a medication used to lower blood pressure) ordered for one of three sampled residents (Resident 40). This failure had the potential to result in uncontrolled blood pressure levels and subsequent complications for Resident 40. Findings: During a medication pass observation on 1/10/24 at 9:18 a.m. with a licensed nurse (LN 4), Resident 40's Losartan Potassium (a medication to treat high blood pressure) scheduled to be administered for 9 a.m. was not available in the medication cart. During a concurrent interview and record review on 1/10/24 at 11:11 a.m. with LN 4, LN 4 stated, This resident (referring to Resident 40) just transitioned from short-term to long-term care ( short stay to long stay in the facility). The pharmacy does not auto refill ( automatic dispensing) medications for short term residents, only for long term. LN 4 verbalized the medication was reordered on paper and showed the facility form titled, Medication Reorder Sheet, dated 1/8/24, was faxed to the pharmacy. LN 4 could not confirm if the faxed reorder form was received by the Pharmacy (1/10/24 the medication is not available in the facility to administered). LN 4 confirmed all resident medications prescribed to be given in the facility should be available at all times. During a review of Resident 40's, Electronic Health Record (EHR), the Medical Diagnosis section dated 12/14/23 indicated, Resident 40 was a [AGE] year-old female with admitting diagnoses including, chronic obstructive pulmonary disease (COPD - a group of diseases that causes airflow blockage and breathing-related problems), chronic atrial fibrillation (quivering of the heart), and essential hypertension (HTN - high blood pressure). Further review of Resident 40's EHR, under Medication Review Report, the report indicated, a medication order for Losartan Potassium oral tablet 100 mg (milligrams), give one tablet by mouth one time a day for HTN. During a review of the facility's policy and procedures (P&P) titled, Medication Ordering and Receiving From Pharmacy Provider, dated 9/2010, the P&P indicated in part, Ordering and Receiving Non-Controlled Medications . Policy: Medications and related products are received from the provider pharmacy on a timely basis. The nursing care center maintains accurate records of medication order and receipt. The P&P indicated further, Procedure . 1.c: If not utilizing cycle fill or anniversary fill system, all medications shall be reordered in advance by writing the medication name and prescription number, or applying the peel-off bar coded label from the prescription label on the reorder sheet and faxing or otherwise transmitting the order to the pharmacy. During a review of the facility's P&P titled, Medication Administration General Guidelines, dated 5/16, the P&P indicated in part, Procedures - Medication Administration .14) Medications are administered within 60 minutes of scheduled time .Unless otherwise specified by the prescriber, routine medications are administered according to the established medication administration schedule for the nursing care center . During a review of the facility's P&P titled,Medication Med Pass and Treatment Times, dated 7/23, the P&P indicated in part, Procedure .2) Medication Pass times will be as follows: QD (Daily) 9 AM .

Based on interview and record review, the facility failed to ensure the facility's Consultant Pharmacist (CP) identified and reported irregularities during the medication regimen review (MRR) when nonpharmacological interventions (NPI) were not implemented for the behaviors exhibited for depression and psychosis for one of 16 sampled residents (Resident 34) This failure had the potential to result in Resident 34 receiving unnecessary medications. Findings: During a review of Resident 34's, Medication Administration Record (MAR), dated 1/1-1/31/24, the MAR indicated the following medication orders: Seroquel Oral Tablet (Quetiapine Fumarate), give 37.5 mg (milligram) by mouth one time a day for psychosis, manifested by aggressive behavior at 4 p.m. (start date: 12/9/23), Seroquel Oral Tablet (Quetiapine Fumarate) Give 12.5 mg by mouth one time a day for psychosis, manifested by aggressive behavior at 9 am (start date: 1/4/24), and Fluoxetine HCl (Prozac) capsule 20 mg, give one capsule by mouth one time a day for depression with anxiety manifested by demonstrating restlessness as evidenced by picking at own skin (start date: 1/4/24). No documentation of the NPI monitoring for psychotic behaviors and picking of skin was noted or located in Resident 34's MAR. During a concurrent interview and record review on 01/12/24 9:26 a.m., with the director of nursing (DON) and nurse supervisor (NS), confirmed NPI's were not documented as implemented in the MAR for Resident 34 and should have been. During a concurrent interview and record review, on 1/12/24, at 9:51 a.m., with the facility's consultant pharmacist (CP) and Manager of Clinical Operations (MCO), in the presence of the DON and NS, Resident 34's psychotropic medication profile was reviewed. The CP confirmed that implementation of NPI's were not reviewed with Resident 34's monthly medication review and acknowledged failing to identify that NPI's were not being implemented while Resident 34 was on psychotropic medication. Review of facility's policy and procedure (P&P) titled, Medication Monitoring 8.1 Medication Regimen Review and Reporting, dated 01/23, the P&P indicated: Policy: Medication Regimen Review (MRR) or Drug Regimen Review is a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication. The MRR includes review of the medical record in order to prevent, identify, report, and resolve medication-related problems, medication errors, or other irregularities. The MRR also involves collaborating with other members of the IDT, including the resident, their family, and/or resident representative. Procedures: 2. The consultant pharmacist reviews the medication regimen and medical chart of each resident at least monthly to appropriately monitor the medication and ensure that the medications each resident receives are clinically indicated. Identification of irregularities may occur by the consultant pharmacist utilizing a variety of sources including medication administration records (MAR), prescriber's orders, progress notes, nurse's notes, the Resident Assessment Instrument (RAI), Minimum Data Set (MDS), laboratory and diagnostic test results, behavior monitoring information and information from the nursing care center staff and other health professional involved in the resident's care. During a review of the facility's, policy and procedures (P&P), titled, Psychotherapeutic Medication Use, dated 5/2013, the P&P indicated in part, .1) The facility will exhaust alternative methods necessary to manage a resident's behavior as much as possible; The initial approach to management of behavioral symptoms in older adults should focus on environmental modifications, behavioral interventions, psychotherapy or other nonpharmacologic interventions .4) A Monthly Summary on the Use of Psychotherapeutic Medications is done to determine the frequency that a behavior was manifested for the past month . During a review of facility's, P&P, titled, Use of Antipsychotic Medications, dated 5/2013, the P&P indicated in part, .2) This facility will exhaust alternative methods necessary to manage a resident's dementia-related behavior as much as possible. The initial approach to management of behavioral symptoms in older adults is focused on environmental modifications, behavioral interventions, psychotherapy, or other non-pharmacological means . 4) Interventions are implemented, monitored and revised as appropriate 5) A monthly summary of behavior manifestation is done and then becomes the basis for recommendation for dose change or maintenance.

Based on observation, interview, and record review, the facility failed to ensure its medication error rate during medication pass observation was less than five percent (5%). The facility had a cumulative medication error rate of 10.34% when three errors out of 29 opportunities for errors were observed between two licensed nurses (LN 2 and LN 4) who administered medication to two sampled residents (Residents 25 & 40) and one unsampled resident (Resident 547). The observed medication administration errors were: 1. LN 4 administered one capsule of Urox (a medication that supports bladder control) by mouth to Resident 25 instead of the prescribed order of two capsules. 2. LN 2 failed to administer the full dose of Clearlax (a laxative to treat occasional constipation) mixed in apple juice to Resident 547 when half of the mixture was thrown away. 3. LN 4 administered one puff of Tiotropium Bromide Monnohydrate (Spiriva - an inhaled medication that relaxes and opens the air passages of the lungs) to Resident 40 instead of the prescribed two puffs. These failures had the potential to compromise the health and safety of these residents. Findings: 1. During a medication pass observation on 1/10/24 at 8:30 a.m., with LN 4, LN 4 was observed administering one capsule of Urox 840 mg (milligram) by mouth to Resident 25. During a concurrent interview and record review, on 1/10/24, at 11:35 a.m., with LN 4, Resident 25's, Medication Review Report (MRR), dated 1/10/24, was reviewed. The MRR indicated the medication order, Urox (Lindera) 840 mg give two capsules by mouth in AM one time a day for OAB (overactive bladder) (start date of 9/2/23). LN 4 confirmed giving only one capsule to Resident 25 instead of two and acknowledged not following the order. 2. During a medication pass observation on 1/10/24 at 8:58 a.m. with LN 2, LN 2 was observed mixing Clearlax 17 gm (gram) with four oz. (ounces) of apple juice in a five oz. cup to administer to Resident 547. Resident 547 was observed to have drank only half of the mixture and the remainder thrown away by LN 2. During a concurrent interview and record review on 1/10/24 at 12 p.m., with LN 2, Resident 547's, Medication Administration Record (MAR), dated 1/1-1/31/24, was reviewed. Resident 547's MAR indicated the medication order, Miralax (different brand name for Polyethylene Glycol, same as Clearlax) Powder 17 gm by mouth in the morning for constipation .Dissolve in 4 oz. of water/juice, hold for loose stools (start date: 11/28/23). LN 2 confirmed that Resident 547 took about 50% of the mixture and did not document it in the chart. LN 2 acknowledged that she should have documented that the resident did not receive the full dose. 3. During a medication pass observation on 1/10/24 at 9:18 a.m. with LN 4, LN 4 was observed administering Tiotropium Bromide inhaler to Resident 40. The resident only received one puff of the inhaled medication. During a concurrent interview and record review on 1/10/24 at 11:11 a.m. with LN 4, Resident 40's, MRR, dated 1/10/24, was reviewed. The MRR indicated the medication order, Spiriva HandiHaler Inhalation capsule 18 mcg (microgram) (Tiotropium .) two puff inhale orally one time a day for COPD (chronic obstructive pulmonary disease - a group of diseases that causes airflow blockage and breathing-related problems) .contents of one cap (18 mcg) daily inhaled with two puffs. LN 4 confirmed that Resident 40 only received one puff of the inhaled medication and acknowledged that the medication order was not followed. During a review of the facility's policy and procedures (P&P) Medication Administration, dated 5/16, the P&P indicated in part, Procedures - Medication Administration .1) Medications are administered in accordance with written orders of the prescriber .5) The resident is always observed after administration to ensure that the dose was completely ingested. If only a partial dose is ingested, this is noted on the MAR and action is taken appropriately .

Based on observation, interview, and record review, the facility failed to ensure expired medications and medical supplies were discarded and not readily available for staff use. This failure had the potential to result in unsafe medication administration or ineffective therapy provided to the residents. Findings: During a concurrent observation and interview on 1/9/24 at 11:09 a.m. in the facility's medication storage room with a licensed nurse (LN 2), the following expired medications were found: six Nicotine Transdermal System patches (expired 8/23), one bottle Slow Magnesium Chloride with Calcium tablets (expired 11/23), one bottle of Calcium Citrate plus Vitamin D3 tablets (expired 11/23), and one refrigerated E-Kit (expired 10/23). LN 2 verified the expired medications found and acknowledged they should have been removed from storage and discarded. During a concurrent observation and interview on 1/9/24 at 11:34 a.m. with LN 2, the facility's treatment cart located in nurse station 2 was inspected. The following expired items were found in the cart: two boxes of Povidone Iodine wipes (expired 10/23 & 12/23), one tube of Coloplast Woun'Dres (expired 6/23), one bottle of Curad Iodine packing strip (expired 3/23), one tube of Santyl ointment (expired 2/23), one tube of Medihoney gel (expired 1/23), one tube of Skintegrity (expired 11/23), one tube of Silvasorb gel (expired 3/23), six Silvercel non-adherent dressings (expired 10/22 & 5/23), one Calcium alginate dressing (opened & expired 10/23), one Vaseline gauze strip (opened & expired 10/23), one Aquacel AG advantage dressing (expired 10/23), one Puracol plus dressing (expired 8/23), and one Enluxtra wound dressing (expired 11/19). LN 2 verified the expired medical supplies found and acknowledged they should have been removed from storage and discarded. During a concurrent observation and interview on 1/9/24 at 12:20 p.m. with LN 2, the facility's emergency crash cart was inspected. The following expired items were found: one box face Aoxing disposable masks (expired 4/22), one general IM E-kit (expired 09/30/23), two IV administration sets (expired 5/22), two Zyno Medical IV tubings (expired 8/23 & 9/23). LN 2 verified the expired medical supplies/medications found and acknowledged they should have been removed from storage and discarded. During a review of facility's, policy and procedures (P&P) titled, Central Supplies, dated 7/2023, the P&P indicated in part, Procedures 1) Do an inventory of supplies every two weeks, 2) Ensure that there is adequate quantity and quality of supplies . 4) Observe the FIFO (first-in, first out) system to ensure that no supplies on hand are outdated and expired; supplies expiring within the month are discarded/disposed appropriately . During a review of facility's P&P, titled, Medication Storage 4.1 Storage of Medication, dated 11/17, the P&P indicated in part, Policy .Medications and biologicals are stored properly, following manufacturers or provider pharmacy recommendations, to maintain their integrity and to support safe effective drug administration . The P&P indicated further, Procedures .14) Outdated, contaminated, discontinued or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock .

Based on observation, interview, and record review, the facility failed to ensure safe food handling when puree chicken, a TCS food (Time-Temperature Control for Safety - food that requires time-temperature control to prevent the growth of bacteria), was not accurately cooled down. As a result, the residents who were scheduled to be served the planned alternate entree of puree chicken, in lieu of the main entree of puree fish, were placed at an increased risk for developing a foodborne illness. Findings: During a concurrent observation and interview on 1/09/24 at 11:15 a.m. with Dietary Manager (DM), in the walk-in refrigerator in the kitchen, a small steam table pan of puree chicken was covered and dated 1/9/24. DM stated the puree chicken was the planned alternate for that night's dinner for the resident's on a puree diet who disliked the main entree of puree fish. During an interview on 01/09/24 at 11:16 a.m. with Cook, Cook stated at 6:30 a.m. that morning he cooked chicken to an internal temperature of 165 degrees F (Fahrenheit). Cook stated he then pureed the chicken and placed the puree chicken in a holding pan that was on ice to cool down. Cook stated two hours later he checked the temperature of the puree chicken and it was 69 degrees F at 9:30 a.m. Cook was asked if there was a cooling log and cook pointed to a log posted on the wall in the kitchen titled, Cooling/Chilling Temperature Log. There were no documented entries on the cooling log for 1/9/24. Cook stated he had not yet documented any cool down temperatures for the puree chicken on the log. Cook was asked if there were any further steps he needed to do for the puree chicken. Cook stated he was done until dinner time when he would then re-heat the puree chicken to 165 degrees F to place into the steam table for dinner meal service. During a concurrent observation and interview on 1/09/24 at 11:20 a.m. with DM, DM removed the pan of puree chicken from the walk-in refrigerator and placed it on a counter in the kitchen. DM inserted a digital thermometer in the middle of the puree chicken, and DM stated, It's 59 degrees F. DM verified the thermometer obtained from the cook was calibrated that morning. DM pointed to the Thermometer Calibration Log posted on the wall that was completed that morning by the cook. During a concurrent observation and interview on 01/09/24 at 11:34 a.m. with Cook, in the presence of DM, Cook stated he cooked the chicken to 165 degrees F this morning. He pureed the chicken and placed the pan of puree chicken on ice and checked the temperature two hours later and it was 69 degrees F. Cook then stated after the 2 hour temperature check of 69 degrees F, he checked the temperature of the puree chicken again three hours later around 11:30 a.m and it was 39 degrees F. The pan of puree chicken was currently located on the counter, and DM stated the temperature was just checked and it was 59 degrees F. Cook was asked if he was able to explain how the temperature reached 39 degrees F at 11:30 a.m., when it was removed from the refrigerator and it was only 59 degrees F currently. Cook did not have an answer, and Cook stated, Anyway we are going to throw it out. A copy of the Cooling/Chilling Temperature Log was requested. During a review of the facility's Cooling/Chilling Temperature Log (CL) that was provided, dated 01/09/24, the CL indicated, Puree, 6:00 [am] 165 degrees F, 8:00 am 69 degrees F, 9:30 am 39 degrees F, initialed as completed by the cook. That was the only logged entry for 1/9/24 on the CL. During an interview on 01/09/24, at 02:46 p.m., with DM, DM stated cook should have documented the cool down process from the start on the cool down log to ensure effective monitoring for accurate and safe cool down of TCS food. DM acknowledged that cook's interview that the puree chicken reached 39 degrees F was not accurate, as the temperature was obtained at 11:34 a.m., upon surveyor request and it was 59 degrees F taken out of the refrigerator. During a review of the facility's policy and procedure (P&P) category titled, HACCP [Hazard Analysis Critical Control Points is a systematic preventive approach to food safety] Chill Method (HACCP), dated 2017, the P&P indicated, HACCP Chill Method: (Time/Temperature Control Foods for Safety) must be cooled from: 135 degrees F to 70 degrees F within two hours and then from 70 degrees F to 41 degrees F or lower in the next four hours . During a review of the FDA Food Code Annex 2022 (Annex), the Annex indicated, Time/Temperature Control for Safety Food . Bacterial growth and/or toxin production can occur if time/temperature control for safety food remains in the temperature Danger Zone . too long.

Based on observation, interview, and record review, the facility failed to ensure documentation of non-pharmacological interventions (NPI - any intervention intended to improve the health or the well-being of individuals that do not involve the use of drugs or medicine) for the use of psychotropic medications (medications used for mood and behavior modification) in one of three sampled residents (Resident 34) was in place. Resident 34 was placed on Prozac (medication to treat depression) and Seroquel (medication to regulate mood, behaviors and thoughts) with no documented NPIs. This failure had the potential to result in incomplete data used as basis for possible continued or discontinued use of psychotropic medication usage on Resident 34 and other residents. Findings: During a concurrent observation and interview on 1/11/24 at 8:30 a.m. with certified nursing assistant (CNA 1), in the facility dining room, Resident 34 was observed eating breakfast. CNA 1 reported Resident 34 eats very well and independently, sometimes able to answer simple questions but other times not able to and usually ate meals in the dining room. CNA 1 verbalized observing Resident 34 exhibiting behaviors such as waving hands or acting like trying to hit someone and other times does not respond to conversations and seemed like not there. During an interview, on 1/11/24 at 8:21 a.m. with licensed nurse (LN 1), LN 1 stated a consent had to be obtained from the resident or responsible party (RP - family member/significant other) prior to starting the resident on psychotropic medication. A new consent is obtained when there an increase in the medication dose. LN 1 added that medication adverse effects to the resident where checked and if needed, staff would try NPIs. When asked what NPI's were implemented, LN 1 stated it was all about the approach to the residents, making them feel they are part of their care. When asked if these NPI's were documented in Resident 34's chart, LN 1 stated they were not. During a review of Resident 34's, Electronic Health Record (EHR), the EHR indicated in part, Resident 34 was admitted to the facility on [DATE], with admitting diagnoses including dementia (a group of symptoms affecting memory, thinking and social abilities) with behavioral disturbance, psychosis (a condition of the mind that results in difficulties determining what is real and what is not real), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 34's, Minimum Data Set (MDS - a federally mandated health status screening and assessment tool used for all residents of long-term care health facilities) Summary, with assessment reference date (ARD) of 11/3/23, indicated in part, Section E: Mood and Behavior Patterns . no hallucination, no delusion, no behaviors exhibited. During a review of Resident 34's, Care Plans (CP), dated 11/10/23, a CP focusing on Resident 34's, Antidepressant use, indicated interventions including, Monitor medication adverse effects . Use of protective sleeves to protect against skin picking. Another CP focusing on Resident 34's, Antipsychotic medication use indicated interventions including, Monitor/document medication adverse effects and occurrence of target behaviors. During a review of Resident 34's, Medication Administration Record (MAR), dated 1/1-1/31/24, the MAR indicated the following medication orders: Seroquel Oral Tablet (Quetiapine Fumarate), give 37.5 mg (milligram) by mouth one time a day for psychosis, manifested by aggressive behavior at 4 p.m. (start date: 12/9/23), Seroquel Oral Tablet (Quetiapine Fumarate) Give 12.5 mg by mouth one time a day for psychosis, manifested by aggressive behavior at 9 am (start date: 1/4/24), and Fluoxetine HCl (Prozac) capsule 20 mg, give one capsule by mouth one time a day for depression with anxiety manifested by demonstrating restlessness as evidenced by picking at own skin (start date: 1/4/24). The MAR failed to indicate NPI monitoring for psychotic behaviors and picking of skin with Resident 34's use of these medications. Further review of the Resident 34's EHR, no NPI documentation could be located . During an concurrent interview and record review, on 1/12/24, at 9:51 a.m., with the Director of Nursing (DON) and Nurse Supervisor (NS), the DON and NS confirmed NPI's were not implemented and documented for Resident 34 and both acknowledged the NPI's should have been implemented and documented. During a review of the facility's, policy and procedures (P&P), titled, Psychotherapeutic Medication Use, dated 5/2013, the P&P indicated in part, . 1) The facility will exhaust alternative methods necessary to manage a resident's behavior as much as possible; The initial approach to management of behavioral symptoms in older adults should focus on environmental modifications, behavioral interventions, psychotherapy or other nonpharmacologic interventions . 4) A Monthly Summary on the Use of Psychotherapeutic Medications is done to determine the frequency that a behavior was manifested for the past month During a review of facility's, P&P, titled, Use of Antipsychotic Medications, dated 5/2013, the P&P indicated in part, . 2) This facility will exhaust alternative methods necessary to manage a resident's dementia-related behavior as much as possible. The initial approach to management of behavioral symptoms in older adults is focused on environmental modifications, behavioral interventions, psychotherapy, or other non-pharmacological means . 4) Interventions are implemented, monitored and revised as appropriate . 5) A monthly summary of behavior manifestation is done and then becomes the basis for recommendation for dose change or maintenance.

Based on record review, and interview, the facility failed to ensure the medical record for one of two sampled residents (Resident 1), was completed for neurological assessments following an unwitnessed fall. This facility failure had the potential to result in a delay of identification and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings: During a review of the facility policy and procedure titled Falls, revised 7/22, indicated in part Initiate neurocheck and monitoring for unwitnessed fall incident, with or without head trauma or injury . During an interview, and concurrent record review, with the Director of Nursing (DON), on 10/19/22, at 11:44 a.m., a document titled Neurological Assessment Sheet, undated, for Resident 1 was reviewed. The form indicated an initial assessment at 3:30 a.m., followed by additional assessments at 3:45 a.m., and 4:00 a.m. The Neurological Assessment Sheet had blank entries at 4:30 a.m., and 5:00 a.m. The DON confirmed this form was not completed by a licensed nurse (LN2), following an unwitnessed fall by Resident 1, on 10/10/22, at 3:30 a.m. During an interview with LN2 on 10/25/22, at 9:27 a.m., LN2 confirmed the Neurological Assessment Sheet for Resident 1 was incomplete, following an unwitnessed fall Resident 1 sustained on 10/10/22.

Based on interview and record review, the facility failed to ensure one of 16 sampled residents (Resident 45) was not prescribed a PRN (as needed) [CONDITION(S)] medication (drugs used to treat mental illness) past 14 days, without a rationale for continuation for its use. This failure placed Resident 45 at risk for receiving an unnecessary [CONDITION(S)] medication. Findings: During a review of Resident 45's Order Details, dated 4/25/22 and 6/2/22, the Order Details indicated in part, .[MEDICATION(S)] (medication for anxiety) tab 0.5 milligrams (MG), PRN every 12 hours for anxiety manifested by agitation. Start date 4/25/2022. End date indefinite. No new orders noted until 6/2/22. The Order Details further indicated, in part . [MEDICATION(S)] Tablet (medication for anxiety) 0.5 MG by mouth every 8 hours as needed for Anxiety manifested by agitation hitting staff. Start date 6-02-2022. End date indefinite During an interview on 7/22/22, at 9:28 a.m., with the Director of Nursing (DON), the DON acknowledged, there was no 14 day expiration date documented. DON stated, Yes, I acknowledge that is not there. During a concurrent interview, and record review, on 7/22/22, at 10:33 a.m., with the DON, Resident 45's Progress Notes by Nurse Practitioner (NP), dated 5/05/22 and by Physician, dated 6/15/22, were reviewed. The Progress Notes by NP, indicated in part . On Risperdone (medication for mental illness) currently with [MEDICATION(S)] prn which helps. The Progress Notes by physician, indicated, no information about rationale to continue the [MEDICATION(S)]. DON confirmed, there was not appropriate documentation for rationale to continue the [MEDICATION(S)] PRN, with a nod of her head. Facility was unable to provide a policy for PRN [CONDITION(S)] medications.

Based on observation, interview, and record review, the facility failed to ensure all drugs and biologicals (medications made from living cells) were labeled correctly when two bottles of Vitamin C supplements had torn off expiration dates and three bottles of Glucerna Shakes (protein supplement) were expired. This failure had the potential to expose residents to expired medications with questionable effectiveness. Findings: During an observation on 7/19/22, at 11:20 a.m., in the medication storage room, two bottles of Vitamin C 500 milligram, with the expiration date torn off, and three bottles of Glucerna Shakes, with an expiration date of 7/1/22 were noted. During an interview on 7/19/22, at 11:40 a.m., with licensed nurse (LN 3), LN 3 confirmed the items were either expired or labeled incorrectly. LN 3 stated, Yes I see they are torn off. They shouldn't be in there and LN 3 removed the Glucerna Shakes. During a concurrent observation, and interview on 7/20/22, at 1:50 p.m., licensed nurse (LN 2) was checking medication cart 1. One bottle of D3 (Vitamin D supplement) 25 micrograms, had no expiration date on the bottle. LN 2 checked the bottle and confirmed, there was no expiration date on it. LN 2 stated, I don't see a date on it. During a review of the facility's policy and procedure (P&P) titled, medications: [MEDICAL RECORD OR PHYSICIAN ORDER] &P indicated in part, .11. Medications shall not be kept in stock after expiration date on the label . 20. Medication containers with illegible, incomplete, makeshift, damaged, worn, soiled or missing labels are returned to the pharmacy .

Based on observation, interview and record review, the facility failed to: a) Provide adequate supervision and assistance while Resident 1 was self-propelling via wheelchair on [DATE] at night (11 pm to 11:30 pm) b) Assess risk for elopement and wandering after witnessing attempts of wandering and elopement, c) Develop and implement comprehensive, person-centered care plan goals and interventions related to wandering and elopement, d) Follow its Elopement Risk Policy, and, e) Identify elopement and wandering as a problem in the fall care plan. for one of three sampled residents (Resident 1) identified to require extensive assist during transfers and mobility and high risk for falls. As a result of these failures, Resident 1 wandered into a dark facility patio on [DATE] after 11:30 p.m., fell from his wheelchair, sustained a [MEDICATION NAME] force trauma to the face and head and died . Findings: Record review of Resident 1's clinical record (facesheet) dated [DATE] indicated, Resident 1 was admitted with [DIAGNOSES REDACTED]. Review of the clinical record entitled, Fall Risk Assessment, dated [DATE] revealed, Resident 1 was a high risk for falls due to: disoriented x 3 (person, place and time) at all times; history of ,[DATE] falls in past 30 days; chair bound; balance problem while standing and walking; requires use of assistive devices (i.e. cane, w/c, walker, furniture); takes ,[DATE] medications that put the resident at risk of falling; and has ,[DATE] predisposing conditions that can lead to a fall. Review of history and physical examination [REDACTED]. Review of the Minimum Date Set (comprehensive resident assessment), dated [DATE], indicated Resident 1 had moderately impaired cognition (mental awareness). Resident 1 required extensive assistance with 2 person-assist with activities of daily living including transfers, bed mobility, walking movement between locations. Resident 1 used walker and wheelchair for mobility. Review of the care plan titled the resident is high risk for falls initiated on [DATE], identified Resident 1 was a high risk for falls related to confusion/disorientation related to hepatic [MEDICAL CONDITION] (disease, damage, or malfunction of the brain), history of falls, and history of [MEDICAL CONDITION] (scarring of the liver). The care plan included intervention to allow Resident to propel himself to encourage mobility and independence and frequent visual check and monitoring of whereabouts throughout the shift. Review of the care plan initiated on [DATE] identified Resident 1 had impaired cognitive (mental process) function, forgetfulness or impaired thought processes related to dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning), and history of TBI ([MEDICAL CONDITION]). The care plan interventions included to cue, reorient and supervise the resident as needed. Review of the care plan initiated on [DATE] identified Resident 1 has communication problems due to TBI. The care plan included intervention to anticipate and meet needs, ensure/provide safe environment, and avoid isolation. Review of Progress Notes electronically signed by a Licensed Nurse (LN 1) on [DATE] at 2:55 pm., documented, Resident 1 was up in a wheelchair propelling himself, confused, at risk for fall, and attempted to transfer himself independently. Review of Progress Notes e-signed by LN 2 on [DATE] at 10:23 p.m., documented, Resident 1 was confused and was trying to leave the facility. Review of Progress Notes electronically signed by LN 3 on [DATE] at 3:45 p.m. documented, Resident 1 was propelling himself in the hall. Resident 1 attempted to elope from the facility, and was redirected by staff. During an interview on [DATE] at 1:53 p.m. LN 3 indicated, Resident 1 was confused and had a habit of wandering. LN 1 indicated Resident 1 had attempted to elope and leave the facility twice ([DATE] and [DATE]). Record review revealed, the facility was unable to provide documentation to indicate the facility assessed, initiated, developed and implemented a plan of care for wandering and elopement in order to provide the necessary supervision to prevent unsupervised fall, injury and/or death for Resident 1. During an interview on [DATE] at 9:03 a.m. the Director of Nursing (DON) confirmed the facility did not develop an elopement care plan for Resident 1. The facility was unable to provide documentation to indicate a plan of care was developed for Resident 1's wandering behavior. Review of the facility policy and procedure titled Elopement Risk Policy with revision date (MONTH) (YEAR) indicated an elopement risk care plan will be written and implemented immediately for residents and patients: a. with a prior history or incident or attempt or actual elopement from home, prior living situation or this facility regardless of the severity or outcome of that history. Review of Progress Notes dated [DATE] at 4:09 a.m., revealed the following documentation on the date on the incident on [DATE]: - At 11 pm Resident 1 was up in wheelchair in front of the computer (at the front lobby area) with other staff hanging out with him. - At around 11:15 - 11:20 pm, about ,[DATE] minutes later, staff saw Resident 1 passing by Station 2, propelling (use of wheelchair) himself. - At 11:25 pm, 10 minutes later, a nurse saw Resident 1 passing by Station 1 making left turn towards the hallway. - At 11:30 pm, CNA 1 (Incoming CNA for the 11 p.m. to 7 a.m. shift) after verbal hand-off, did not find Resident 1 in his bed, instead, Resident 1 was outside room [ROOM NUMBER]. CNA 1 directed Resident 1 to the main lobby, which is about 18 feet to the patio where Resident 1 fell . - At around 11:40 pm, about 10 minutes later, CNA 1 found Resident 1 lying on the front patio ground, with blood on the face, unresponsive, no pulse and no respiration. -Resident 1 was pronounced dead at approximately 11:50 p.m. Review of the above Progress Notes revealed, late in the night and during the change of shift, staff were aware that Resident 1 was able to move independently by propelling himself via his wheelchair, and within a very short span of time (5 to 10 minutes), Resident 1 was found at different areas of the facility. At this time of the night, and with Resident 1's known behavior of wandering, there was no evidence that the staff kept Resident 1 within eyesight at all times. The facility was unable to provide documentation to indicate Resident 1 was redirected back to his room or other area where he can be seen constantly, or offered any kind of activity to occupy him. There was no evidence that staff anticipated Resident 1 going to the main patio which was in close proximity to where Resident 1 was last seen at the main lobby. The main lobby was 18 feet to the patio. The patio, at this time was dark and no staff available to supervise his movements. Observation on [DATE] 11:19 a.m. indicated the main lobby was 18 feet to the patio's unsecured door. The computer area was in close proximity to the main entrance that opens to the parking lot and onto a busy city street. During an interview on [DATE] at 1:45 pm, American Medical Response (AMR) Clinical Manager indicated, AMR received the facility's 911 call on [DATE] at 23:47 and arrived at the facility at 23:54. According to AMR Resident 1 was found at a dark patio on the concrete (no outdoor lightening). The resident was in supine (on his back) position with his head propped on a pillow, bleeding from face and nose, and pulseless. Review of the Coroner Report, dated [DATE], indicated on [DATE], at approximately 2345 hours, decedent, (Resident 1) was located unresponsive on the ground of the patio at (name of facility) skilled nursing facility. He had [MEDICATION NAME] force head injuries on the right side of his face that were the result of an unwitnessed fall from his wheel chair ., all trauma was consistent with a ground level fall. The report further indicated Cause of Death: It was determined that the decedent (Resident 1) died as a result of the following cause: complications of [MEDICATION NAME] force head trauma due to: unwitnessed fall from wheelchair.

Based on record review, observation, and interview, the facility failed to provide adequate supervision, proper use of an assistance device to alert staff of an unassisted transfer, and maintain an environment free of accident hazards to prevent accidents for two of 13 sampled residents (Resident 1 and 3) and residents receiving physical therapy utilizing the stair step equipment device. * The facility failed to turn on the monitoring device designed to alert staff when Resident 1 got out of bed unassisted. As a result, Resident 1 transferred unassisted, fell to the ground, and sustained a scalp laceration requiring ambulance transport to the emergency department for evaluation and closure of a wound. * The facility failed to secure Resident 3's urinary catheter tubing off the ground. As a result, Resident 3 was placed at risk for stepping on the urinary catheter tubing, tripping, and pulling the catheter out of the bladder. * The facility failed to maintain resident stair step equipment device, used in physical therapy, in a manner that secured the tread and carpeting on the stairs. This placed residents receiving physical therapy utilizing the stair stepping device at risk for tripping and sustaining injury. Findings: 1. During an observation and concurrent interview on 12/20/11 at 12 noon, revealed a pad alarm on Resident 1's bed. A certified nurse assistant (CNA 3) demonstrated how to turn the pad alarm on and off. With the pad alarm switch in the "on" position, CNA 3 demonstrated the activation of the pad alarm when pressure was removed stating, "The resident is a fall risk and it is important to have the alarm on when she is in bed." During an interview on 12/20/11 at 3:15 p.m., the administrator and director of nursing (DON) indicated Resident 1 was a fall risk and therefore had a tab alarm when she was up in her wheelchair and a pad alarm when she was in bed. The DON indicated Resident 1 had fallen on 11/23/11 of which the facility investigated. The DON explained the facility investigation revealed a licensed nurse (LN 2) found Resident 1's pad alarm was turned off. The CNA assigned to Resident 1 was responsible for putting the resident to bed and had not turned the alarm on. During an interview on 12/20/11 at 3:55 p.m., LN 2 reported being the evening charge nurse for Resident 1 on 11/23/11. LN 2 explained, while giving report to the night shift charge nurse, they heard a noise, went to investigate, and found Resident 1 lying on her back, on the floor, near the bathroom door. LN 2 reported finding blood on the back of Resident 1's head and called 911. The result of LN 2's investigation of Resident 1's fall revealed Resident 1's pad alarm did not sound and alert staff Resident 1 was attempting to self transfer because it was turned off. LN 2 stated, "It (pad alarm) should have been on." Record review on 12/23/11, revealed Resident 1 was admitted to the facility with [DIAGNOSES REDACTED]. A fall risk assessment was completed on 1/6/11, indicating Resident 1 was at risk for falls. Review of Resident 1's fall risk care plan dated 1/6/11, identified Resident 1 was at risk for falls due to poor balance, gait instability, poor safety awareness secondary to dementia, and a history of falls at home. Interventions included placing the call light within reach, assistance during transfer and mobility, and physical therapy for transfer, gait, and balance training. The comprehensive assessment, dated 1/12/11, indicated Resident 1 was able to make her needs known and had clear comprehension in understanding others. Resident 1 required extensive assistance for transferring and ambulation. Review of the nursing notes dated 6/2/11, indicated Resident 1 slid from the wheelchair and was found sitting on the floor of Resident 1's room near the bathroom door. There was no documented evidence changes were made to Resident 1's fall risk care plan following this fall. Nursing notes dated 6/9/11 at 6:30 a.m., revealed Resident 1 was found out of bed, ambulating in Resident 1's room. Resident 1 had not used the call light to request assistance and indicated she was checking on her roommate. The licensed nurse faxed a request to Resident 1's physician asking for an order for [REDACTED]. Review of the physician's orders [REDACTED]. Nursing notes dated 11/23/11, at 6:10 a.m. and 3 p.m., revealed, "Bed alarm on while resident in bed." Later, on that same date at 11:03 p.m., nursing notes revealed Resident 1 was found lying on the floor of her room with a laceration to the back of her head. Resident 1 was transferred, that same day, by paramedics to the hospital emergency department and received five staples to repair a scalp laceration. Review of the facility post fall investigation dated 11/23/11, revealed the "pad alarm" (not a tab alarm as ordered by the physician) on Resident 1's bed was "not turned on." This failure resulted in staff not being alerted when Resident 1 attempted to transfer unassisted. 2. During an observation and concurrent interview on 12/20/11 at 9:03 a.m., Resident 3 was observed sitting in a merry-walker (an ambulation assistance device with a seat) while being pulled into Resident 3's room by a certified nursing assistant (CNA 5). Resident 3's urinary catheter tubing was observed dragging on the floor near Resident 3's feet. CNA 5 explained not having noticed the urinary catheter tubing dragging on the floor. CNA 5 explained the urinary catheter tubing is to be secured off the floor to prevent Resident 3 from stepping on the tubing and pulling the urinary catheter out of the bladder. 3. During the environmental tour on 12/21/11 beginning at 2:20 p.m., a two step stair equipment device used by therapy for resident training to climb stairs was observed outside the therapy room. The tread on the stairs was worn off. On the riser portion of the stairs the carpeting was still attached and loose. Residents using the stairs were at risk of catching their feet in the loose carpeting and falling.