Every finding on record at The Meadows Post Acute

Based on observation, interview, and record review, the facility failed to protect a resident's right to be free from physical abuse (deliberately aggressive or violent behavior with the intention to cause harm) for one of four sampled residents (Resident 3) when on 3/19/2026 at 10:55 a.m., Resident 4 hit Resident 3 in the right eye with a closed fist (a person's hand when the fingers are bent in toward the palm and held there tightly).This deficient practice resulted in Resident 3 being subjected to physical abuse while under the care of the facility. Resident 3, sustained purplish discoloration (purple or darkened area on the skin, usually caused by bruising or bleeding under the skin), a cut (an opening in the skin caused by trauma) measuring 0.5 centimeters (cm-unit of measurement) in length x 0.1 cm in width x 0.1 cm in depth above his right eye and pain on the right eye. Findings:a. During a review of Resident 3's Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated the facility originally admitted Resident 3 on 12/5/2024 and readmitted Resident 3 on 1/16/2026, with diagnoses including chronic obstructive pulmonary disease (COPD-a long term disease that makes it hard to breathe due to damaged, inflamed and narrowed airways), heart failure (a condition where the heart cannot pump blood throughout the body effectively enough to maintain the body's normal function), and type 2 diabetes (a condition where the body cannot control the level of sugar in the blood).During a review of Resident 3's Physician Progress Note, dated 1/17/2026, the Physician Progress Note indicated Resident 3 has the capacity to understand and make decisions.During a review of Resident 3's Minimum Data Set (MDS - a resident assessment tool) dated 2/2/2026, the MDS indicated Resident 3's cognition (the process of acquiring knowledge and understanding through thought, experience, and the senses) was intact. The MDS indicated Resident 3 required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) in most areas of activities of daily living (ADLs-activities such as bathing, dressing and toileting a person performs daily).During a review of Resident 3's Situation-Background-Assessment-Recommendation (SBAR-a document used to communicate a resident's major decline or improvement in status that will not resolve without intervention) Communication Form, dated 3/19/2026 and timed at 10:57 a.m., the SBAR Communication Form indicated on 3/19/2026 at 10:55 a.m., Resident 3 was sitting on a patio chair interacting with other residents including Resident 4, and without warning, Resident 4, who was sitting in a wheelchair in front of Resident 3, stood up and hit Resident 3 on the right upper eyebrow causing a cut measuring, 0.5 cm (in length) x 0.1 cm (in width), with a small amount of bleeding. The SBAR Communication Form indicated first aid treatment (treatment given at the time and location of an injury) was provided to Resident 3.During a review Resident 3's Skin Supplemental assessment dated [DATE], timed at 11:10 a.m., the Skin Supplemental Assessment indicated a Registered Nurse (unidentified) assessed Resident 3 and observed Resident 3 with a linear (a straight-line incision or wound) cut to the right upper eye measuring 0.5 cm x 0.1 cm x 0.1 cm with reddish discoloration.b. During review of Resident 4's Face Sheet, the Face Sheet indicated the facility admitted Resident 4 on 7/1/2024 with diagnoses including acute kidney failure (a sudden, often reversible loss of kidney function), dysphagia (difficulty swallowing), and anemia (a blood condition where a person lacks enough health red blood cells to carry adequate oxygen to the body tissues).During a review Resident 4's Physician Progress Note, dated 4/9/2025, the Physician Progress Note indicated Resident 4 has the capacity to understand and make decisions. During review of Resident 4's MDS dated [DATE], the MDS indicated Resident 4's cognition was intact. The MDS indicated Resident 4 required setup or clean-up assistance (helper sets up or cleans up; resident completes activity) in most areas of ADLs.During a review of Resident 4's SBAR Communication Form dated 3/19/2026 timed at 10:58 a.m., the SBAR Communication Form indicated on 3/19/2026 at 10:55 a.m., Resident 4 was on the patio interacting with other residents (unidentified) including Resident 3, in the presence of Activity Staff 1 (ACS 1) when suddenly Resident 4 stood up and raised his (Resident 4's) hand toward Resident 3. The SBAR Communication Form indicated that ACS 1 attempted to intervene; however, Resident 4 had already hit Resident 3 in the face.During a review of Resident 4's Progress Note, dated 3/20/2026, the Progress Note indicated the facility transferred Resident 4 to another facility on 3/20/2026.During a concurrent observation of Resident 3's right eye, and interview with Resident 3 in Resident 3's room on 3/20/26 at 3:45 p.m., Resident 3's cut to the right upper eye was covered with clear steri-strips (a bandage used to help close a cut and support healing), with purplish discoloration present. Resident 3 stated (on 3/19/26, at 10:55 a.m.) Resident 3 was in the patio with other residents including Resident 4 having a discussion, when Resident 4 stood up and used Resident 4's left closed fist to hit Resident 3's right eye area. Resident 3 stated Resident 3 was shocked because Resident 3 considered Resident 4 to be a friend. Resident 3 stated Resident 3's right eye ached and rated Resident 3's pain to be 2 out of 10 (on the numeric pain rating scale [a pain assessment tool that uses a scale ranging from zero {0- no pain} to 10 {worst pain imaginable} to quantify pain intensity). Resident 3 stated, I wish it didn't happen. During a concurrent observation of Resident 3's right eye in the presence of the Assistant Director of Nursing (ADON) and interview with the ADON in Resident 3's room on 3/20/2026, at 3:47 p.m., Resident's 3 right eye area had purplish discoloration and a cut covered with clear steri-strips. The ADON stated Resident 3 had an area of purplish discoloration approximately 1.0 cm x 1.0 cm in size next to Resident 3's right eye and a laceration (a tear or cut in the skin or tissue, typically caused by blunt or sharp trauma, often with irregular or jagged edges) measuring approximately 1.0 cm in length x 0.1 cm in width x 0.1 cm in depth covered with clear steri-strips. The ADON asked Resident 3 to rate Resident 3's pain on the numeric pain rating scale and Resident 3 responded that Resident 3's pain on the right eye area was 2 out of 10.During an interview on 3/20/2026, 4:22 p.m., with ACS 1, ACS 1 stated he witnessed Resident 4 using Resident 4's left hand to slap the right eye area of Resident 3, causing a laceration just above Resident 3's right eye area.During a concurrent interview with the Director of Nursing (DON) and record review on 3/23/2026 at 4:56 p.m., the facility's document titled, CDPH (California Department of Public Health) 5-Day Report, dated 3/23/26 was reviewed. The 5-Day Report indicated on 3/19/2025, Resident 4 stated he (Resident 4) felt his hand made contact with Resident 3's face. The DON stated Resident 4 used Resident 4's hand to strike the right eye area of Resident 3. During a concurrent interview with the Administrator (ADM) and record review on 3/24/2026 at 4:30 p.m., the facility's Policy and Procedure (P&P) titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, dated 11/5/2025 was reviewed. The P&P indicated, Residents have the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. The ADM stated that willful non-consensual contact between residents is abuse and abuse is never to be deemed unavoidable.

Based on observation, interview, and record review, the facility:A. Failed to implement its policy and procedure (P&P) titled Food Preparation and Service, dated 11/5/2025 and failed to ensure safe and sanitary food storage and food preparation practices in the kitchen for 79 of 85 sampled residents when on 2/9/2026 [NAME] 1 thawed fish in the preparation sink without monitoring and adhering to required time and temperature guidelines for thawing, in accordance with Federal and Retail Food Code (2022) which requires that time and temperature control for safety [TCS - food items requiring strict temperature controls] foods that are slacked (the process of raising the temperature of frozen TCS foods to make it easier to cook evenly) may be held at any temperature only if the food remains frozen. Food must be completely submerged under running water during thawing, and the process does not allow thawed portions of raw animal food requiring cooking to exceed 41 degrees Fahrenheit ( F, a scale of temperature) for more than four (4) hours. This four-hour time frame includes: (a) the time the food is exposed to running water and the time required for preparation prior to cooking, (b) and the time it takes under refrigeration to reduce the food temperature to under 41 F. B. Failed to ensure one of four racks in the walk-in refrigerator was in good condition and free from chipped surfaces and peeling paint. C. Failed to ensure one of three racks in the walk-in freezer were free of rust and food residue. D. Failed to ensure dented cans were not stored with non-dented cans. E. Failed to ensure the dry storage area was maintained in a clean condition, with floor corners and storage racks free of dust. F. Failed to ensure trays were not stacked while still wet during the drying process. These deficient practices placed the residents at risk for foodborne illnesses (a disease caused by consuming food or drinks that are contaminated by germs and harmful toxins [poisonous substances that cause diseases or damage when absorbed by the body] or chemicals) from fish that were served to the residents, which could result in serious complications including dehydration (a condition occurring when the body loses more fluids primarily water, than it takes in, preventing normal, healthy functioning), malnutrition (a serious condition resulting from an imbalance in nutrient intake), sepsis (a life-threatening medical emergency caused by the body's extreme response to an infection), leading to hospitalization. On 2/10/2026 at 5:23 p.m. while onsite at the facility, the State Survey Agency (SSA) called an Immediate Jeopardy (IJ- a situation in which the facility's non-compliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death of a resident) under 42 CFR S483.60 Food and Nutrition Services, in the presence of the Administrator (ADM) and the Director of Nursing (DON) due to the facility's failure to ensure safe and sanitary food storage and food preparation practices in the kitchen by failing to monitor and adhere to required time and temperature control guidelines for thawing fish. On 2/12/2026 at 11:36 a.m., the ADM provided an acceptable IJ Removal Plan (a detailed plan that identifies all actions the facility will take to immediately address the non-compliance that has resulted to the IJ situation) for the facility's failure to ensure safe and sanitary food storage and food preparation practices. On 2/12/2026 at 3:23 p.m., while onsite at the facility, the SSA verified and confirmed the facility's full implementation of the IJ Removal Plan through observations, interviews, and record reviews, and determined the IJ situation regarding the facility's failure to ensure safe and sanitary food storage and food preparation practices in the kitchen were no longer present. The SSA removed the IJ situation, while onsite, on 2/12/2026 at 3:23 p.m., in the presence of the ADM. The acceptable IJ Removal Plan included the following summarized actions:1. On 2/9/2026 at 9:45 a.m., [NAME] 1 immediately discarded the improperly thawed fish. On 2/9/2026 at 9:50 a.m., [NAME] 1 restarted the thawing process using a new batch of fish by submerging the fish completely under running water at 70 F for an hour. [NAME] 1 took the temperature of the fish prior to cooking it at 9:50 a.m., and at 10:50 a.m. the fish temperature was 36 F. 2. On 2/10/2026, the Registered Dietitian (RD) created a Time and Temperature Monitoring form for thawing foods. The form includes the date, time the food was removed from the freezer (an appliance, room or device designed to maintain temperatures at or below 0 F to preserve food), start time of thawing, and documentation of water and food temperatures every 20 minutes. 3. On 2/10/2026 at 8:00 p.m. and 2/11/2026 at 9:30 a.m., the RD conducted an in-service (short teaching sessions designed to update staff on best practices, safety protocols, and regulatory requirements) training with nine (9) dietary staff regarding proper thawing procedures and completion of the Time and Temperature Monitoring form. One (1) dietary staff who was on vacation will receive in-service training and competency validation upon return. 4. On 2/10/2026 at 1:00 p.m., the RD and Dietary Supervisor (DS) provided a one-on-one (1:1) in-service (1:1 in-service - refers to individualized, one-on-one education a staff member or professional provides to a single individual) to [NAME] 1 on the importance of proper thawing procedures. The RD and the DS conducted a posttest regarding the proper way of thawing foods to [NAME] 1 and [NAME] 1 was able to answer correctly.5. On 2/10/2026 the RD developed a competency skills checklist to validate staff knowledge and skills related to proper thawing procedures. 6. On 2/11/2026 at 7:30 a.m., the RD provided a 1:1 education to [NAME] 1, utilizing a Spanish interpreter, regarding the facility's Policy and Procedures (P&P) for Proper Thawing of Foods under running water and completion of the temperature log. [NAME] 1 responded to oral quizzes and questions correctly.7. On 2/11/2026 at 1:00 p.m. the RD conducted an additional 1:1 in-service with [NAME] 1 regarding the thawing policy and thawing fish under cold running water. [NAME] 1 answered 12 of 12 questions competency questions correctly.8. On 2/11/2026, the DON and the Assistant Director of Nursing (ADON) identified all residents receiving a per os (PO - by mouth) diet who had the potential to be affected by the deficient practice. There were 85 in-house (individuals currently residing within the facility) residents; 83 of 85 residents were receiving oral intake, including two (2) residents receiving enteral feeding (or tube feeding, a method of delivering liquid nutrients directly into the stomach via a tube) but are on oral gratification (refers to satisfying a resident's need for oral stimulation, often stemming from dementia [a decline in mental ability - specifically memory, thinking, and reasoning severe enough to interfere with daily life] or cognitive decline). Upon review of all 85 residents determined that no residents were served the improperly thawed fish, as it had been discarded. There were no residents negatively affected. 9. On 2/11/2026 from 9:30 a.m. to 1:30 p.m., the RD conducted in-service training and competency validation with nine dietary staff regarding the following:a. When thawing fish in the sink, the fish must be completely submerged under running water at a temperature of 70 F or below.b. Proper thawing method which includes the monitoring of temperatures every 20 minutes and documented on the Sink Defrost (to turn frozen food into a thawed, unfrozen state) Temperature Log.c. Maximum thawing time under running water is two hours.d. Maintain food thawing temperature at 41 F or below.e. Food products must not remain in the temperature danger zone of 41 F to 140 F for more than four (4) hours, including thawing and preparation time. f. All food must be cooked immediately after thawing.g. Any food found to be in the temperature danger zone beyond allowable time limits must be discarded.h. The safest and easiest method of thawing is under refrigeration 48 to 72 hours (2 to 3 days) prior to cooking. All nine (9) staff members achieved a competency score of 100 percent (%). 10. Starting on 2/11/2026, the DS will provide in-service education to dietary staff on the facility's thawing policy on a quarterly basis for three (3) months, and as needed thereafter. The next scheduled in-service will occur on 5/11/2026 and continue every three (3) months. The thawing policy and its process will be incorporated into the dietary department orientation program. The DS will complete knowledge and skills competency validation with all newly hired dietary staff during their orientation period. 11. Starting on 2/11/2026, the DS will review the Defrosting Temperature Log twice a week, every Tuesday and Wednesday, to validate compliance. The review of the temperature log will be completed for four (4) weeks and evaluated for continuation as indicated. The review will be recorded in the Defrosting Temperature log and audit form by the DS. 12. Starting on 2/18/2026 the RD will validate the use of audit tool for compliance through direct observation of the thawing process during weekly facility visits and will conduct oral quizzes using the knowledge competency form. The outcome of the validation will be discussed with the ADM and DS for further corrective action. 13. Starting on 2/17/2026, the DS will conduct oral quizzes and observe thawing process at least weekly for a minimum of 3 consecutive months. Immediate 1:1 counseling will be provided as needed. Oral quizzes and observations will be documented on the competency and audit form. 14. The ADM and/or the DS will monitor and track any trends or concerns related to improper thawing of food; this will be communicated to the Quality Assessment and Assurance (QAA- a continuous process used in healthcare to evaluate and improve the quality of care and services provided to the residents) Committee for further evaluation and recommendations monthly. The QAA committee will continue to review until such time that the deficiency has been proven to be resolved for three (3) consecutive months, and/or advised by the QAA Committee. Non-compliance with F812 remained at a scope and severity level of E, indicating a pattern, with no actual harm, with potential for more than minimal harm that is not immediate jeopardy. Findings: A. During an observation in the kitchen on 2/9/2026 at 8:37 a.m., of the meat preparation sink, observed a pan of fish (not in a sealed plastic) thawing under slow running water. During a follow-up observation in the kitchen on 2/9/2026 at 9:00 a.m., observed [NAME] 1 removed the fish from the preparation sink and transferred it to a colander (a bowl-shaped kitchen utensil with small holes used for rinsing food or draining liquids from food items). During a concurrent interview and review of the video recorded by the surveyor during an observation conducted on 2/9/2026 at 8:37 a.m., of the fish being thawed on the sink, on 2/9/2026 at 9:18 a.m., with the DS stated that the fish was not in sealed plastic while being thawed. The DS stated the facility's process for thawing fish is to first place the fish in the refrigerator, then transfer it to a pan, defrost it in the sink, followed by breading (coating fish in layers typically flour, egg and breadcrumbs to create a crispy, protective crust) the fish and cooking it. The DS stated that dietary staff (Cook 1) thaw fish in the preparation sink under running water, however, dietary staff (not specified) would not know the temperature of the water because they (dietary staff) do not check or record the water temperature. The DS stated that the temperature of the fish must be monitored to ensure it does not rise above or enter the unsafe temperature danger zone range ([41 F to 135 F], where bacteria multiply rapidly, doubling in as little as 20 minutes) within four (4) hours. The DS stated the food temperature should not exceed 45 F during thawing and stated that the cooks (not specified) should be monitoring food temperatures throughout the thawing process. During an interview on 2/9/2026 at 9:32 a.m., with [NAME] 1 and the DS, [NAME] 1 stated that on 2/9/2026, he (Cook 1) was responsible for thawing the fish in the preparation sink by placing the fish in a pan under cold flowing water. [NAME] 1 stated he did not take the temperature of the fish, but since it came from the freezer, the temperature was at 0 F. [NAME] 1 stated he (Cook 1) removed the fish from the freezer and started thawing the fish around 6 a.m. [NAME] 1 stated he (Cook 1) discontinued thawing and removed the fish from the sink at around 9:00 a.m. [NAME] 1 further stated that he (Cook 1) did not check or record the temperature of the fish when he took it out from the sink. During a concurrent observation and interview on 2/9/2026 at 9:40 a.m., of the thawed fish, with the DS and [NAME] 1, [NAME] 1 stated the fish were inside the oven. Observed [NAME] 1 removed three (3) pans of fish from the oven. The DS and the surveyor obtained temperatures of five (5) randomly selected pieces of fish with the following results: Fish 1: 64.9 F (within the temperature danger zone at the time of observation) Fish 2: 64.9 F (within the temperature danger zone at the time of observation) Fish 3: 63.9 F (within the temperature danger zone at the time of observation) Fish 4: 65.1 F (within the temperature danger zone at the time of observation) Fish 5: 69.6 F (within the temperature danger zone at the time of observation) During an interview on 2/9/2026 at 9:41 a.m., with the DS and [NAME] 1, [NAME] 1 stated he (Cook 1) was waiting for the pureed food to finish cooking, which is why he (Cook 1) did not cook the fish immediately after thawing. The DS stated that staff (not specified) did not measure the temperature of the fish during the thawing process. The DS further stated the fish could not be served to residents because the temperature exceeded 45 F. The DS stated he would contact the RD Consultant to obtain a substitute menu item. During an interview on 2/9/2026 at 11:37 a.m., with the DS, the DS stated the facility does not have records or time and temperature logs for monitoring the thawing of foods, however, he (DS) would start a log moving forward. The DS stated the facility's current process for temperature monitoring is to measure the final cooking temperature of food and to recheck the temperature prior to serving it in tray line (an area where foods were assembled from the steamtable to the resident's trays). The DS stated they (dietary staff) do not measure the temperature of foods prior to the start of cooking. During an interview on 2/9/2026 at 12:07 p.m., with [NAME] 2, [NAME] 2 stated their thawing process is to thaw food in the refrigerator for three (3) days, but sometimes they (dietary staff) thaw under running water. [NAME] 2 stated that he [NAME] 2) usually thaws the thin fish in the sink for 20 to 40 minutes. [NAME] 2 stated he begins cooking the fish when it is not too frozen . [NAME] 2 stated that fish at 50 F or below, is okay and safe to cook, but fish at 51 F or above, is too thawed and not safe to cook. During a follow-up interview on 2/10/2026 at 9:50 a.m. with the DS and [NAME] 1, [NAME] 1 stated he did not cook the fish immediately after thawing yesterday (2/9/2026) because it was too early to cook it at 10 a.m., and he needed to wait until 11 a.m. to cook it. The DS then stated that delaying cooking the fish until 11 a.m. could allow the fish temperature to rise, making it unsafe to cook. The DS also stated that [NAME] 1 did not measure the temperature during the thawing process and would not measure the temperature of the fish at the start of cooking. The DS stated therefore [NAME] 1 would not know if the fish had entered the temperature danger zone before cooking. The DS stated that this could cause residents to get sick and develop foodborne illness such as salmonella poisoning (a common bacterial foodborne illness causing diarrhea [loose, watery stools], fever [high body temperature, usually above 100.4 F, signaling the body is fighting an infection or illness], and abdominal cramps [sudden, tight or aching sensations in the stomach muscles] within six hours to six days of exposure). During an interview on 2/10/2026 at 10:14 a.m., with the RD, the RD stated that the facility's thawing process involves pulling the food item such as fish or meat from the freezer three (3) days before use and placing it in the refrigerator. The RD also stated that fish or meat may be thawed under running water for as long as the flow is sufficient and they food is cooked immediately afterward. The RD stated the process of thawing in the sink included:1. Cold water must be continuously flowing. 2. [NAME] the food immediately and food must not be refrozen.3. Thawing requires time and temperature monitoring. Staff have two (2) hours to complete thawing, and the food temperature should be at a chilled temperature (refers to holding, storing or serving cold TCS food at a temperature of 41 F and below) and refrigerated temperature of 41 F and below.4. Staff do not log time and temperature during thawing due to the time limit, so the temperature of the food is not checked during the thawing process. The RD stated that staff (dietary/kitchen staff) were not required to complete a log because they have a two-hour time limit for thawing under the water. The RD stated the thawing process was too long yesterday (2/9/2026), and the fish temperature could rise further if it was not cooked immediately. The RD stated that the fish was not appropriate to cook because the extended thawing and preparation time compromised its safety. The RD stated that monitoring time and temperature is essential for food safety and that food should be cooked to its required internal temperature. However, if food is already compromised due to improper time and temperature before cooking and is then consumed by the residents, they (residents) could potentially become ill from foodborne illnesses. The RD also stated that there may have been a misunderstanding regarding staff not needing to fully thaw food before cooking and stated that additional in-service training on proper thawing procedures is needed. During a concurrent interview and record review on 2/10/2026 at 12:36 p.m., with the DS and RD, the facility's P&P titled Policy: Thawing of Meats, dated 11/5/2025 was reviewed. The P&P indicated (3) Submerge under running, potable water (water that is safe for consumption, bathing and cleaning) at a temperature of 70 F or lower, with a pressure sufficient to flush away loose particles. (a) The food product cannot remain in the temperature danger zone (41 F to 140 F) for more than four hours, which includes the time the food was thawed. Use immediately. The RD stated that staff have two hours for thawing and four hours total for food thawing and food preparation. The RD stated that the temperature of the fish must be checked because staff (dietary/kitchen staff) would not know when the fish temperature rises during the thawing process, particularly in the thin portion of the fish. The RD stated that the policy requires both time and temperature control, however, staff (dietary/kitchen staff) were only using time control and therefore did not complete a log. The RD stated that monitoring temperature is necessary to ensure the fish remains below 41 F and is safe to cook, to prevent foodborne illnesses. During a concurrent interview and record review on 2/10/2026 at 3:16 p.m., with the DS and RD, the in-services log for thawing of food, dated 4/3/2023, 9/26/2023, 10/25/2023, 4/3/2024, 5/15/2024, 8/20/2024 and 1/12/2026 were reviewed. The DS stated that he provided in-service training to staff regarding thawing of meats by pulling them from the freezer to the refrigerator according to the pull schedule. The DS stated he (DS) could only locate lesson plans and sign in sheets for in-services on 1/12/2026, 5/15/2024 and 10/25/2023 related to meat thawing. The DS stated he only provided an in-service to the staff regarding thawing in the refrigerator by pulling the meat or fish from the freezer to the refrigerator three (3) days before use and using a meat thawing label and tracker. The DS stated that he (DS) did not provide in-service training on thawing in the sink. The RD stated that while each in-service includes discussion of different thawing processes, they were unable to provide lesson plans or documentation to verify this. During a concurrent interview and record review on 2/11/2026 at 4:48 a.m., with the DS, the Competency Test for [NAME] 1 dated 6/2023 was reviewed. The competency test indicated [NAME] 1 received a score of zero (0) on his Competency Test. The DS stated [NAME] 1 received a score of zero in the in-service test and that he (DS) did not review the test and the incorrect answers with the employee (Cook 1). The DS further stated that the score should have been totaled to verify [NAME] 1's competency, and he (DS) failed to document the score to determine whether [NAME] 1 was competent on the day the test was given. The DS stated he (DS) has no other records for [NAME] 1. During a review of the facility's P&P titled Food Preparation and Service, dated 11/5/2025, the P&P indicated, Food and Nutrition service employees prepare, distribute and serve food in a manner that complies with safe food handling practices. Policy interpretation and implementation:1. Danger zone means temperatures above 41 F and below 135 F that allow the rapid growth of pathogenic microorganisms (or pathogens, tiny organisms that can make you sick if they get inside your body) that can cause foodborne illness. Potentially Hazardous Foods (PHF - also known as TCS foods, are items that require strict temperature management to prevent rapid growth of infectious bacteria or toxin production) or Time/Temperature Control for Safety (TCS) Foods held in the danger zone for more than 4 hours (if being prepared from ingredients at ambient temperature) or 6 hours (if cooked and cooled) may cause foodborne illness outbreak if consumed. 2. Potentially Hazardous Food (PHF) or Time/Temperature Control for Safety (TCS) Food means food that requires time and temperature control for safety to limit the growth of pathogens (i.e., bacterial or viral organisms capable of causing a disease or toxin formation). Example of PHF/TCS foods include ground beef, poultry, chicken, seafood (fish or shellfish), cut melon, unpasteurized (food or beverages that have not been heated to kill pathogens, bacteria, and germs, leaving them in their raw, natural state) eggs, milk, yogurt and cottage cheese. The P&P further indicated Food Preparation, Cooking, and Holding time/Temperatures (1) The danger zone for food temperatures is above 41 F and below 135 F. This temperature range promotes the rapid growth of pathogenic microorganisms that cause foodborne illness. (3) The longer foods remain in the danger zone the greater the risk for growth of harmful pathogens. Therefore, PHF must be maintained or below 41 F or at or above 135 F. (4) Potentially hazardous foods held in the danger zone for more than 4 hours (if being prepared from ingredients at room temperature) or 6 hours (if cooked and then cooled) may cause foodborne illness. B. During an observation on 2/9/2026 at 8:41 a.m. of the racks in the walk-in refrigerator, observed one (1) of four (4) racks with chips and peeling paint. During a concurrent observation and interview on 2/9/2026 at 8:48 a.m. of the walk-in refrigerator rack with the DS, the DS stated the racks should be free of chips to prevent the harboring of bacteria. The DS stated if the racks were contaminated, food could get contaminated too and residents could get sick of foodborne illnesses because of cross-contamination. During a review of the facility's P&P titled Sanitation, dated 11/5/2025, the P&P indicated (2) All utensils, counters, shelves and equipment are kept clean, maintained in good repair and are free from breaks, corrosion, open seams, cracks and chipped areas that may affect their use or proper cleaning. Seals, hinges and fasteners are kept in good repair. During a review of Food Code 2022, dated 1/18/2023 the Food Code 2022 indicated, 4-202.11 Food-Contact Surfaces. (A) Multiuse Food-contact surfaces shall be (1) Smooth (2) Free of breaks, open seams, cracks, chips, inclusions, pits, and similar imperfections. (3) Free of sharp internal angles, corners, and crevices, (4) Finished to have smooth welds and joints. C. During an observation on 2/9/2026 at 8:45 a.m. in the walk-in freezer, observed one rack with amber discoloration. During a concurrent observation and interview on 2/9/2026 at 8:53 a.m. with the DS, observed the racks in the walk-in freezer. The DS stated that one rack had rust on it, and the other racks had food or ice cream residue. The DS stated the racks should be maintained clean to prevent contaminating other food in the freezer. The DS stated cross contamination had the potential to cause foodborne illness to the residents. During a review of the facility's P&P titled Refrigerator and Freezers, dated 11/5/2025, the P&P indicated This facility will ensure safe refrigerator and freezer maintenance, temperatures, and sanitation, and will observe food expiration guidelines.(10) Supervisors inspect refrigerators and freezer monthly for gasket condition, presence of rust, excess condensation, and any other damage or maintenance needs. Necessary repairs are initiated immediately.Refrigerator and freezers are kept clean, free of debris, and disinfected with sanitizing solution on a scheduled basis and more as often as necessary. During a review of Food Code 2022, the Food Code 2022 indicated,4-602.13 Nonfood-Contact Surfaces. Nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues. D. During an observation on 2/9/2026 at 8:58 a.m. of the dry storage area, observed an area by the paper storage rack labeled with a sign Dented Cans. Observed one (1) dented can that was not separated from the non-dented cans. During a concurrent observation and interview on 2/9/2026 at 9:10 a.m., of the dry storage area, with the DS, observed four (4) dented cans that were stored with non-dented cans. The DS stated dented cans should be separated from non-dented cans because the dented cans cannot be used and should be returned to the vendor. The DS stated dented cans are harmful because it could build rust inside and consumption would be harmful as it could cause botulism (a rare but severe, potentially fatal paralytic illness caused by toxins), food poisoning, diarrhea and all symptoms of food poisoning to the residents. During a review of the facility's P&P titled Food Receiving and Storage, dated 11/5/2025, the P&P indicated, Dry foods and goods are handled and stored in a manner that maintains the integrity of the packaging until they are ready to use. During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated, 3-101.11 Safe Unadulterated, and Honestly Presented. Food shall be safe, unadulterated, and, as specified under 3-601.12, honestly presented. 3-201.11 Compliance with Food Law. A primary line of defense ensuring that food meets the requirements of S3-101.11 is to obtain food from approved sources, the implications of which are discussed below. However, it is also critical to monitor food products to ensure that, after harvesting, processing, they do not fail victim to conditions that endanger their safety, make them adulterated, or compromise their honest presentation. The regulatory community, industry, and consumers should exercise vigilance in controlling the conditions to which foods are subjected and be alert to signs of abuse. FDA considers food in hermetically sealed containers that are swelled or leaking to be adulterated and actionable under the Federal Food, Drug, and Cosmetic Act. Depending on the circumstances, rusted, and pitted or dented cans may also present a serious potential hazard. E. During a concurrent observation and interview on 2/9/2026 at 9:05 a.m. of the dry storage area with the DS, the DS stated there was dust on the floor corners, storage racks, and the lid of the chocolate chip container. The DS stated it was important to maintain the storage area in a clean condition and free of dust to prevent food contamination. During a review of the facility's P&P titled Sanitation, dated 11/5/2025, the P&P indicated, The food service area is maintained in a clean and sanitary manner. During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated, 3-307.11 Miscellaneous Sources of Contamination. Food shall be protected from contamination that may result from a factor or source not specified under subparts 3-391 - 3-306. F. During an observation on 2/10/2026 at 8:41 a.m. in the kitchen, of the dishwashing process, observed clean trays stacked while still wet after being washed in the dish machine. The DS stated the trays should not be stacked wet during the drying process because the moisture from the trays could promote bacterial growth. The DS stated residents could potentially get sick of foodborne illnesses due to bacteria. During a review of the facility's P&P titled Sanitation, dated 11/5/2025, the P&P indicated, (7) Food preparation equipment and utensils that are manually washed are allowed to air dry whenever practical. Drying food preparation equipment and utensils with a towel or cloth may increase risk for cross-contamination. During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated, 4-901.11 Equipment and Utensils, air-drying required. After cleaning and sanitizing equipment and utensils: (A) Shall be air-dried or used after adequate draining as specified in the first paragraph of 40 CFR 180.940 tolerance exemptions for active and inert ingredients for use in antimicrobial formulations (food-contact surface sanitizing solutions), before contact with food and; (B) May not be cloth dried except that utensils that have been air-dried may be polished with cloths that are maintained clean and dry.

Based on observation, interview, and record review, the facility failed to ensure the confidential personal information of residents were protected when meal tickets containing protected information ([PHI]- any health information that can be used to identify specific individual which must remain confidential to prevent harmful consequences) were not shredded prior to disposing in the waste container. This failure had the potential to violate 85 of 85 residents' rights to privacy and confidentiality of personal and medical records. Findings: During an observation on 2/10/2026 at 8:38 a.m. of the dishwashing area, observed meal tickets in the trash. During a concurrent observation and interview on 2/10/2026 at 8:44 a.m. of the dishwashing process with the Dietary Supervisor (DS), observed Dietary Aide 1 (DA 1) threw the meal tickets in the trash. The DS stated the trash bag would be taken to the dumpsters upstairs after dishwashing. The DS stated the meal ticket should be placed in an empty box and shredded to protect resident privacy and dignity because the meal tickets contained resident information. The DS stated what needed to get done was for the dietary aide to place the meal tickets in a box then shred it before throwing it to the dumpster. The DS stated they needed to shred the meal tickets because it had residents' name, room number, diet, likes and dislikes, and photographs of the residents. The DS stated throwing the meal tickets in the trash could result in someone accessing residents' information. The DS stated the facility has the responsibility to protect the residents' confidential information During a review of the facility's policies and procedures (P&P) titled Confidentiality of Information and Personal Privacy, dated 11/5/2025, the P&P indicated, Our facility will protect and safeguard resident confidentiality and personal privacy. Policy and interpretation. (1) The facility will safeguard the personal privacy and confidentiality of all resident personal and medical records. (2) The facility will strive to protect the resident's privacy regarding his or her: a) accommodations b) medical treatment c) Written and telephone communications d) Personal care e) Visits f) Family and resident group meetings. (4) Access to resident personal and medical records will be limited to authorized staff and business associates.

Based on observation, interview, and record review the facility failed to maintain an infection prevention and control program to help prevent the development and transmission of communicable diseases and infections by failing to:a. Ensure two (2) dented cans were separated from non-dented cans.b. Ensure the facility dumpster (a movable waste container designed to be brought and taken away by special collection vehicle, or to a bin that a specially designed garbage truck lifts) had tight fitting cover and its surrounding area was free from trash.c. Ensure a soiled towel was not touching the base of the salad plate while [NAME] 3 was preparing the salad plate.d. Ensure [NAME] 3 washed hands when changing tasks during food preparation. These failures had the potential to spread infection and cause cross contamination (contamination (the physical movement or transfer of harmful bacteria [germs] from one person, object, or place to another) among staff and 95 out of 95 residents. Findings: During an interview on 3/19/2026 at 2:56 p.m. with the Dietary Supervisor (DS), the DS stated there were 2 dented cans stored with non-dented cans. The DS stated they could not mix the dented cans with non-dented cans because residents could get sick of botulism (a rare but severe, potentially fatal paralytic illness caused by toxins) if they eat the food from the dented cans. The DS stated botulism is a parasite and if consumed it could multiply in the body. During a review of the facility's policies and procedures (P&P) titled Food Storage-Dented Cans, dated 11/5/2025, the P&P indicated, Food in unlabeled, rusty, leaking, broken containers or cans with side seam dents, rim dents or swells shall not be retained or used by the facility. Procedure: All dented cans (defined as side seam or rim dents) and rusty cans are to be separated from remaining stock and placed in a specified labeled area for return to purveyor for refund. All leaking cans are to be disposed of immediately. During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated, 3-101.11 Safe Unadulterated, and Honestly Presented. Food shall be safe, unadulterated, and, as specified under 3-601.12, honestly presented. 3-201.11 Compliance with Food Law. A primary line of defense ensuring that food meets the requirements of S3-101.11 is to obtain food from approved sources, the implications of which are discussed below. However, it is also critical to monitor food products to ensure that, after harvesting, processing, they do not fail victim to conditions that endanger their safety, make them adulterated, or compromise their honest presentation. The regulatory community, industry, and consumers should exercise vigilance in controlling the conditions to which foods are subjected and be alert to signs of abuse. FDA considers food in hermetically sealed containers that are swelled or leaking to be adulterated and actionable under the Federal Food, Drug, and Cosmetic Act. Depending on the circumstances, rusted, and pitted or dented cans may also present a serious potential hazard. b. During an observation on 3/19/2026 at 9:20 a.m. with the DS, of the facility dumpster, observed the dumpster cover had a gap in between its cover and there were piles of trash, paper, and plastic in the area surrounding the dumpster. During an interview on 3/19/2026 at 3:03 p.m. with the DS, the DS stated there was a gap in the dumpster lid, and trash and wooden pallet were present in the surrounding area. The DS stated it is important to keep the area clean because trash attracts rodents, cats, pests and other critters (an animal). The DS stated residents could get ill when there are pests in the facility as pests could transfer bacteria from one place to another. During an interview on 3/19/2026 at 3:25 p.m. with the Director of Nursing (DON), the DON stated dumpster maintenance is part of infection control. The DON stated the dumpster needed to be covered and the area surrounding the dumpster should be free from debris and trash. The DON stated flies and other insects could go in and out the facility and spread infection to the residents if the dumpster was not kept closed and the surrounding area was not maintained clean and free of debris. During an interview on 3/19/2026 at 3:37 p.m. with the Infection Preventionist Nurse (IPN), the IPN stated the dumpster needed to be covered and kept completely closed to prevent the release of airborne bacteria and odors from chemicals. The IPN stated the trash could attract bugs and flies and flies carry large amounts of bacteria and potentially spread germs that may affect residents. The IPN stated it was important to keep the dumpster completely closed and maintain the surroundings clean to prevent infection and the spread of germs to the residents. During a review of the facility's P&P titled Food-Related Garbage and Refuse Disposal, dated 11/5/2025, the P&P indicated, Food-related garbage and refuse are disposed of in accordance with state laws. (2) All garbage and refuse containers are provided with tight fitting lids or covers and must be kept covered when stored or not in continuous use. (7) Outside dumpsters provided by garbage pickup services will be kept closed and free of surrounding litter. During a review of the facility's P&P titled Kitchen-Sanitation and Infection Control, dated 11/5/2025, the P&P indicated (14) Garbage and refuse containers are in good condition, without leaks, and waste is properly contained in dumpster/compactors with lids (or otherwise covered). During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated, 5-501.113 Covering Receptacles and waste handling units for refuse, recyclables, and returnable shall be kept covered: (A) Inside food establishment if the receptacles and units: (1) Contain food residue and are not in continuous use; or (2) After they are filled; and 174 (B) With tight-fitting lids or doors if kept outside the food establishment. During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated, 5-501.116 Cleaning Receptacles. Proper storage and disposal of garbage and refused are necessary to minimize the development of odors, prevent such waste from becoming an attractant and harborage of breeding places for insects and rodents, and prevent the soiling of food preparation and food service areas. Improperly handled garbage creates nuisance conditions, makes housekeeping difficult, and may be possible source of contamination of food, equipment, and utensils. Outside receptacles must be constructed with tight-fitting lids or covers to prevent the scattering of the garbage or refuse by birds, the breeding of flies, or the entry of rodents. Proper equipment and supplies must be made available to accomplish thorough and proper cleaning of garbage storage areas and receptacles so that unsanitary conditions can be eliminated. c.During a concurrent observation and interview on 3/19/2026 at11:40 a.m., of [NAME] 3's salad preparation in the preparation area with [NAME] 3 and the DS, observed a soiled towel touching the base of the plate where salad was being plated. [NAME] 3 stated he was using the soiled towel and stated that he should not done so because it could contaminate the salad. During an interview on 3/19/2026 at 2:58 p.m. with the DS, the DS stated the soiled towel on the preparation countertop needed to be placed in the red bucket with sanitizer because it could contaminate food and could cause foodborne illness (a disease caused by consuming food or drinks that are contaminated by germs and chemicals) to the residents. During an interview on 3/19/2026 at 3:20 p.m. with the DON, the DON stated it was not acceptable to have food and soiled towels in the same place or soiled towels in the clean area because of cross-contamination (transfer of harmful bacteria from one place to another) that could lead to foodborne illness (a disease caused by consuming food or drinks that are contaminated by germs or chemicals). During an interview on 3/19/2026 at 3:35 p.m. with the IPN, the IPN stated dirty and clean items should be separated to prevent contamination. The IPN stated the soiled cloth, or towel should not be next to the salad because it could result in cross-contamination. During a review of the facility's P&P titled Kitchen-Sanitation and Infection Control, dated 11/5/2025, the P&P indicated (9) Service area wiping cloths are cleaned and dried or placed in a chemical sanitizing solution of appropriate concentration. During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated, 3-307.11 Miscellaneous Sources of Contamination. Food shall be protected from contamination that may result from a factor or source not specified under subparts 3-391 - 3-306. d. During an observation on 3/19/2026 at 12:16 p.m. of [NAME] 3's food preparation, observed [NAME] 3 chopped vegetables then held the walk-in refrigerator handle, got carrots and returned to food preparation without washing his hands. During an interview on 3/19/2026 at 3:00 p.m. with the DS, the DS stated [NAME] 3 should have washed his hands in between tasks to prevent cross-contamination. The DS stated kitchen staff should wash hands when changing tasks, after touching the trash and soiled items, after coming from outside the kitchen, after eating, and after touching any body parts. During an interview on 3/19/2026 at 3:20 p.m. with the DON, the DON stated to help prevent infection, the facility emphasizes that staff must perform before and after any task and when changing tasks. The DON stated it was not acceptable to not wash hands when changing tasks due to the potential for bacteria transfer to food, which could result in residents developing infections. During an interview on 3/19/2026 at 3:30 p.m. with the IPN, the IPN stated dietary staff should wash hands when changing tasks to prevent contamination of food from contact with soiled surfaces. The IPN stated that not performing handwashing when changing tasks could potentially spread bacterial growth and infections to residents. During a review of the facility's P&P titled Hand Hygiene, dated 11/5/2025, the P&P indicated, The facility considers hand hygiene the primary means to prevent the spread of infections. (2) All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents and visitors. (7) The use of gloves does not replace hand hygiene/handwashing. During a review of the facility's P&P titled Infection Prevention Quality Control Plan, dated 11/5/2025, the P&P indicated, General Guidelines (4) Employees must wash their hands for 20 seconds using antimicrobial or non-antimicrobial soap and under running water under the following conditions:.(f) before and after eating or handling food (hand washing with soap and water).(r ) after handling soiled equipment and utensils.(s) after removing gloves. During a review of Food Code 2022, the Food Code 2022 indicated 2-301.14 When to Wash. Food employees shall clean their hands and exposed portions of their arms as specified under S 2-301.12 immediately before engaging in food preparation including working with exposed food, clean equipment and utensils, and unwrapped single-service and single-use articles and: (A) After touching bare human body parts other than clean hands and clean, exposed portions of arms; P (B) After using the toilet room; P (C) After caring for or handling service animals or aquatic animals as specified in 2-403.11(B); P (D) Except as specified in 2-401.11(B), after coughing, sneezing, using a handkerchief or disposable tissue, using tobacco products, eating, or drinking; P (E) After handling soiled equipment or utensils; P (F) During food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; P (G) When switching between working with raw food and working with ready-to-eat-food; P (H) Before donning gloves to initiate a task that involves working with food; P and (I) After engaging in other activities that contaminate the hands.

Based on observation, interview, and record review, the facility failed to dispose garbage and refuse properly when: a. One (1) dumpster (a movable waste container designed to be brought and taken away by special collection vehicle, or to a bin that a specially designed garbage truck lifts) was not completely closed and was propped open by a box when not actively in use. b. Food residue and paper trash were found on the ground surrounding the dumpster. Findings: a &b. During a concurrent observation and interview on 2/10/2026 at 9:13 a.m., of the dumpster area, with the Dietary Supervisor (DS) observed one dumpster that was not fully closed and the ground surrounding the dumpster had food particles and trash. The DS stated the dumpster was not fully closed and there were cheese, noodles smudges and plastic trash on the ground. The DS stated the dumpster should remain closed when not in use and the surrounding area should be kept clean to prevent attracting flies and other pests (destructive animals that spread diseases). The DS stated flies and pests could go into the facility and could potentially bring bacteria to residents resulting in infection. The DS stated the trash was not full but there was a box that was not broken down, which resulted in the dumpster lid being propped open. During a review of the facility's policies and procedures (P&P) titled Food-Related Garbage and Refuse Disposal, dated 11/5/2025, the P&P indicated, Food-related garbage and refuse are disposed of in accordance with current state laws. (1) All food waste shall be kept in containers. (2) All garbage and refuse containers are provided with tight-fitting lids or covers and must be kept covered when stored or not in continuous use. (7) Outside dumpsters provided by garbage pickup services will be kept closed and free of surrounding litter. During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated, 5-501.113 Covering Receptacles and waste handling units for refuse, recyclables, and returnable shall be kept covered: (A) Inside food establishment if the receptacles and units: (1) Contain food residue and are not in continuous use; or (2) After they are filled; and 174 (B) With tight-fitting lids or doors if kept outside the food establishment. During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated, 5-501.116 Cleaning Receptacles. Proper storage and disposal of garbage and refused are necessary to minimize the development of odors, prevent such waste from becoming an attractant and harborage of breeding places for insects and rodents, and prevent the soiling of food preparation and food service areas. Improperly handled garbage creates nuisance conditions, makes housekeeping difficult, and may be possible source of contamination of food, equipment, and utensils. Outside receptacles must be constructed with tight-fitting lids or covers to prevent the scattering of the garbage or refuse by birds, the breeding of flies, or the entry of rodents. Proper equipment and supplies must be made available to accomplish thorough and proper cleaning of garbage storage areas and receptacles so that unsanitary conditions can be eliminated.

Based on observation, interview, and record review, the facility failed to ensure residents were invited to attend group activities for two of three sampled residents (Resident 50 and Resident 54). This deficient practice had the potential to result in psychosocial decline and decreased quality of life. Findings: a. During a review of Resident 50's admission Record, the admission Record indicated the facility originally admitted Resident 50 on 5/26/2022 and readmitted Resident 50 on 10/8/2024 with diagnoses that included encephalopathy (a broad term for any brain disease that alters brain function or structure), reduced mobility, depression (a common, serious medical illness characterized by a persistent low mood, sadness, and loss of interest in activities), and unspecified osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage). During a review of Resident 50's Minimum Data Set (MDS - a resident assessment tool) dated 11/10/2025, the MDS indicated Resident 50 had clear speech, was able to make himself understood, and could understand others. The MDS indicated Resident 50's cognition (the mental action or process of acquiring knowledge and understanding through thought, experience and the senses) was moderately impaired. The MDS indicated Resident 50 was dependent (helper does all of the effort and resident does none of the effort to complete activity) on staff with oral hygiene, toileting hygiene, dressing, personal hygiene and mobility (movement). During an observation on 2/9/2026 at 10:41 a.m., in Resident 50's room, observed Resident 50 in bed with call light within reach and watching television (T.V.). During an observation on 2/10/2026 at 3:58 p.m., in Resident 50's room, observed Resident 50 in bed with call light within reach and watching T.V. During a concurrent observation and interview on 2/11/2026 at 12:54 p.m., with Resident 50, in Resident 50's room, observed Resident 50 in bed with call light within reach and having lunch. Resident 50 stated that he has not participated in group activities because no one has invited him. Resident 50 continued to state that if he was invited to group activities Resident 50 would attend. During a concurrent interview and record review on 2/11/2026 at 1:16 p.m., with the Activities Director (AD), reviewed Resident 50's Activity Notes from 11/2025 to present (2/11/2026). The AD stated that all residents are invited to join activities every morning. The AD continued to state that for the residents who choose not to participate in group activities, the activities department will provide one-on-one room visits. The AD reviewed Resident 50's Activity Notes from 11/2025 to present (2/11/2026) and stated that there was no documented evidence that Resident 50 was invited/offered to join group activities. The AD stated that Resident 50 should have been invited to group activities. b. During a review of Resident 54's admission Record, the admission Record indicated the facility originally admitted Resident 54 on 12/14/2022 and readmitted Resident 54 on 12/7/2025 with diagnoses that included acute embolism (a life-threatening condition that occurs when a blood clot that has arisen from a different area obstructs the pulmonary arteries [he major blood vessel that carries oxygen-poor blood from the right side of the heart to the lungs]) and thrombosis (the formation of a blood clot inside a blood vessel that restricts or blocks the normal flow of blood) of unspecified deep veins of left lower extremities, muscle weakness, and atelectasis (collapse lung). During a review of Resident 54's History and Physical (H&P) dated 12/10/2025, the H&P indicated Resident 54 had the capacity to understand and make medical decisions. During a review of Resident 54's MDS dated [DATE], the MDS indicated Resident 54 required substantial/maximal assistance from staff with eating and was dependent on staff with oral hygiene, and toileting. During an observation on 2/10/2026 at 10:35 a.m., in Resident 54's room, observed Resident 54 in bed, watching T.V., and with call light within reach. During an observation on 2/10/2026 at 12:35 p.m., in Resident 54's room, observed Resident 54 in bed, watching T.V., and with call light within reach. During a concurrent observation and interview on 2/11/2026 at 12:46 p.m., in Resident 54's room, observed Resident 54 in bed, having lunch. Resident 54 stated that he does not get offered to go to group activities. Resident 54 stated that it would be nice to be asked every now and then. During a concurrent interview and record review on 2/11/2026 at 1:37 p.m., with the AD, reviewed Resident 50's Activity Notes from 11/2025 to present (2/11/2026). The AD stated that all residents are offered to go to group activities every morning and throughout the day. The AD stated that if residents refuse, we cannot force residents to attend group activities, but we can encourage residents to go. The AD stated that Resident 54 does not get out of bed and does not participate in group activities. The AD reviewed Resident 50's Activity Notes from 11/2025 to present (2/11/2026) and stated that there was no documented evidence that Resident 50 was invited/offered to join group activities. The AD reviewed Resident 50's Activity Notes from 11/2025 to present (2/11/2026) and stated that there was no documented evidence that Resident 50 refused to join group activities. The AD stated that Resident 54 should have been invited to group activities. The AD stated that it is important to invite all residents to attend group activities and document their responses to activities because it is important for residents to socialize with others for the residents' psychosocial wellbeing. During a review of the facility's policy and procedure (P&P) titled, Activity Program, last reviewed on 11/5/2025, the P&P indicated activity programs are designed to meet the interests of and support the physical, mental and psychosocial well-being of each resident. The activities program is provided to support the well-being of residents and to encourage both independence and community interaction. The activities program is ongoing and includes facility-organized group activities, independent individual activities and assisted individual activities. Activities are considered any endeavor, other than routine activities of daily living (ADLs - activities related to personal care), in which the resident participates, that is intended to enhance his or her sense of well-being and to promote or enhance physical, cognitive or emotional health. Our activity programs are designed to encourage maximum individual participation and are geared to individual resident's needs. All activities are documented in the resident's medical record.

Based on observation, interview, and record review, the facility failed to prepare food in a form designed to meet individual needs when pureed rice was too sticky and did not fall off the spoon during the spoon tilt test (a method used to determine the stickiness of food and ability of the food to hold together) and pureed salad was too watery. These failures had the potential to result in difficulty in swallowing, decrease in food and nutrient intake to 14 of 85 residents on puree diet, resulting in unintended (not planned) weight loss and choking (when food gets stuck in your airway, blocking the flow of air to your lungs). Findings: During a review of the facility's cook spreadsheet (a sheet containing the kind and amount of food each diet would receive) titled, Winter Menus, dated 1/12/2026, the spreadsheet indicated residents on puree diet/International Dysphagia Initiative ([IDDSI] a framework for categorizing food textures and drink thickness) Level 4 would include the following foods on the tray: Puree fish 1/2 cup (c, a household measurement) with tarragon sauce 1 ounce (oz, a unit of measurement) Puree tartar sauce 1 tablespoon Puree creamed spinach 1/3 c Puree Cajun country rice 1/3 c Puree sweet corn salad 1/3 c Puree fruit Bavarian Milk 4 oz During a concurrent test tray (a process of tasting, temping, and evaluating the quality of food) observation and interview of the puree diet with the Dietary Supervisor (DS), observed the salad looked watery. Observed the DS performed a spoon tilt test of the puree Cajun country rice, and it did not fall off the spoon. The DS stated the puree rice did not pass the spoon tilt test because it is stickier and starchier. The DS stated puree food should not be too hard and should hold its shape on the plate however, the salad looked watery and did not hold its shape. The DS stated if the rice was too sticky, it could get stuck in their throat causing choking as a potential outcome. The DS stated if the corn salad is too watery and consumed by the residents, it could cause choking and aspiration (accidental breathing in of food and liquid into the airway and lungs) as a potential outcome. During a review of the facility's policies and procedures (P&P) titled Nutritional Care Management, dated 11/5/2025, the P&P indicated, The facility will have an approved diet manual in Food and Nutrition Services Department and at each Nurses' station. Procedure: The facility Registered Dietitian is responsible for the selection of the diet manual. The Patient Care Policy Committee must approve this selection prior to designation as the official facility diet manual. This is the primary source of therapeutic diet information. Its contents should be frequently reviewed by all Food and Nutrition Services personnel, especially the FNS Director and cooks. During a review of the facility's diet manual (a manual containing different diets descriptions, foods allowed and avoided and sample menus the facility have) titled IDDSI Level 4: Regular Pureed Diet, dated 11/5/2025, the diet manual indicated, The pureed diet is a regular diet that has been designed for resident who have difficulty chewing and/or swallowing. The texture of the prepared food items included on this diet should be smooth and free of lumps, hold their shape, while not being too firm or sticky, and should not weep. Detailed recipes and procedures for pureeing foods may be found in Book #1, under the Food Safety/Miscellaneous Section. All foods are to be prepared in a blender. This diet has texture specifications that must pass IDDSI Level #4 testing requirements. IDDSI Testing Requirements: The finished puree food item must pass IDDSI Level #4 testing requirements (i.e. appearance, fork drip, and spoon tilt tests). During a review of the facility's standardized recipe titled Recipe: Pureed (IDDSI Level 4) Starch (Rice, Pasta, Polenta, Potatoes), dated 11/5/2025, the recipe indicated, (5) The finished puree items should be smooth and free of lumps, hold its shape, while not being too firm or sticky, and should not weep. The finished pureed item must pass IDDSI Level 4, testing requirements. (i.e. the fork drip, fork pressure, and spoon tilt test). During a review of the facility's standardized recipe titled Recipe: Pureed (IDDSI Level 4) Salad, the recipe indicated, (3) the finished pureed item should be smooth and free of lumps, hold its shape, while not being too firm or sticky, and should not weep. The finished pureed item must pass IDDSI level 4 testing requirements (i.e. the fork drip, fork pressure, and spoon tilt tests). During a review of the IDDSI guideline website titled IDDSI, dated 7/2019, the IDSSI guideline indicated, Level 4 Pureed is usually eaten with spoon, falls off spoon in a single spoonful when tilted and continues to hold shape on the plate, no lumps, not sticky, and liquid must not separate from solid. Food testing method: Spoon tilt test and fork drip test.

Based on observation, interview, and record review the facility failed to follow the methods that conserved temperature for lunch when cold foods were not cold and hot food were not hot. The corn salad, tartar sauce, puree fish and puree rice were not in palatable temperatures. This failure had the potential to result in decrease in food intake to 78 of 85 residents on regular and therapeutic diets, resulting in unplanned weight loss. Findings: During a review of the facility's cook spreadsheet (a sheet containing the kind and amount of food each diet would receive) titled, Winter Menus dated 1/12/2026, the spreadsheet indicated residents on regular and therapeutic diets would include the following foods on the tray: -Fish fillet three (3) ounces (oz, a unit of measurement) -Tarragon sauce one (1) oz -Tartar sauce 1 tablespoon (tbsp, household measurement) -Cajun Country [NAME] 1/3 cup (c, household measurement) -Creamed spinach 1/2 c -Parsley Spring Garnish -Sweet corn salad 1/2 c -Fruit Bavarian Cream 3x2 1/2 inches -Milk 4 oz During an observation on 2/9/2026 at 11:44 a.m. observed staff placing milk, salad and dessert on the individual trays in the carts. During an observation on 2/9/2026 at 11:58 a.m. of the trayline (an area in the kitchen where meals are assembled on trays before being delivered to residents), observed staff started scooping food onto the resident's plate. During an observation on 2/9/2026 at 12:35 p.m. of the trayline, observed staff ending trayline lunch service. During a test tray process (a process of tasting, temping, and evaluating the quality of food) observation on 2/9/2026 at 12:47 p.m. of the regular diet with the Dietary Supervisor (DS), observed the DS took the temperature of the foods with the following results: -Sweet corn salad 50 degrees Fahrenheit ( F, a scale of temperature) -Tartar Sauce 92 F. During a test tray process observation on 2/9/20206 at 12:51 p.m. of the puree diet with the DS, observed the DS took the temperature of the foods with the following results: -Puree corn salad 58 F -Milk 48 F -Puree fruit Bavarian cream 44 F. -Puree fish 125 F -Puree creamed spinach 128 F -Puree rice 107 F. During an interview on 2/9/2026 at 12:53 p.m. with the DS, the DS stated the puree fish and rice dropped temperatures and the salad was plated in an insulated cup. The DS stated the staff should have plated the salad close to service or in batches and not ahead of time to ensure it remains cold. The DS stated hot foods should be served hot and cold foods should be served cold to prevent bacterial growth and encourage residents to eat, helping prevent weight loss. During an interview on 2/9/2026 at 1:14 p.m. with the DS, the DS stated the tartar sauce should be plated outside the plate so it would not heat up, allowing the corn salad to reach palatable temperature. The DS stated palatability could improve by placing the canned corn in the refrigerator a day before use. During a review of the facility's policies and procedures (P&P) titled Nutrition Retention of Foods, dated 11/5/2025, the P&P indicated, This facility will endeavor to prepare and serve food in such a manner as to conserve the nutritive value of food (3) Food to be prepared and refrigerated or frozen before service will be chilled to storage temperature in 2 hours or less. During a review of the facility's P&P titled Food Preparation, dated 11/5/2025, the P&P indicated, Food shall be prepared by methods that conserve nutritive value, flavor and appearance. (1) The facility will use approved recipes, standardized to meet the resident census. This count is to be kept current so that an accurate amount of food is prepared. (2) Recipes are specific as to portion yield, method of preparation, quantities of ingredients, and time and temperature guidelines.(5) Prepare foods as close as possible to serving time in order to preserve nutrition, freshness, and to prevent overcooking. During a review of the facility' P&P titled Standardized Recipe, dated 11/5/2026, the P&P indicated Standardized recipe shall be developed and used in the preparation of foods. During a review of the facility's standardized recipe titled Fish with Tarragon Sauce, dated 11/5/2026, the recipe indicated Serve on trayline at a recommended temperature of 160 F to 180 F. During a review of the facility's standardized recipe titled Homemade Tartar Sauce, dated 11/5/2025, the recipe indicated, Serve on trayline at a recommended temperature of 41 F. During a review of the facility's standardized recipe titled Sweet Corn Salad, dated 11/5/2026, the recipe indicated, Refrigerate. Serve on trayline at the recommended temperature of 41 F or less. During a review of the facility's standardized recipe titled Recipe: Pureed (IDDSI LEVEL #4) Vegetables, dated 11/5/2025, the recipe indicated Serve on trayline at the recommended temperature of 160 F -180 F. During a review of the facility's standardized recipe titled Recipe: Pureed (IDDSI LEVEL 4) Starch (Rice, Pasta, Polenta, Potatoes), dated 11/5/2025, the recipe indicated, Serve on trayline at the recommended temperature of 160 F-180 F.

Based on observation, interview, and record review, the facility failed to ensure kitchen staff were routinely trained and evaluated for competency skills when [NAME] 1 and [NAME] 2 were unable to verbalize or demonstrate the process of safely thawing food in the preparation sink and were unable to verbalize the temperature danger zone for food (41 degrees Fahrenheit [ F, a scale of temperature]-135 F, a temperature where bacteria multiply rapidly, doubling in as little as 20 minutes). These failures had the potential to result in harmful bacterial growth and cross-contamination in food, placing 83 of 85 medically compromised residents at risk for food borne illnesses (a disease caused by consuming food or drinks that are contaminated by germs and harmful toxins [poisonous substances that cause diseases or damage when absorbed by the body] or chemicals). Findings: During an observation in the kitchen, on 2/9/2026 at 8:37 a.m., of the meat preparation sink, observed a pan of fish (not in a sealed plastic) thawing under slow running water. During a follow-up observation in the kitchen, on 2/9/2026 at 9:00 a.m., observed [NAME] 1 removed the fish from the preparation sink and transferred it to a colander (a bowl-shaped kitchen utensil with small holes used for rinsing food or draining liquids from food items). During a concurrent interview and review of the video recorded by the surveyor during an observation conducted on 2/9/2026 at 8:37 a.m., on 2/9/2026 at 9:18 a.m., of the fish being thawed on the sink, with the DS, the DS stated that the fish was not in sealed plastic while being thawed. The DS stated the facility's process for thawing fish is to first place the fish in the refrigerator, then transfer it to a pan, defrost it in the sink, followed by breading (coating fish in layers typically flour, egg and breadcrumbs to create a crispy, protective crust) the fish and cooking it. The DS stated that staff thaw fish in the preparation sink under running water, however, they do not know the temperature of the water because they do not monitor or record the water temperature. The DS stated that the temperature of the fish must be monitored to ensure it does not enter or remain in the temperature danger zone ([41 F to 135 F], where bacteria multiply rapidly, doubling in as little as 20 minutes) within four (4) hours. The DS stated the food temperature should not exceed 45 F during thawing and stated that the cooks (not specified) should be monitoring food temperatures throughout the thawing process. During an interview on 2/9/2026 at 9:32 a.m., with [NAME] 1 and the DS, [NAME] 1 stated that on 2/9/2026, he (Cook 1) was responsible for thawing the fish in the preparation sink by placing the fish in a pan under cold flowing water. [NAME] 1 stated he did not take the temperature of the fish, but it came out of the freezer, so it was at 0 F. [NAME] 1 stated he (Cook 1) took the fish out from the freezer and started thawing the fish around 6 a.m. [NAME] 1 stated he (Cook 1) discontinued thawing and removed the fish from the sink at around 9:00 a.m. [NAME] 1 further stated that he (Cook 1) did not obtain or document the temperature of the fish when he took it out from the sink. During a concurrent observation and interview on 2/9/2026 at 9:40 a.m., of the thawed fish, with the DS and [NAME] 1, [NAME] 1 stated the fish were inside the oven. Observed [NAME] 1 removed three (3) pans of fish from the oven. The DS and the surveyor obtained temperatures of five (5) randomly selected pieces of fish with the following results: Fish 1: 64.9 F (within the temperature danger zone at the time of observation) Fish 2: 64.9 F (within the temperature danger zone at the time of observation) Fish 3: 63.9 F (within the temperature danger zone at the time of observation) Fish 4: 65.1 F (within the temperature danger zone at the time of observation) Fish 5: 69.6 F (within the temperature danger zone at the time of observation) During an interview on 2/9/2026 at 9:41 a.m., with the DS and [NAME] 1, [NAME] 1 stated he (Cook 1) was waiting for the pureed food to finish cooking, which is why he (Cook 1) did not cook the fish immediately after thawing. The DS stated that staff (not specified) did not obtain the temperature of the fish during the thawing process. The DS further stated the fish could not be served to residents because the temperature exceeded 45 F. The DS stated he would contact the RD Consultant to obtain a substitute menu item. During an interview on 2/9/2026 at 11:37 a.m., with the DS, the DS stated the facility does not have records or time and temperature log for monitoring the thawing of foods, however, he (DS) would start a log moving forward. The DS stated the facility's current process for temperature monitoring was to obtain the final cooking temperature of food and to recheck the temperature prior to serving it in trayline (an area where foods were assembled from the steamtable to the resident's trays). The DS stated they do not take or document food temperatures prior to the start of cooking. During an interview on 2/9/2026 at 12:07 p.m., with [NAME] 2, [NAME] 2 stated their thawing process is to thaw food in the refrigerator for three (3) days, but sometimes they (dietary staff) thaw under running water. [NAME] 2 stated that he [NAME] 2) usually thaws the thin fish in the sink for 20 to 40 minutes. [NAME] 2 stated he begins cooking the fish when it is not too frozen. [NAME] 2 stated that fish at 50 F or below, is okay and safe to cook, but fish at 51 F or above, is too thawed and not safe to cook. During an interview on 2/10/2026 at 9:50 a.m. with the DS and [NAME] 1, [NAME] 1 stated he did not cook the tilapia immediately after thawing yesterday because it was too early to cook it at 10 a.m. and he needed to wait until 11 a.m. to cook it. The DS stated the fish would raise its temperature more if it was not cooked until 11 a.m. and it would not be safe for cooking. The DS stated [NAME] 1 did not take the temperature during the thawing process and would not take the temperature of the fish at the start of cooking. The DS stated [NAME] 1 would not know the temperature of the fish was in the danger zone and would proceed cooking the fish. The DS stated the residents could get sick of foodborne illness or salmonella poisoning (a common bacterial foodborne illness causing diarrhea, fever, and abdominal cramps within 6 hours to 6 days of exposure). During an interview on 2/10/2026 at 10:14 a.m., with the RD, the RD stated that the facility's thawing process involves pulling the food item such as fish or meat from the freezer three (3) days before use and placing it in the refrigerator. The RD also stated that fish or meat may be thawed under running water for as long as the flow is sufficient and they food is cooked immediately afterward. The RD stated the process of thawing in the sink included: 1. Cold water must be continuously flowing. 2. [NAME] the food immediately and food must not be refrozen. 3. Thawing requires time and temperature monitoring. Staff have two (2) hours to complete thawing, and the food temperature should be at a chilled temperature (refers to holding, storing or serving cold TCS food at a temperature of 41 F and below) and refrigerated temperature of 41 F and below. 4. Staff do not log time and temperature during thawing due to the time limit, so the temperature of the food is not checked during the thawing process. The RD stated that staff (dietary/kitchen staff) were not required to complete a log because they have a two-hour time limit for thawing under the water. The RD stated the thawing process was too long yesterday (2/9/2026), and the fish temperature could rise further if it was not cooked immediately. The RD stated that the fish was not appropriate to cook because the extended thawing and preparation time compromised its safety. The RD stated that monitoring time and temperature is essential for food safety and that food should be cooked to its required internal temperature. However, if food is already compromised due to improper time and temperature before cooking and is then consumed by the residents, they (residents) could potentially become ill from foodborne illnesses. The RD also stated that there may have been a misunderstanding regarding staff not needing to fully thaw food before cooking and stated that additional in-service training on proper thawing procedures is needed. During a concurrent interview and record review on 2/10/2026 at12:36 p.m. with the DS and RD, the Policy: Thawing of Meats, dated 11/5/2025 was reviewed. The P&P indicated (3) Submerge under running, potable water at a temperature of 70 F or lower, with a pressure sufficient to flush away loose particles. (a) The food product cannot remain in the temperature danger zone (41 F to 140 F) for more than 4 hours, which includes the time the food was thawed. Use immediately. The RD stated the staff has 2 hours of thawing and 4 hours total for food thawing and food preparation. The RD stated they needed to check the temperature of the fish because they would not know when the fish temperature rises during the thawing process, especially the thin portion of the fishes. The RD stated the policy indicated time and temperature control, but they had time control, so they did not use a log. The RD stated they also needed to monitor temperature to ensure that the fish was below 41 F and it was safe to cook to prevent foodborne illnesses. During a concurrent interview and record review on 2/10/2026 at 3:16 p.m., with the DS and RD, the in-services log for thawing of food, dated 4/3/2023, 9/26/2023, 10/25/2023, 4/3/2024, 5/15/2024, 8/20/2024 and 1/12/2026 were reviewed. The DS stated that he provided in-service training to staff regarding thawing of meats by pulling them from the freezer to the refrigerator according to the pull schedule. The DS stated he (DS) could only locate lesson plans and sign in sheets for in-services on 1/12/2026, 5/15/2024 and 10/25/2023 related to meat thawing. The DS stated he only provided an in-service to the staff regarding thawing in the refrigerator by pulling the meat or fish from the freezer to the refrigerator three (3) days before use and using a meat thawing label and tracker. The DS stated that he (DS) did not provide in-service training on thawing in the sink. The RD stated that while each in-service includes discussion of different thawing processes, they were unable to provide lesson plans or documentation to verify this. During a concurrent interview and record review on 2/11/2026 at 4:48 p.m., with the DS, the Competency Test for [NAME] 1 dated 6/2023 was reviewed. The competency test indicated [NAME] 1 received a score of zero (0) on his Competency Test. The DS stated [NAME] 1 received a score of zero in the in-service test and that he (DS) did not review the test and the incorrect answers with the employee (Cook 1). The DS further stated that the score should have been totaled to verify [NAME] 1's competency, and he (DS) failed to document the score to determine whether [NAME] 1 was competent on the day the test was given. The DS stated he (DS) has no other records for [NAME] 1. The DS further stated the competency tests for [NAME] 2 and all other cooks were not scored. During a review of the facility's P&P titled Food Preparation and Service, dated 11/5/2025, the P&P indicated, Food and Nutrition service employees prepare, distribute and serve food in a manner that complies with safe food handling practices. Policy interpretation and implementation. 1.Danger zone means temperatures above 41 F and below 135 F that allow the rapid growth of pathogenic microorganisms that can cause foodborne illness. Potentially Hazardous Foods (PHF) or Time/Temperature Control for Safety (TCS) Foods held in the danger zone for more than 4 hours (if being prepared from ingredients at ambient temperature) or 6 hours (if cooked and cooled) may cause foodborne illness outbreak if consumed. 2. Potentially Hazardous Food (PHF) or Time/Temperature Control for Safety (TCS) Food means food that requires time and temperature control for safety to limit the growth of pathogens (i.e., bacterial or viral organisms capable of causing a disease or toxin formation). Example of PHF/TCS foods include ground beef, poultry, chicken, seafood (fish or shellfish), cut melon, unpasteurized eggs, milk, yogurt and cottage cheese. The P&P further indicated Food Preparation, Cooking, and Holding time/Temperatures (1) The danger zone for food temperatures is above 41 F and below 135 F. This temperature range promotes the rapid growth of pathogenic microorganisms that cause foodborne illness. (3) The longer foods remain in the danger zone the greater the risk for growth of harmful pathogens. Therefore, PHF must be maintained or below 41 F or at or above 135 F. (4) Potentially hazardous foods held in the danger zone for more than 4 hours (if being prepared from ingredients at room temperature) or 6 hours (if cooked and then cooled) may cause foodborne illness. During a review of the facility's job description (JD) titled Job Description: Dietary Cook, dated and signed by [NAME] 1 on 4/6/2013, the JD indicated, Essential responsibilities and job functions: (1) Performs food preparation and cooking duties in accordance with sanitary regulations, as well as our established policies and procedures.(13) Prepares food in accordance with food safety guidelines. During a review of the facility's competency test for [NAME] 1 titled Competency Test for Cooks and [NAME] Staff, dated 7/29/2024, the competency test indicated, the number of correct items was blank and did not indicate if [NAME] 1 was competent or not. The competency test further indicated if the number of correct is eight (8) or less, the DS will review in-service training relation to the question and have staff member take posttest. During a review of the facility's Job Description, titled Job Description: Dietary Cook, signed by [NAME] 2 and dated on 2/23/2022, the JD indicated, Essential Responsibilities and Job Functions: (1) Performs food preparation and cooking duties in accordance with sanitary regulations, as well as our established policies and procedures. (13) Prepares food in accordance with food safety guidelines.

Based on interview and record review, the facility failed to ensure ongoing monitoring and evaluation of a resident's diabetes mellitus (a metabolic disorder characterized by impaired blood glucose regulation and risk for complications) for one of five sampled residents (Resident 82) reviewed for unnecessary medications by failing to: 1. Ensure the physician-ordered Hemoglobin A1c (HgbA1c-a laboratory test reflecting the average blood glucose control over approximately 2-3 months) was obtained upon admission as ordered. The CMP was not re-ordered until 2/12/2026. 2. Ensure blood glucose monitoring results were consistently documented when obtained as two licensed nurses failed to record capillary blood glucose readings after testing. These deficient practices had the potential to result in undetected hyperglycemia or hypoglycemia, delayed medical intervention and avoidable complications associated with uncontrolled diabetes. Findings: During a review of Resident 82's Face Sheet, the facesheet indicated the resident was admitted to the facility on [DATE] with diagnoses that included diabetes mellitus. During a review of Resident 82's Minimum Data Set (MDS, a resident assessment tool), dated 1/23/2026, the MDS indicated Resident 82's cognitive skills (the process of acquiring knowledge and understanding through thought, experience, and senses) skills required for daily decision making were moderately impaired. The MDS indicated Resident 82 required supervision (helper provides verbal cues as resident completes activity) with eating. During a review of Resident 82's Physician Orders, the Physician Orders indicated the following orders:- Hgb A1C on admission for diagnosis of diabetes, dated 1/16/2026.- Diabetic Protocol, fingerstick blood sugar (blood sugar levels checked by analyzing a small drop of blood, obtained by pricking a finger with a small needle). Call physician if blood sugar is less than 70 milligrams per deciliter (mg/dL, a unit of measure for blood sugar, normal reference range 70-99 mg/dL) or greater than 250 mg/dL, one time a day for diabetes for seven days, dated 1/16/2026. During a review of Resident 82's January 2026 Medication Administration Record (MAR, a daily documentation record used by a licensed nurse to document medications and treatments given to a resident), the MAR indicated the licensed nurses took Resident 82's fingerstick blood sugar on 1/17/2026 through 1/23/2026. The MAR indicated by a check mark that the blood sugars were taken, but there were no blood sugar numerical values indicated on those days. During a concurrent interview and record review with the Assistant Director of Nursing (ADON) on 2/11/2026 at 2:47 p.m., the ADON reviewed Resident 82's January 2026 MAR. The ADON stated the check mark on the MAR for the fingerstick indicated that the licensed nurses performed a fingerstick to check Resident 82's blood sugar values, but did not document the results in the MAR. The ADON stated the licensed nurses should have documented the results of the fingerstick performed. The ADON stated this was important in order that Resident 82 could be assessed for hypoglycemia (low blood sugar) or hyperglycemia (high blood sugar). The ADON stated this was important so that Resident 82's physician could access whether the resident needed insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) to control the blood sugars. The ADON reviewed Resident 82's lab values. The ADON was unable to locate and confirm that an A1C was drawn. The ADON stated there had been no A1C lab drawn by the licensed nurses since Resident 82's admission to the facility. The ADON stated this was important to determine how Resident 82's diabetes was being managed. The ADON stated if Resident 82's diabetes was not controlled, she could experience diabetic ketoacidosis (a life-threatening complication of diabetes, where a severe lack of insulin forces the body to break down fat for energy, producing dangerous acidic byproducts called ketones) which could be life-threatening and result in a coma. During a concurrent interview and record review with Registered Nurse 1 (RN 1) on 2/12/2026 at 7:19 a.m., RN 1 reviewed Resident 82's 1/2026 MAR. RN 1 confirmed she checked Resident 82's blood sugar on 1/18/2026, 1/21/2026, and 1/22/2026 and documented it, but did not check to see if the value was recorded in the system. RN 1 stated she did not remember the fingerstick values. RN 1 stated it is important to have actual numerical finger stick number so the physician can access whether the resident should be prescribed insulin. During a concurrent interview and record review with the Director of Nurses (DON) on 2/12/2026 at 2:46 p.m., the DON reviewed Resident 82's January 2026 MAR and Resident 82's lab values. The DON confirmed the values were not recorded for Resident 82's blood sugars for 1/17/2026 through 1/23/2026. The DON confirmed there was no A1C taken for Resident 82 and there were no recorded fingerstick numerical values. The DON stated having lab values and actual numerical values is important in case there is an abnormal result. The DON stated Resident 82 could be at risk for hyperglycemia or hypoglycemia resulting in a change in condition such as becoming unconscious and requiring hospitalization. During a concurrent interview and record review with RN 2 on 2/12/2026 at 3:53 p.m., RN 2 reviewed Resident 82's January 2026 MAR. RN 2 confirmed she took Resident 82's blood sugar on 1/19/2026. RN 2 stated she took the value but did not know why it was not there. RN 2 stated she could not remember the exact value of the fingerstick. RN 2 stated the value should be there so Resident 82's physician can evaluate the resident's diabetes. During a record review of the facility's policy and procedure (P&P) titled, Charting and Documentation, last reviewed 11/05/2025, the P&P indicated the following:- Documentation in the medical record will be objective, complete, and accurate.- Documentation of procedures and treatments will include care-specific details, including assessment data and/or any unusual findings obtained during the procedure/treatment. During a record review of the facility's policy and procedure titled, Diabetes - Clinical Protocol, last reviewed 11/05/2025, the P&P indicated the physician will order appropriate lab tests (for example, periodic finger sticks or A1C) and adjust treatments based on these results and other parameters such as glycosuria (excessive sugar in the urine), weight gain or loss, hypoglycemic episodes, etc.

Based on observation, interview, and record review, the facility failed to ensure residents were provided with necessary assistance with activities of daily living, specifically with mobility and getting out of bed for three of three sampled residents (Resident 50, Resident 54 and Resident 9). This deficient practice resulted in residents remaining in bed for prolonged periods and had the potential to compromise residents' dignity, preferences, and functional well-being. Findings: a. During a review of Resident 50's admission Record, the admission Record indicated the facility originally admitted Resident 50 on 5/26/2022 and readmitted Resident 50 on 10/8/2024 with diagnoses that included encephalopathy (a broad term for any brain disease that alters brain function or structure), reduced mobility, depression (a common, serious medical illness characterized by a persistent low mood, sadness, and loss of interest in activities), and unspecified osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage). During a review of Resident 50's Minimum Data Set (MDS - a resident assessment tool) dated 11/10/2025, the MDS indicated Resident 50 had clear speech, was able to make himself understood, and could understand others. The MDS indicated Resident 50's cognition (the mental action or process of acquiring knowledge and understanding through thought, experience and the senses) was moderately impaired. The MDS indicated Resident 50 was dependent (helper does all of the effort and resident does none of the effort to complete activity) on staff with oral hygiene, toileting hygiene, dressing, personal hygiene and mobility (movement). During an observation on 2/9/2026 at 10:41 a.m., in Resident 50's room, observed Resident 50 in bed with call light within reach and watching television (T.V.). During an observation on 2/10/2026 at 8:58 a.m., in Resident 50's room, observed Resident 50 in bed with call light within reach and having breakfast. During an observation on 2/10/2026 at 3:58 p.m., in Resident 50's room, observed Resident 50 in bed with call light within reach and watching T.V. During a concurrent observation and interview on 2/11/2026 at 12:54 p.m., with Resident 50, in Resident 50's room, observed Resident 50 in bed with call light within reach and having lunch. Resident 50 stated that Resident 50 does not get out of bed. Resident 50 continued to state that no one has offered for Resident 50 to get out of bed and if staff offered Resident 50 would like to get out of bed and get some fresh air. During an interview on 2/11/2026 at 2:25 p.m., with Certified Nursing Assistant 1 (CNA 1), CNA 1 stated that she (CNA 1) is assigned to Resident 50 today (2/11/2026). CNA 1 stated that she (CNA 1) provided Resident 50 with morning care (care given in the morning to prepare the resident for the day). When asked if Resident 50 was assisted and taken out of bed, CNA 1 stated that she (CNA 1) did not take Resident 50 out of bed because Resident 50 does not like to get out of bed. When asked if Resident 50 was offered to get out of bed, CNA 1 stated that she (CNA 1) did not offer to get Resident 50 out of bed because every time she offers Resident 50 does not like to get out of bed. When asked about the importance of taking residents out of bed, CNA 1 stated that it important to get residents out of bed because it will help residents not develop bed sores (skin injury caused by prolonged pressure on the body, particularly over bony areas), to help with their (residents) mobility, and to help with their (residents) entertainment. b. During a review of Resident 54's admission Record, the admission Record indicated the facility originally admitted Resident 54 on 12/14/2022 and readmitted Resident 54 on 12/7/2025 with diagnoses that included acute embolism (a life-threatening condition that occurs when a blood clot that has arisen from a different area obstructs the pulmonary arteries [the major blood vessel that carries oxygen-poor blood from the right side of the heart to the lungs]) and thrombosis (the formation of a blood clot inside a blood vessel that restricts or blocks the normal flow of blood) of unspecified deep veins of left lower extremities, muscle weakness, and atelectasis (collapse lung). During a review of Resident 54's History and Physical (H&P) dated 12/10/2025, the H&P indicated Resident 54 had the capacity to understand and make medical decisions. During a review of Resident 54's MDS dated [DATE], the MDS indicated Resident 54 required substantial/maximal assistance from staff with eating and was dependent on staff with oral hygiene, and toileting. During an observation on 2/9/2026 at 11:30 a.m., in Resident 54's room, observed Resident 54 in bed with call light within reach. During an observation on 2/10/2026 at 9:00 a.m., in Resident 54's room, observed Resident 54 in bed, watching T.V., with call light within reach. During a concurrent observation and interview on 2/11/2026 at 12:50 p.m., in Resident 54's room, observed Resident 54 in bed with call light within reach. Resident 54 stated that he does not usually get out of bed because no one offers to get Resident 54 out of bed since Resident 54 requires assistance to get out of bed. Resident 54 continued to state that he would like to get out of bed and go to the patio every now and then but staff do not offer. During an interview on 2/11/2026 at 2:28 p.m., with CNA 1, CNA 1 stated that she (CNA 1) is assigned to Resident 54 today (2/11/2026). CNA 1 stated that she (CNA 1) provided Resident 54 with morning care. When asked if Resident 54 was assisted and taken out of bed, CNA 1 stated that she (CNA 1) did not take Resident 54 out of bed because Resident 54 gets out of bed only during shower days. When asked if Resident 54 was offered to get out of bed, CNA 1 stated that she (CNA 1) did not offer to get Resident 54 out of bed because CNA 1 stated that she (CNA 1) knows that Resident 54 does not like to get out of bed. CNA 1 continued to state that she should have offered for residents to get out of bed because it will help prevent bed sores and to give residents a different atmosphere. c. During a review of Resident 9's admission Record, the admission Record indicated the facility originally admitted Resident 9 on 2/12/2022 and readmitted Resident 9 on 6/27/2025 with diagnoses that included encephalopathy, irritable bowel syndrome (causes uncomfortable or painful abdominal symptoms), unspecified dementia (a general term for a decline in mental ability such as memory, thinking, and reasoning severe enough to interfere with daily life), and depression. During a review of Resident 9's MDS dated [DATE], the MDS indicated Resident 9's cognition was severely impaired. The MDS indicated Resident 9 required supervision or touching assistance with staff with eating, required substantial/maximal assistance from staff with oral hygiene and personal hygiene, and was dependent on staff with toileting. During an observation on 2/9/2026 at 9:46 a.m., in Resident 9's room, observed Resident 9 in bed with call light within reach. During an observation on 2/9/2026 at 12:48 p.m., in Resident 9's room, observed Resident 9 in bed with call light within reach. During an observation on 2/10/2026 at 9:50 a.m., in Resident 9's room, observed Resident 9 in bed with call light within reach. During an observation on 2/10/2026 at 1:48 p.m., in Resident 9's room, observed Resident 9 in bed with call light within reach. During an observation on 2/11/2026 at 10:28 a.m., in Resident 9's room, observed Resident 9 in bed with call light within reach. During an observation on 2/11/2026 at 2:55 p.m., in Resident 9's room, observed Resident 9 in bed with call light within reach. During an interview on 2/11/2026 at 2:57 p.m., with CNA 3, CNA 3 stated that she (CNA 3) is assigned to Resident 9 today (2/11/2026) and yesterday (2/10/2026). CNA 3 stated that she (CNA 3) provided Resident 9 with morning care. When asked if Resident 9 was assisted and taken out of bed, CNA 3 stated that she (CNA 3) did not assist Resident 9 out of bed today (2/11/2026) and yesterday (2/10/2026) because Resident 9 cannot tolerate being in a wheelchair. When asked where CNA 3 received information of Resident 9 not being able to tolerate being in a wheelchair, CNA 3 stated that she (CNA 3) did not know. CNA 3 continued to state that Resident 9 also says it hurt and to put Resident 9 back to bed. When asked if CNA 3 made licensed nurses aware, CNA 3 stated she (CNA 3) did not. CNA 3 continued to state that Resident 9 did not complain of pain today (2/11/2026) and did not complain of pain yesterday (2/10/2026) and she (CNA 3) did not offer Resident 9 to get out of bed today (2/11/2026) and yesterday (2/10/2026). When asked why CNA 3 did not offer Resident 9 to get out of bed CNA 3 did not answer. CNA 3 stated I'm sorry. During an interview on 2/12/2025 at 3:53 p.m. with the Assistant Director of Nursing (ADON), the ADON stated that all residents should be offered to get out of bed as part of the residents' activities of daily living (ADLs - activities related to personal care). The ADON continued to state that it is the responsibility of the charge nurses to ensure residents are up out of bed. The ADON continued to state that it is important to get residents out of bed because getting residents out of bed affects residents' quality of life because residents staying in their rooms and not given an opportunity to get out of bed can lead to residents' decline in their psychosocial well-being During a review of the facility's policy and procedure (P&P) titled, Activities of Daily Living (ADL), Supporting, last reviewed on 11/5/2025, the P&P indicated it is the policy that each resident will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. Residents will be provided with care, treatment and services to ensure that their activities of daily living (ADLs) do not diminish unless the circumstances of their clinical conditions(s) demonstrate that diminishing ADLs are unavoidable. Appropriate care and services will be provided for resident who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with : a. hygiene (bathing, dressing, grooming, and oral care); b. mobility (transfer and ambulation, including walking); c. elimination (toileting); d. dinning (meals and snacks); and e. communication (speech, language, and any functional communication systems). If residents with cognitive impairment or dementia resist care. Staff will attempt to identify the underlying cause of the problem and not just assume the resident is refusing or declining care. Approaching the resident in a different way or at a different time or having another staff member speak with the resident may be appropriate. During a review of the facility's P&P titled, Quality of Care, last reviewed on 11/15/2025, the P&P indicated each resident shall be cared for in a manner that promotes and enhances quality of care.

Based on observation, interview, and record review, the facility failed to ensure a resident was provided with a Magic Cup (a high-calorie, high-protein nutritional supplement designed for individuals needing to gain weight or requiring specialized diets) as ordered by the physician for one of one sampled residents (Resident 93). This deficient practice had the potential to result in decreased meal intake which could lead to weight loss and malnutrition (lack of sufficient nutrients in the body).Findings: During a review of Resident 93's admission Record, the admission Record indicated the facility admitted Resident 93 on 1/20/2026 with diagnoses that included metabolic encephalopathy (underlying systemic conditions or substances that disrupt the brain's chemical balance, leading to brain dysfunction), dysphagia (difficulty swallowing), and epilepsy (a disorder in which nerve cell activity in the brain is disturbed, causing seizures [sudden, uncontrolled body movements and changes in behavior that occur because of abnormal electrical activity in the brain]). During a review of Resident 93's Minimum Data Set (MDS - a resident assessment tool) dated 2/5/2026, the MDS indicated Resident 93's cognition (the mental action or process of acquiring knowledge and understanding through thought, experience and the senses) was severely impaired. The MDS indicated Resident 93 was dependent (helper does all of the effort and resident does none of the effort to complete activity) on staff with eating, oral hygiene, toileting hygiene, dressing, personal hygiene and mobility (movement). During a review of Resident 93's Order Summary Report, the Order Summary Report indicated an order for Magic Cup two times a day for supplement, ordered 2/3/2026. During a review of Resident 93's care plan (a document that summarizes a resident's needs, goals, and care/treatment) for at risk for weight changes/dehydration (the body uses or loses more fluid than it takes in) /malnutrition (a condition resulting from an unbalanced diet where the body does not receive the proper amount of calories and nutrients needed to function correctly) related to dysphagia initiated on 2/2/2026, indicated an intervention for nutrition supplement as ordered. During an observation on 2/10/2026 at 1:00 p.m., in Resident 93's room, observed Resident 93's lunch meal tray and lunch meal ticket. Resident 93's lunch meal ticket indicated: Standing orders (protocols approved by a qualified health care provider): four (4) ounces (oz.- unit of measurement) Magic Cup. During a concurrent observation, interview, and record review on 2/10/2026 at 1:01 p.m., with Certified Nursing Assistant 2 (CNA 2), observed Resident 93's lunch meal tray. CNA 2 stated that there is no Magic Cup on Resident 93's lunch meal tray. CNA 2 then reviewed Resident 93's lunch meal ticket and stated that Resident 93's lunch meal tray should have a Magic Cup because it says on Resident 93's lunch meal ticket as a standing order. During a concurrent interview and record review on 2/12/2026 at 10:46 a.m., with the Registered Dietician (RD), reviewed Resident 93's diet orders. The RD stated that Resident 93 has an order for Magic Cup two times a day at lunch and dinner. The RD stated that a Magic Cup is a nutrition supplement that can be served as a pudding or as an ice cream that will provide extra calories and protein to the resident. The RD stated that during meal service it is the responsibility of the dietary aide (individual that works in the kitchen that assists in preparing, serving, and delivering meals in healthcare settings, ensuring resident nutritional needs are met by following diet plans) to place the Magic Cup onto residents' tray and it is also nursing's responsibility prior to serving residents' meal tray to ensure everything on residents' meal ticket and meal tray are accurate. The RD stated that it was important to provide Resident 93 with the Magic Cup because it is a supplement to maintain Resident 93's weight and to support skin and wound healing. The RD continued to state that if Resident 93 does not get his Magic Cup as ordered, Resident 93 has the potential to lose weight and have prolonged skin and wound healing. The RD further stated that dietary aides should have placed Resident 93's Magic Cup on his lunch tray. During a review of the facility's policy and procedure (P&P) titled, Diet Order, last reviewed on 11/5/2025, the P&P indicated diet orders as prescribed by the physician will be provided by the Food & Nutrition Service Department. During a review of the facility's P&P titled, Tray Card System, last reviewed on 5/14/2025, the P&P indicated the Food & Nutrition Service Director is responsible for the tray card system.

Based on observation, interview, and record review, the facility failed to ensure buprenorphine (used to treat pain and opioid use disorder [chronic use of opioids that causes clinically significant distress or impairment]) was administered sublingually (method of administering medication by placing it under the tongue to dissolve) as per the physician's order for one of five sampled residents observed during medication administration. This deficient practice had the potential for the medication not to work as intended, which can lead to the return of opioid withdrawal symptoms (physical and mental symptoms that a person has when they suddenly stop or cut back the use of an addictive substance) and cravings. Findings: During a review of Resident 92's admission Record, the admission Record indicated that the facility originally admitted the resident on 3/22/2024 and readmitted the resident on 2/6/2026 with diagnoses including muscle weakness and anxiety disorder (intense, excessive, and persistent worry and fear about everyday situations). During a review of Resident 92's History and Physical (H&P) dated 10/11/2025, the H&P indicated the resident can make needs known but cannot make medical decisions. During a review of Resident 92's Order Summary Report dated 2/12/2026, the Order Summary Report indicated an order for buprenorphine hydrochloride tablet sublingual two (2) milligrams (mg- unit of measurement), give two (2) tablets sublingually four times a day for opioid use disorder. During a concurrent medication administration observation and interview on 2/11/2026 at 4:43 p.m., with Licensed Vocational Nurse 1 (LVN 1), observed LVN 1 administer medications to Resident 92. When LVN 1 administered two (2) tablets of buprenorphine to Resident 92, LVN 1 gave the resident water, and the resident swallowed the medication with water. LVN 1 did not explain the medication and did not instruct Resident 92 to place the tablet directly under the tongue and allow it to dissolve completely without swallowing or chewing. LVN 1 stated that he (LVN 1) should have given instruction to Resident 92 on how to take the buprenorphine and stated that it was a medication error and can affect the efficacy of the medication if taken a wrong route. During an interview on 2/12/2026 at 9:41 a.m., with Registered Nurse 5 (RN 5), RN 5 stated that administration of sublingual medication should be given as per physician's order because if the medication is given another route, the desired effect will not be achieved. RN 5 stated that the sublingual medication is absorbed directly into the bloodstream which has a faster absorption with a more immediate efficacy than through swallowing or oral administration of medication. During a review of the facility's policy and procedure titled, Administering Medications, last reviewed on 11/5/2025, the policy indicated, Medications shall be administered in a safe and timely manner, and as prescribed. the individual administering the medication must check the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication .

Based on observation, interview, and record review, the facility failed to ensure staffing information of the actual hours worked by licensed and unlicensed nursing staff directly responsible for resident care per shift was posted daily for two of two days on 2/11/2026 and 2/12/2026. This deficient practice had the potential to keep residents and visitors unaware of the total number of staff and the actual hours worked by the staff in the facility.Findings: During an observation on 2/11/2026 at 12:10 p.m., observed posted in nurse's station 1, framed, the facility document titled, Census and Direct Care Service Per Patient Day (DHPPD- the number of hours worked by nurses or aides in relation to the number of patients within a facility at a given time), dated 2/11/2025. During an interview on 2/11/2026 at 12:12 p.m., with Registered Nurse 5 (RN 5), RN 5 stated that the Director of Staff Development (DSD) is responsible for posting daily nursing postings. During a concurrent observation and interview on 2/12/2026 at 10:37 a.m., observed posted in nurse's station 1, framed, the facility document titled, Census and Direct Care Service Per Patient Day (DHPPD), dated 2/12/2025. The DSD stated that DHPPD hours posted are projected hours. During a concurrent interview and record review on 2/12/2026 at 11:31 a.m., with the DSD, reviewed the facility documents titled, Census and Direct Care Service Per Patient Day (DHPPD), dated 2/11/2025 and 2/12/2025. The DSD stated that the dates are incorrect and should be 2/11/2026 and 2/12/2026. The DSD stated that the nursing hours posted are projected hours. The DSD further stated that Accounts Payable/Payroll will calculate actual hours the following business day. During an interview on 2/12/2026 at 12:40 p.m., with the Accounts Payable/Payroll (AP/PR), the AP/PR stated that the nursing hours (licensed and unlicensed) posted by the DSD are projected nursing hours. The AP/PR stated she (AP/PR) is responsible for calculating the actual nursing hours worked by the licensed and unlicensed staff; however, these hours are not calculated on the day worked and are instead calculated on the next business day. The AP/PR stated that she calculated actual hours for 2/11/2026, today (2/12/2026). The AP/PR further stated that she will not calculate actual hours for today (2/12/2026) until tomorrow (2/13/2026). During an interview on 2/12/2026 at 3:51 p.m., with the Assistant Director of Nursing (ADON), the ADON stated that the facility document titled, Census and Direct Care Service Per Patient Day (DHPPD), posted and framed on nurse's station 1 are projected hours and not the actual hours. The ADON continued to state that actual nursing hours should be posted to make sure there is enough staff for the residents. The ADON continued to state that it is important to have the correct dates on the facility document Census and Direct Care Service Per Patient Day (DHPPD) because it is legal document. During a review of the facility's policy and procedure (P&P) titled, Posting Direct Care Daily Staffing, last reviewed 11/5/2025, the P&P indicated within two (2) hours of the beginning of each shift, the number of licensed nurses (RNs, LPNs, and LVNs) and the number of unlicensed nursing personnel (CNAs) directly responsible for resident care is posted in a prominent location (accessible to residents and visitors) and in a clear and readable format. Shift staffing information shall be recorded on the Nursing Staff Directly Responsible for Resident care form for each shift. The information recorded on the form shall include: b. The date for which the information is posted; f. Type (RN, LPN, LVN, CNA) and category (licensed or non-licensed) of nursing staff working during that shift; h. Total number of licensed and non-licensed nursing staff working for the posted shift. Within two (2) hours of the beginning of each shift, the shift supervisor shall compute the number of direct care staff and complete the Nursing Staff Directly Responsible for Resident Care Form. The shift supervisor shall date the form, record the census and post the staffing information in the location(s) designated by the Administrator.

Based on observation, interview and record review, the facility failed to ensure services were provided in accordance with professional standards of practice by failing to reconcile and clarify a pending ophthalmology consult order upon hospital readmission for one of one (Resident 11) resident reviewed for vision services. The facility failed to: 1. Ensure a previously ordered ophthalmology consult for cataract evaluation remained active or was clarified with the physician upon the resident's return from a general acute care hospital (GACH). 2. Review and clarify any previously scheduled specialist appointments at the time of readmission to determine whether they should be continued, discontinued, or rescheduled, in accordance with the facility's readmission process. These deficient practices resulted in a delay in ophthalmologic evaluation and cataract treatment for Resident 11. Findings:During a review of Resident 11's Face Sheet, the facesheet indicated the resident was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included hypertension (HTN, high blood pressure). During a review of Resident 11's Optometry Consultation (note from an optometrist, a practitioner who examining the eyes for visual defects and prescribes corrective lenses), dated 11/17/2025, indicated the optometrist recommended referral to an ophthalmologist for evaluation of cataracts (a medical condition in which the lens of the eye becomes progressively opaque, resulting in blurry vision). During a review of Resident 11's Physician Orders, the Physician Orders indicated: -An ophthalmology consult related to cataracts of both eyes, dated 11/17/2025.-An Appointment for cataract evaluation scheduled for 2/12/2026 at 1:30 p.m., documented on 12/05/2025. -The appointment was cancelled on 1/05/2026, when Resident 11 was transferred to a GACH on 1/02/2026. During a review of the GACH Medication Reconciliation/Physician Order Form, dated 1/06/2026, did not include a physician's order for an ophthalmology consult. During a review of Resident 11's Minimum Data Set (MDS, a resident assessment tool), dated 1/08/2026, the MDS indicated Resident 11 was moderately impaired in cognitive (the process of acquiring knowledge and understanding through thought, experience, and the senses) skills for daily decision making. The MDS further indicated Resident 11 required substantial assistance (helper does more than half the effort) with eating and oral hygiene. During an observation and interview with Resident 11 on 2/09/2026 at 9:15 a.m., Resident 11 stated she wanted an eye examination because she was unable to see the television screen clearly while in bed. During a concurrent interview and record review with the Assistant Director of Nursing (ADON) on 2/11/2026 at 11:26 a.m., the ADON reviewed Resident 11's physician's orders and was unable to locate an order for an active ophthalmology appointment. The ADON stated a physician's order is required for a resident to attend a consultation appointment. The ADON stated this was important because the facility needs to accommodate a resident's needs, especially if it involves the eyes because it can affect their vision. During a concurrent interview and record review with Registered Nurse 5 (RN 5) on 2/11/2026 at 3:30 p.m., RN 5 reviewed the physician's orders and was unable to confirm or locate an active ophthalmology order for Resident 11. During an interview on 2/11/2026 at 3:52 p.m., with Registered Nurse 4, who completed the readmission of Resident 11 on 1/6/2026, RN 4 stated, besides reviewing the GACH Medication Reconciliation/Physician Order Form, the licensed nurses view the discontinued orders from the resident's previous stay in the facility prior to hospitalization. RN 4 stated she contacted the physician regarding continuation of orders but did not obtain clarification regarding whether the ophthalmology consult should be continued or discontinued. RN 4 stated she did not follow-up with the physician to clarify the status of the consult and acknowledged she should have confirmed whether the ophthalmology consultation remained indicated. RN 4 stated Resident 11 had a urinary tract infection (UTI- an infection in the bladder/urinary tract) and was re-admitted with an antibiotic medication and she was focused on that issue. RN 4 stated this is important because Resident 11's vision problems would not have been addressed if she did not go to the ophthalmology consultation. During a review of the facility's policy and procedure (P&P) titled, admission Readmission, last reviewed 11/05/2025, the P&P indicated that upon readmission, nurses are to review and reconcile pertinent orders from previous admission including pending doctor's appointment and other orders as indicated.

Based on interview and record review, the facility failed to revise Resident 10's comprehensive person-centered care plan to include sufficiently specific and individualized interventions addressing supervision, monitoring and access to smoking materials after identifying ongoing non-compliance with smoking safety protocol, for one of one resident reviewed for smoking safety. The care plan failed to address: 1. Process of supervision by the receptionist between 8:00 a.m. and 8:00 p.m.2. Interventions to ensure other residents do not light Resident 10's cigarette.3. Activity staff monitoring while Resident 10 is smoking. 4. Specific measures to prevent burn injury related to lighter use.5. Clear parameters governing Resident 10's access to cigarette lighters. 6. Designated staff roles and responsibilities for monitoring smoking activities. This deficient practice had the potential to result in burn injury to Resident 10 and others and posed a risk to resident safety. Findings: During a review of Resident 10's Face Sheet (the front page of the chart that contains a summary of basic information about the resident), the document indicated the resident was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included paraplegia (loss of movement and/or sensation, to some degree, of the legs), hemiplegia and hemiparesis (total paralysis of the arm, leg, and trunk on the same side of the body) following cerebral infarction (a type of stroke characterized by the death of brain due to a prolonged lack of blood flow) affecting the right dominant side, and tobacco use. During a review of Resident 10's Care Plan for Smoking, initiated on 10/22/2023, the care plan indicated Resident 10 was a smoker, uses a cigarette holder during smoke breaks with assistance from staff, and had a potential for safety hazard, injury related to smoking due to non-compliance; was non-compliant with safety, refuses to surrender smoking materials. The care plan included the following interventions: 1. Instruct resident about smoking risks and hazards. 2. Instruct residents about the facility policy on smoking: locations, times, and safety concerns. 3. Notify charge nurse immediately if it is suspected resident has violated facility smoking policy. 4. Observe clothing and skin for signs of cigarette burns. 5. Resident requires supervision while smoking, during supervised smoke breaks and as needed,6. Residents also needs a cigarette adapter (a metal device where a cigarette is placed and held to resident's mouth so he can smoke without staff having to touch the cigarette). During a review of Resident 10's Progress Notes, dated 5/02/2024, and authored by the Activities Director (AD), the note indicated Resident 10 had episodes of getting upset during smoke breaks if activity assistant doesn't assist him his way or fast enough. During a review of Resident 10's Minimum Data Set (MDS, a resident assessment tool), dated 9/17/2025, the MDS indicated Resident 10 was cognitively (the process of acquiring knowledge and understanding through thought, experience, and the senses) intact with skills required for daily decision making. The MDS indicated Resident 10 was dependent on staff (helper does all the effort; resident does none of the effort to complete the activity) for dressing, eating, and oral hygiene. The MDS indicated Resident 10 currently uses tobacco. During a review of Resident 10's Interdisciplinary (a group of disciplines such as nursing, physician, and social services who meet with a resident or their responsible party to discuss interventions for their care plan) Care Conference Notes, dated 12/30/2025, the IDT note indicated Resident 10 spends time in the patio for smoke break. During a review of Resident 10's Smokin) assessment, dated 1/21/2026 indicated Resident 10 is non-compliant with the facility's smoking policy regarding the smoking schedule, smoking schedules in different areas, use of a smoking apron (fire-resistant garment designed to cover a person's chest and lap to protect them from burns caused by dropped cigarettes), and keeping his own smoking materials. The Smoking Assessment recommendations indicated Resident 10 requires supervised smoking and for his smoking materials to be secured at the nurse's station. During a review of Resident 10's Care Plan for Smoking Behavior, initiated 2/09/2026, indicated Resident 10 has a behavior of not following the smoking schedule, smoking by himself, and having other residents light cigarettes for him. The care plan goal indicated that Resident 10 would be aware of the importance of the treatment regimen and the possible consequences of non-compliance daily through the next review date. The care plan interventions included to anticipate and meeting the resident's needs; educate resident on risks and benefits; honor residents' rights and wishes for refusal of treatment/procedures. During an interview with Resident 10 on 2/12/2025 at 9:25 a.m., he stated that in the past, residents held his cigarettes to his mouth while he smoked because he could not hold it himself. Resident 10 stated those residents that held the cigarette were no longer living in the facility. Resident 10 stated he keeps one to two or more cigarettes on him at any time. During an interview with the AD on 2/12/2026 at 10:02 a.m., she stated Resident 10 smokes often, and in the past other residents have lit his cigarettes. The AD stated Resident 10 refuses to let staff keep his cigarettes and lighter or he gets upset. The AD stated he needs supervision while smoking because he is unable to move his arms. When asked how the facility ensures he does not smoke without supervision, she stated the receptionist, who works from 8 a.m. to 8 p.m. every day, notifies activities staff if the resident goes to the smoking patio alone. The AD stated Resident 10 goes to bed at 1 p.m. and wakes up at 5 a.m. The AD did not state if Resident 10 goes to smoke before 8 a.m. When asked why these interventions are not in the care plan, the AD stated she did not know they needed to be there. During a concurrent interview and record review with the Assistant Director of Nurses (ADON) on 2/12/2026 at 2:39 p.m., the ADON reviewed Resident 10's Care Plan for Smoking and Smoking Behavior. When asked if Resident 10 keeps his own cigarettes or lighter, the ADON stated she did not know. The ADON stated the care plans could have more specific interventions such as ensuring that other residents are educated to not light Resident 10's cigarettes. The ADON stated the care plan could indicate how the activities staff are involved in monitoring Resident 10 while smoking. The ADON stated it is important to have a person-centered care plan to ensure Resident 10 does not injure himself by burning himself with a cigarette. During a concurrent interview and record review with the Director of Nursing (DON) on 2/12/2026 at 3:11 p.m., the DON reviewed Resident 10's Care Plan for Smoking and Smoking Behavior. The DON stated Resident 10's care plans should have more specific interventions such as how Resident 10 has access to his cigarettes and lighter and the roles of the various staff in monitoring Resident 10's smoking. The DON stated it is important to have a specific care plan for Resident 10's smoking to ensure he does not cause burn injuries to himself or others. During a review of the facility's policy and procedure titled, Safety and Supervision of Residents, last reviewed 11/05/2025, the policy indicated the following:- Our individualized, resident-centered approach to safety addresses safety and accident hazards for individual residents.- The IDT 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 and assistive devices. - Implementing interventions to reduce accident risks and hazards shall include the following: communicating specific interventions to all relevant staff. During a review of the facility's policy and procedure titled, Smoking Policy - Residents, last reviewed 11/05/2025, the policy indicated the following:- Any resident with smoking privileges requiring monitoring shall have the direct supervision of a staff member, family member, visitor, or volunteer worker at all times while smoking.- Residents who have independent smoking privileges are permitted to keep cigarettes, electronic cigarettes, pipes, tobacco, and other smoking items in their possession.- Residents are not permitted to give smoking items to other residents. During a review of the facility's policy and procedure titled, Care Plans, Comprehensive Person-Centered, last reviewed 11/05/2025, indicated the following:- The comprehensive, person-centered care plan includes measurable objectives and timeframes; describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. - Assessments of residents are ongoing, and car plans are revised as information about the residents and the residents' condition change.

Based on interview and record review, the facility failed to follow-up with the Preadmission Screening and Resident Review (PASARR- a mandatory federal program requiring all applicants to Medicaid-certified nursing facilities to be screened for serious mental illness [SMI] or intellectual disability [ID/DD]) recommendation to obtain a PASARR Level II evaluation (an in-depth, mandatory assessment conducted when a Level I screen indicates a potential SMI, ID/DD, or related condition [RC]) for one of one sampled residents (Resident 3). This deficient practice had the potential to result in inappropriate placement and unidentified specialized services for Resident 3. Findings: During a review of Resident 3's admission Record, the admission Record indicated the facility originally admitted Resident 3 on 5/15/2024 and readmitted Resident 3 on 12/11/2025 with diagnoses that included unspecified dementia (a progressive state of decline in mental abilities), schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), bipolar disorder (mental disorder that causes unusual shifts in mood, energy, activity levels, concentration, and the ability to carry out day-to-day tasks), and depression (a common, serious medical illness characterized by a persistent low mood, sadness, and loss of interest in activities). During a review of Resident 3's Minimum Data Set (MDS - a resident assessment tool) dated 12/15/2025, the MDS indicated Resident 3's cognition (the mental action or process of acquiring knowledge and understanding through thought, experience and the senses) was moderately impaired. The MDS indicated Resident 3 required substantial/maximal assistance with staff with eating, oral hygiene and dependent (helper does all of the effort and resident does none of the effort to complete activity) on staff with toileting hygiene and dressing. During a review of Resident 3's PASARR I screening document dated 11/28/2024, the PASARR I indicated that a serious mental health (SMI) Level II Mental Health Evaluation is required. During a concurrent interview and record review on 2/12/2026 at 8:40 a.m., with the MDS Nurse (MDSN), reviewed Resident 3's PASARR I screening document, dated 11/28/2024. The MDSN stated that when a resident is admitted from a General Acute Care Hospital (GACH), the GACH initiates a PASARR I screen. The MDSN stated that upon a resident's admission to the facility, the MDSN will review residents' PASARR I screening. The MDSN stated that Resident 3 required a SMI level II mental health evaluation. The MDSN reviewed Resident 3's nursing progress notes and stated that there is no documented evidence that a follow-up was made after reviewing Resident 3's PASARR I screening document requiring Resident 3 to have a SMI level II mental health evaluation. The MDSN stated that she did not follow up on Resident 3's PASARR II evaluation because it was missed. The MDSN continued to state that she should have followed up with a PASARR representative regarding the need for Resident 3's PASARR Level II evaluation however, the MDSN did not. The MDSN stated that PASARR Level II mental health evaluations are important because the PASARR Level II mental health evaluation will help determine residents' need for specialized services and would assist in providing Resident 3 with quality care. During a review of the facility's policy and procedure titled, Pre-admission Screening Level II Resident Review (PASARR Level II), last reviewed 11/5/2025, the policy indicated the facility staff will coordinate their recommendations from the level II PASARR determination and the PASARR evaluation report with the resident's assessment, care planning and transition of care. The admission licensed staff or designee will review completion of PASARR on admission. Facility designated staff will log onto the PASARR portal weekly to check for level II determinations and evaluators reports. Designated staff/designee will report the status of the PASARRs; including level II determinations with evaluation date(s) to the Director of Nursing (DON). In the absence of the Medical Records staff the DON or designee will review the PASARR portal for new admissions and level II determinations. Designated staff will print the evaluators' report for Interdisciplinary Team (IDT- a group of health care professionals with various areas of expertise who work together toward the goals of the residents' care plan) review and place a copy of the report in the medical record. The IDT will review the level II evaluation report to develop a care plan and arrange the specialized services recommended for the resident.

Based on interview and record review, the facility failed to discuss and provide a resident's representative with information regarding formulating an advance directive (AD- a legal document indicating resident preference on end-of-life treatment decisions) for one of eight sampled residents (Resident 87). This deficient practice had the potential for Resident 87 and their representative to not be informed of their right to formulate an advance directive and not honor the resident's wishes regarding end-of-life care.Findings: During a review of Resident 87's admission Record, the admission Record indicated the facility originally admitted the resident on 1/18/2019 and readmitted the resident on 5/31/2025 with diagnoses including dementia (decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities) and hypertension (high blood pressure [the force of the blood pushing on the blood vessel walls is too high]). During a review of Resident 87's Minimum Data Set (MDS- a resident assessment tool) dated 12/31/2025, the MDS indicated the resident had severely impaired cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses). The MDS indicated that Resident 87 required substantial/maximal assistance (helper does more than half the effort) with activities of daily living (ADLs -activities related to personal care). During a review of Resident 87`s History and Physical (H&P) dated 12/10/2025, the H&P indicated that the resident does not have the capacity to understand and make medical decisions. During a concurrent interview and record review on 2/11/2026 at 9:21 a.m., with Registered Nurse 3 (RN 3), reviewed Resident 87's Advance Directive Acknowledgment form dated 5/21/2023. Resident 87's Advance Directive Acknowledgment form indicated that the resident had affixed her thumb-mark instead of her signature and had declined to receive assistance in formulating an advance directive. RN 3 stated that Resident 87's H&P dated 12/10/2025 and MDS dated 12/31/2025 indicated that Resident 87 had no capacity to make healthcare decisions and did not have the capacity to understand what is in the Advance Directive Acknowledgment form. RN 3 stated that Resident 87's responsible party or representative should have been the person provided with the Advance Directive Acknowledgment form and materials regarding the resident's right to formulate an advance directive. RN 3 stated that it is a violation of the resident's rights if they are not provided any assistance and informed of their rights to formulate an advance directive. During a review of the facility`s policy and procedure (P&P) titled, Advance Directive, last reviewed on 11/5/2025, the P&P indicated that the facility will provide residents with the opportunity to make decisions regarding their healthcare and treatment options.Upon admission, the admission Staff or designee will inform the resident of his/her right to execute an Advance Healthcare Directive.

Based on observation, interview, and record review, the facility failed to ensure residents were provided with a safe, clean, comfortable, and homelike environment for one of five sampled residents (Resident 1) by failing to provide a clean shower room.This deficient practice violated the resident's right to a comfortable, homelike environment and had the potential to negatively impact their quality of life.Findings:During a review of Resident 1's admission Record, the admission Record indicated that the facility originally admitted the resident on 12/10/2024 and readmitted the resident on 2/1/2025 with diagnoses including osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage) of left hip and immunodeficiency (a condition where the immune system is weakened, making the body unable to fight off infections and diseases effectively, leading to frequent or severe illnesses from germs that a healthy immune system would normally handle).During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 12/5/2025, the MDS indicated that Resident 1's cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and senses) was intact. The MDS indicated that Resident 1 required setup or clean-up staff assistance with shower/bathe self and supervision or touching staff assistance with tub/shower transfer. During an interview on 12/10/2025 at 1:15 p.m., with Resident 1 in Resident 1's room, Resident 1 stated that the facility had a total of four shower booths in two shower rooms. Resident 1 stated the shower rooms were not clean all of the time and Resident 1 could smell mold (a type of fungus that grows as fuzzy spots on damp organic stuff [like food, wood, or drywall] often smelling musty and potentially causing allergies or breathing problems if sensitive) while taking a shower and made her uncomfortable. Resident 1 stated when Resident 1 took a shower on the morning of 12/10/2025, Resident 1 observed black spots on the corners of the floors where the walls met and around the soap rest that was mounted in shower booth 1.During a concurrent observation and interview on 12/10/2025 at 2:28 p.m., with Maintenance Assistant 1 (MA 1) and MA 2 in shower room [ROOM NUMBER], MA 1 and MA 2 observed the following black color discolorations in shower booth 1 of shower room [ROOM NUMBER]:- Around the soap rest mounted to the wall under the hand bar.- On the cracks on the corners of both right and left sides where the mosaic tile floors and the tile walls met.- On the left corner edge of the tiled wall where the drywall met next to the stainless-steel grab bar.Both MA 1 and MA 2 checked the mentioned areas above and stated that they were discolored but the facility needed to clean them.During a concurrent observation and interview on 12/10/2024 at 3:13 p.m., with the Maintenance Supervisor (MS), the Administrator (ADM), and the Director of Nursing (DON) in shower room [ROOM NUMBER], observed black discolorations in shower booth 1 around the soap rest that is mounted to the wall under the hand bar, on the cracks on the corners on both right and left sides where the mosaic tile floors and the tiled walls met, and on the left corner edge of the tiled wall where the drywall met next to the stainless-steel grab bar. The MS swiped the discolored areas with black color and stated that it was dirty and needed to be cleaned. When the DON was asked if shower booth 1's condition was a home-like environment and safe and clean, the DON stated that the shower rooms should have been in better condition and not like that.During a concurrent interview on 12/11/2025 at 12:25 p.m., with Janitor 1 and Receptionist 1 in shower room [ROOM NUMBER], Janitor 1 stated that Janitor 1 was in charge of the cleaning of the shower rooms. Janitor 1 stated the facility did not have a schedule for deep cleaning of the shower rooms and Janitor 1 performed a deep cleaning for the shower rooms once or twice per week depending on the dirtiness of the shower rooms. Janitor 1 stated that after cleaning shower room [ROOM NUMBER] yesterday (12/10/2025), shower room [ROOM NUMBER] was dirty with a blackish color around the soap rest areas and on both corners of shower booth 1 where the floors and walls met. Janitor 1 stated Janitor 1 could not remove those black spots, but Janitor 1's supervisors were not in the facility and did not report yesterday, 12/10/2025. When Janitor 1 was asked if Janitor 1 would have taken a shower in a shower booth with black discolorations, Janitor 1 stated that it was dirty and felt like something was growing, so Janitor 1 was going to report to their supervisor immediately if they are not able to remove the dirty spots with discoloration.During a further interview on 12/11/2025 at 1:04 p.m., with the MS, the MS stated that the facility did not have a schedule for shower room deep cleaning or a check list of what areas needed to be cleaned.During a concurrent interview and record review on 12/11/2025 at 2:05 p.m., with the ADM, the ADM stated that the deep cleaning for the shower rooms was done yesterday, 12/10/2025, and provided a work invoice dated 12/11/2025. The invoice indicated the following: Description: Inspection and Cleaning - Shower Room. Conducted a full inspection of shower room for grime. Identified areas requiring deep cleaning and surface treatment.During a review of the facility's policy and procedure titled, Homelike Environment, last reviewed on 11/5/2025, the P&P indicated, Residents are provided with a safe, clean, comfortable and homelike environment. The facility staff and management maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include a clean, sanitary and orderly environment.During a review of the facility's P&P titled, Cleaning and Disinfection of Environmental Services, last reviewed on 11/5/2025, the P&P indicated, Environmental surfaces will be disinfected (or cleaned) on a regular basis (e.g., daily, three times per week) and when surfaces are visibly soiled.

Based on interview and record review the facility failed to ensure one of three sampled residents (Resident 1) responsible party (RP) was informed of the Interdisciplinary Team (IDT - a group of professionals from different fields who collaborate to achieve a common goal for the resident) Care Conference on 4/8/2025. This deficient practice violated Resident 1's RP right to participate in decisions regarding Resident 1's care, treatment and services. Findings: During a review of Resident 1's admission Record, the admission Record indicated that Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included Parkinson's Disease (a brain condition that causes problems with movement, mental health, sleep, pain and other health issues), rheumatoid arthritis (a chronic progressive disease causing inflammation in the joints and resulting in painful deformity and immobility especially in the fingers, wrists, feet and ankles) and type 2 diabetes mellitus (a chronic condition characterized by high blood sugar levels). During a review of Resident 1's Physician Progress Notes dated 4/7/2025, the Physician Progress Notes indicated Resident 1 can make needs known but can not make medical decisions. During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool) dated 4/11/2025, the MDS indicated that Resident 1 had moderately impaired cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) and was dependent on staff with toileting hygiene, shower or bathing, dressing, personal hygiene, and mobility (movement). During a review of Resident 1's IDT Care Conference Note dated 4/8/2025, the IDT Care Conference Note indicated Resident 1 attended the conference however there was no documented evidence found indicating Resident 1's RP was informed or invited to participate in the Resident 1's IDT Care Conference. During an interview on 6/3/2025 at 10:43 a.m., with Resident 1's RP, Resident 1's RP stated that the facility should have notified him of Resident 1's Care Conference and provided him an opportunity to be informed of Resident 1's health status, care and treatment received, and to be an advocate for Resident 1's needs and inform the facility of any unaddressed concerns regarding Resident 1's care. During a concurrent interview and record review on 6/3/2025 at 12:05 p.m., with the Social Services Director (SSD), Resident 1's Physician Progress Notes dated 4/7/2025 and IDT Care Conference Note dated 4/8/2025 were reviewed. The SSD stated that Resident 1's RP should have been informed of the IDT Care Conference prior to the meeting scheduled on 4/8/2025, as it is the RP's right to be notified and involved in the resident's plan of care and treatment decisions. During an interview on 6/5/2025 at 2:45 p.m., with the Director of Nursing (DON), the DON stated that the facility should have notified Resident 1's RP prior to the meeting scheduled on 4/8/2025, as Resident 1 is able to express needs but lacks the capacity to make medical decisions. The DON stated notifying the RP is essential to uphold the resident's right to be informed and involved in their plan of care and treatment. The DON stated failure to notify the RP could result in delays in care planning and implementation of appropriate treatment interventions. During a review of the facility`s policy and procedure (P&P), titled Resident Rights last reviewed on 11/6/2024, the policy indicated federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's rights to be informed of, and participate in, his or her care planning and treatment. During a review of the facility's P&P titled Care Planning - Interdisciplinary Team, last reviewed on 11/6/2024, the P&P indicated the resident, the resident's family and/or the resident's legal representative or guardian are encouraged to participate in the development of and revisions to the resident's care plan. Care plan meetings are scheduled at the best time of the day for the resident and family when possible.

Based on interview and record review, the facility failed to protect the resident ' s right to be free from physical abuse (deliberately aggressive or violent behavior with the intention to cause harm by one resident towards another) by Resident 2 for one of four sampled residents (Resident 1). On 9/5/2023, Resident 2 threw a plastic trash bin at Resident 1 causing skin discoloration (change in natural skin color) and a one centimeter (cm - unit of measurement) long skin tear (a wound that happens when the layers of skin separate) to Resident 1 ' s right upper eye that needed first aid (immediate care given to an injured or suddenly ill person) and daily wound treatments. This deficient practice resulted in Resident 1 being subjected to physical abuse by Resident 2 while under the care of the facility and had the potential to cause emotional harm which could result to a feeling of low self-esteem and self-worth. Based on the reasonable person concept (hypothetical [suggested], average person's reaction to the actual circumstances of alleged illegal activities) due to Resident 1 ' s moderately impaired cognition (ability to think and make decisions), an individual subjected to physical abuse has lifetime physical pain and psychological (mental or emotional) effects including feelings of embarrassment and humiliation. Findings: A review of Resident 1 ' s Admission Record indicated Resident 1 was admitted on [DATE] with diagnoses that included dementia (group of symptoms affecting memory, thinking and social abilities severely enough to interfere with daily life), schizophrenia (serious mental illness that interferes with a person's ability to think clearly, manage emotions, make decisions and relate to others) and hypertension (high blood pressure). A review of Resident 1 ' s Minimum Data Set (MDS, a standardized assessment and care planning tool) dated 3/5/2023 indicated Resident 1 had moderately impaired cognition. A review of Resident 1 ' s Interdisciplinary Team (IDT - a group of members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities) Progress Note dated 9/7/2023 indicated on 9/5/2023, at around 7:35 a.m. Resident 1 was observed by Certified Nurse Assistant 1 (CNA 1) sitting on his bed with a skin tear on his right eye. Resident 1 ' s IDT Progress Note further indicated Resident 1 told Registered Nurse 1 (RN 1) that he was by his closet when he heard Resident 2 yell and as he turned to face him, he felt a trash can hit him. A review of Resident 1 ' s Situation-Background-Assessment-Recommendation (SBAR) Communication Form (a form used to facilitate prompt communication regarding a change in a resident ' s health condition), dated 9/5/2023, indicated at around 7:35 a.m. CNA 1 observed Resident 1 sitting on his bed with a skin tear on his right upper eye socket (the two hollow parts on either side of your face, where your eyeballs are) with minimal bleeding. Resident 1 complained of pain and Acetaminophen (a medication used to relieve pain) was administered as ordered. A review of Resident 1 ' s Order Summary Report indicated a physician ' s order dated 9/5/2023 for treatment for Resident 1 ' s Right Upper Socket Skin Tear: cleanse with Normal Saline (NS - sterile solution composed of salt and water), pat dry, cover with dry dressing (used to protect a wound from infection and absorb wound drainage), daily for 21 days. Further review of Resident 1 ' s SBAR Communication Form dated 9/7/2023 indicated Resident 1 ' s right periorbital (pertaining to or surrounding the orbit of the eyes) discoloration was bigger with an order from Resident 1 ' s physician to monitor the skin discoloration every shift for further skin breakdown. A review of Resident 2 ' s Admission Record indicated Resident 2 was admitted on [DATE] with diagnoses that included cerebral infarction (stroke, occurs because of disrupted blood flow to brain) and hypertensive emergency (when a person ' s blood pressure surges to an unusually high level). A review of Resident 2 ' s MDS dated [DATE] indicated Resident 2 had fully intact cognition. A review of Resident 2 ' s SBAR Communication Form dated 9/5/2023 indicated Resident 2 displayed aggressive behavior towards another resident (Resident 1). Resident 2 ' s SBAR Communication Form further indicated Resident 2 told RN 1 that he lifted the trash can and threw it towards Resident 1. A review of Resident 2 ' s Individual Psychotherapy Progress Notes dated 9/6/2023 indicated Resident 2 presented with paranoid delusions (unfounded feelings that someone or some group is out to mistreat, harm and sabotage you or someone close to you), poor impulse control (ability to control oneself, especially one ' s emotions and desires) and poor coping skills (activities used to reduce a stressful or emotional situation). Resident 2 ' s Individual Psychotherapy Progress Notes further indicated that Resident 2 admitted to acting on his impulses during the physical altercation with his roommate (Resident 1). During an interview with Resident 1 on 9/18/2023 at 9:43 a.m., Resident 1 was unable to recall the incident with Resident 2 on 9/5/2023. During an interview with CNA 1 on 9/18/2023 at 1:44 p.m., CNA 1 stated on 9/5/2023 she was about to start passing out breakfast trays at around 7:30 a.m. when she heard screaming coming from Resident 1 and Resident 2 ' s room. CNA 1 stated that when she ran into Resident 1 and Resident 2 ' s room, CNA 1 found Resident 2 standing at the foot of his bed yelling at Resident 1. CNA 1 stated that Resident 1 was sitting on his bed. CNA 1 stated that she immediately got in between both Resident 1 and Resident 2 as she called out for help. CNA 1 stated that she noticed that Resident 1 had blood around his right eye. CNA 1 stated that Licensed Vocational Nurse 1 (LVN 1) came in right away to assist and removed Resident 2 from the room. During an interview with LVN 1 on 9/18/2023 at 2:02 p.m., LVN 1 stated she was setting up her medicine cart at around 7:35 a.m. when she heard yelling coming from Resident 1 and Resident 2 ' s room. LVN 1 stated when she arrived in Resident 1 and Resident 2 ' s room, she found Resident 1 sitting on his bed with blood around his right eye. LVN 1 stated that Resident 2 was standing at the foot of his bed and yelling at Resident 1 to stay out of his closet. LVN 1 stated that CNA 1 was standing in between Resident 1 and Resident 2. LVN 1 stated she immediately removed Resident 2 from the room. LVN 1 stated Resident 2 explained to her that Resident 1 was standing by his closet, so he threw his trash bin towards Resident 1 to get him away from his closet. LVN 1 stated that Resident 2 told her that he never meant to hit Resident 1, he just wanted to stop him from going into his closet. LVN 1 stated that when she went to check on Resident 2 a few minutes later, Licensed Vocational Nurse 2 (LVN 2) was already tending to Resident 1 ' s right eye skin tear. During an interview with LVN 2 on 9/18/2023 at 2:33 p.m., LVN 2 stated on 9/5/2023 at around 7:30 a.m., LVN 2 was stocking his treatment cart when he heard yelling coming from Resident 1 and Resident 2 ' s room. LVN 2 stated when he arrived in Resident 1 and Resident 2 ' s room, he saw that Resident 1 was bleeding around his right eye. LVN 2 stated he had Resident 1 hold a tissue to his right eye skin tear and apply pressure while he gathered some wound care supplies. LVN 2 stated he provided first aid care to Resident 1 ' s right eye skin tear. LVN 2 stated that he cleaned off Resident 1 ' s right eye skin tear that had minimal bleeding and placed a clean, dry dressing on the skin tear. LVN 2 stated the skin tear was about one cm long. LVN 2 stated after a few days, on 9/7/2023, he noticed Resident 1 was starting to have right periorbital discoloration. LVN 2 stated the discoloration was purple in color and around the outer corner of Resident 1 ' s right eye. LVN 2 stated he informed Resident 1 ' s physician who ordered for the discoloration to be monitored. During an interview with the Administrator (ADM) on 9/21/2023 at 3:40 p.m., the ADM stated during her investigation of the altercation between Resident 1 and Resident 2, she found that Resident 2 admitted ly threw his trash bin towards Resident 1. The ADM stated that Resident 2 expressed remorse after the incident. The ADM stated that Resident 2 ' s action of throwing his trash bin at Resident 1 was deliberate and therefore willful and the action of Resident 2 deliberately throwing the trash bin at Resident 1 fits the criteria of abuse. A review of the facility ' s policy and procedure (P&P) titled, Abuse Prevention Program, last revised on 12/2016, indicated residents have the right to be free from abuse. The policy and procedure further indicated that the facility is to protect its residents from abuse by anyone.

Based on observation, interview, and record review, the facility failed to provide treatment and services to prevent formation and progression of pressure sore (or pressure ulcer, an injury to the skin and underlying tissue from prolonged pressure on the skin) to the left ischium (back of the lower portion of the hip bone) for a resident who was readmitted to the facility without a pressure sore, for one of 20 sample residents (Resident 3), by failing to: 1. Implement pressure sore prevention interventions as indicated on the plan of care, such as turning and repositioning for a resident who required extensive assistance with one person assisting for bed mobility (moving to and from lying positions, turning side to side, and positioning body while in bed), and was not willing to reposition as needed. 2. Accurately identify the actual location of the pressure sore in order to ensure consistency in assessment, treatment, and monitoring. 3. Ensure assessments were done weekly in order to determine the healing status of the pressure ulcer in accordance with the National Pressure Ulcer Advisory Panel. 4. Immediately provide nutritional measures to promote healing of the pressure sore as indicated in the facility policy for Care and Prevention of Pressure Sore. 5. Develop a care plan to address an actual pressure sore the resident acquired in the facility to ensure prompt and consistent interventions were provided to promote healing of the pressure sore. 6. Notify the physician when the resident's pressure sore worsened as indicated in the plan of care, in order to obtain additional interventions necessary to promote healing of the pressure sore. These deficient practices resulted in Resident 3 developing while in the facility an unstageable pressure sore (pressure sore that is covered with dead tissue and unable to determine how deep the wound is), to the left ischium and had a potential to result in delayed healing of the pressure sore. Findings: A review of the Resident Face Sheet indicated Resident 3 was initially admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. A review of the Minimum Data Set (MDS- a comprehensive assessment and care screening tool), dated March 22, 2017, indicated Resident 3's cognitive skills (the act or process of knowing, perceiving) were moderately impaired and required extensive assistance with one person assisting for bed mobility (moving to and from lying positions, turning side to side, and positioning body while in bed), transfer (moving to or from: bed, chair, wheelchair, standing position), dressing, toilet use, and personal hygiene. The MDS indicated Resident 3 had no pressure sore, wounds and skin problems. A review of the Braden Scale for Predicting Pressure Sore Risk form dated February 4, 2017, indicated Resident 3 had a total score of 15. The Braden Scale includes the risk factors of sensory perception, moisture, activity, mobility, nutrition, and friction and shear. Resident 3 was assessed at risk for skin breakdown. (According to the Braden Scale, a total score of 15 to 18, indicates at risk). A review of the Resident Admission Form, an initial data collection nursing assessment, dated February 4, 2017, indicated Resident 3 had no pressure sores on admission from an acute care facility. A review of the care plan on admitted d February 4, 2017, indicated Resident 3 had a care plan for at risk for developing pressure sore, bruising, and other types of skin breakdown related to reduced mobility, fragile skin, use of [MEDICAL CONDITION] and [MEDICATION NAME] medications, incontinence of bowel and bladder, history of skin alteration, [MEDICAL CONDITIONS] disease, and aging process. The interventions included turning and repositioning as needed when in in bed or wheelchair, weekly body checks, treatments as ordered, pressure relieving devices as needed, and notify the physician of any changes. On April 28, 2017 at 4:30 p.m., Resident 3 was observed in bed lying on her back. During an interview at the time of the observation, Resident 3 stated her legs are numb and she is unable to walk. Resident 3 further stated I have a bad sore on my buttocks. Resident 3 also stated she cannot turn to reposition herself in bed because she has numbness in her legs so the nursing staff has to do it for her. During an observation of skin treatment on April 29, 2017 at 10:15 a.m., Resident 3 had an unstageable pressure sore located on the left ischial area. During an interview with Licensed Vocational Nurse 1 (LVN 1) at the time of the observation, LVN 1 stated Resident 3 acquired the pressure sore located in the left ischial area at the facility. LVN 1 stated the pressure sore began as a Stage 1 and progressed to an unstageable pressure sore. LVN 1 stated the pressure was unstageable because the depth cannot be determined because of the presence of eschar (dead tissue found in full thickness wound). A review of the Resident Progress Notes dated April 4, 2017, indicated Resident 3 was noted with 4 centimeter by 2.5 centimeter nonblanchable (an area of persistent redness), redness on right buttock. The skin was intact and did not have a discharge. The physician was made aware and new orders were received. A review of the treatment flowsheet dated April 4, 2017, to April 19, 2017, indicated Resident 3 was receiving treatment to the right inner buttock. The order indicated to cleanse the right inner buttock with normal saline, pat dry, apply Venelex (ointment to help wound heal), cover with dry dressing daily for 14 days. A review of the physician's orders [REDACTED]. The treatment indicated to cleanse the area with normal saline, pat dry, apply Venelex ointment, and cover with dry dressing daily for 30 days. On April 29, 2017 at 11:10 a.m., during an interview and concurrent review of Resident 3's progress notes dated April 4, 2017 to April 29, 2017, Licensed Vocational Nurse 2 (LVN 2) stated Resident 3 developed a Stage 1 on the left ischial area at the facility but the site of the pressure sore that was documented and reported to the physician was on the right buttock. LVN 2 stated a clarification was done on April 20, 2017, indicating the pressure sore was on the left ischial area and not on the right buttock. LVN 2 stated a reassessment of the pressure sore area should have been done the following day after the resident's pressure sore was identified. On April 29, 2017 at 11:10 a.m., during an interview and concurrent review of Resident 3's Skin Progress Report, LVN 2 stated the location of the pressure sore documented on the report was on the right inner buttock when it was first observed on April 4, 2017. However, Resident 3 did not have a pressure sore on the right inner buttock. The location of the pressure sore was actually on the left ischial area. LVN 2 also confirmed the weekly assessment of the pressure sore was not done on April 18, 2017, a week after the pressure sore on the left ischial area worsened to Stage 2. The Skin Progress Report indicated treatment was provided to the right buttock, (while actually treatment was provided to the left ischial area per staff) as follows: 1. On April 4, 2017, initial assessment of a Stage 1 pressure sore measuring 3.5 centimeters (cm) in length by 4 cm in width and indicated presence of [MEDICATION NAME] tissue on the wound bed. 2. On April 11, 2017, Stage 2 pressure sore measuring 3.5 cm in length by 4 cm in width and indicated presence of [MEDICATION NAME] tissue on the wound bed. The report did not indicate the pressure sore's response to the current treatment nor was there a description of the pressure sore's surrounding tissue character. 3. On April 18, 2017, the report did not indicate an assessment was done of the pressure sore in order to determine the status of the pressure sore such as if it was healing, or worsening, to include stage, size and depth, wound bed description, drainage, response to treatment, wound bed characteristic, and surrounding tissue character. 4. On April 25, 2017, unstageable pressure sore to the left ischial measuring 3.5 cm in length and 4 cm in width and indicated presence of [MEDICATION NAME] tissue, granulation tissue, slough (dead tissue, usually cream or yellow in color) light drainage. The report did not indicate response to treatment, wound bed characteristic and surrounding tissue characteristic. A review of Resident 3's Trunk Wound Assessment indicated an initial consultation was done on April 27, 2017, by a wound care specialist. According to the assessment Resident 3 had an unstageable pressure sore to the left ischium measuring 4.0 cm in length and 5.1 cm in width with presence of odor, scant drainage, and necrotic tissue/devitalized tissue. A review of Resident 3's clinical records dated April 4, 2017 to April 29, 2017, did not indicate a plan of care that documented Resident 3 developed a pressure sore on the left ischial with interventions that addressed management and treatment of [REDACTED]. A review of the Certified Nursing Assistant Daily Charting Form for Resident 3 for the the month of April 2017, indicated the following: 1. On April 1, 2017- April 30, 2017, during the night shift (11:00 p.m.- 7:00 a.m. shift, Resident 3 was not positioned every two hours and as needed. 2. On April 8, 2017-April 30, 2017, during the day shift (7:00 a.m.- 3:00 p.m. shift, Resident 3 was not positioned every two hours and as needed. On April 28, 2017 at 9:22 p.m., during an interview, Certified Nursing Assistant 4 (CNA 4) stated Resident 3 was able to reposition herself but needs two people to pull her up in bed. CNA 4 was aware Resident 3 has a pressure sore but was not able to identify the correct location of the pressure sore. On April 29, 2017 at 11:10 a.m., during an interview, LVN 2 stated there should have been a care plan and an interdisciplinary (IDT) meeting to identify possible causes of how the pressure developed and identify interventions to manage and treat the pressure sore. LVN 2 was unable to provide documented evidence the resident's physician was notified of Resident 3's change of condition on April 11, 2017, when the pressure sore on the left ischial area worsened from Stage 1 to Stage 2, and on April 25, 2017, when the pressure sore on the left ischial area worsened from Stage 2 to unstageable pressure sore, in order to obtain additional interventions necessary to promote healing of the pressure sore. On April 29, 2017 at 11:10 a.m., during an interview and concurrent review of Dietary Progress Notes for Resident 3, LVN 2 stated the RD's latest progress notes entry was dated March 24, 2017, and indicated Resident 3 did not have a pressure sore at the time of the review. LVN 2 stated the RD was not notified when Resident 3 developed pressure sore in the left ischium. Nutritional measures from the RD meant to prevent further deterioration of the skin, were not provided immediately as indicated in the facility policy for Care and Prevention of Pressure Sore. For example, on April 11, 2017, Resident 3's pressure sore on the left ischial area worsened from Stage 1 to Stage 2, but nutritional measures from the RD were not provided immediately. On April 25, 2017, the resident's pressure sore on the left ischial area worsened from Stage 2 to unstageable pressure sore, but nutritional measures from the RD were not provided immediately. A review of the facility's undated policy titled Care and Prevention of Pressure Sore, indicated all available measures shall be taken to prevent skin breakdown and pressure sores. If these conditions occur, treatment is to be initiated immediately and preventive measures taken to prevent further deterioration of the skin. According to the National Pressure Ulcer Advisory Panel (NPUAP), a comprehensive assessment of the individual and his or her pressure ulcer (sore) informs development of the most appropriate management plan and ongoing monitoring of wound healing; that includes a focused physical examination, nutrition, pain related to pressure ulcers, employment of pressure relieving and redistributing maneuvers, risk for developing additional pressure ulcers, ability to adhere to a prevention and management plan. Assessment of the pressure ulcer includes reassessing it at least weekly and document results of all wound assessments. Wound assessment includes location, category/stage, size, tissue type, color, periwound condition, wound edges, exudates, odor. (National Pressure Advisory Panel. (2014). npuap.org).

Based on observation, interview, and record review, the facility failed to identify, assess, treat, and monitor pressure sores (or pressure ulcer, an injury to skin and underlying tissue from prolonged pressure on the skin) for two out of 20 sampled residents (Resident 11 and Resident 18). Resident 11, who had multiple pressure sores, was not followed by a wound care specialist from 10/14/15, for seven months. This deficient practice resulted in: 1. Resident 11 developing an unstageable pressure sore (pressure sore that is covered with dead tissue and unable to determine how deep the wound is) to the right upper ear. 2. Resident 18 developing deep tissue injury to the left wrist and left elbow. Findings: 1. A review of Resident Face Sheet (admission record) indicated Resident 11 was admitted to the facility on [DATE] and was re-admitted on [DATE], with [DIAGNOSES REDACTED].); Stage 4 pressure ulcer of left buttock; Stage 1 (intact skin with non-blanchable redness (redness that won't go away when pressed) of localized area usually over a bony prominence); pressure ulcer of the right heel; and Stage 1 pressure ulcer of the left heel. A review of the Minimum Data Set ((MDS), a resident assessment and care screening tool), dated 9/25/15, indicated Resident 11 had moderate cognitive (ability to think and reason) impairment, and required extensive assistance (weight bearing support and at times requires full staff performance) with staff for bed mobility (moving to and from lying positions, turn side to side, and positions body while in bed). A review of Resident 11's physician's History and Physical, dated 4/14/16, indicated Resident 11 had [DIAGNOSES REDACTED]. A review of a document titled, Braden Scale- for Predicting Pressure Sore Risk,dated 12/28/15, indicated Resident 11 was assessed as high risk for developing pressure sores. a. During an observation of skin treatment at 9:50 a.m. on 5/12/16, Resident 11 had a light brown, yellow scab located at the top of the right ear. During a concurrent interview, licensed vocational nurse (LVN 3) stated that she did not notice the scab located at the top of the right ear of Resident 11 yesterday. LVN 3 stated the scab was an unstageable pressure sore and was not being assessed, treated, and monitored. During an interview and concurrent record review of the document titled, Wound Evaluation Flow Sheet for Resident 11 at 12:35 p.m. on 5/12/16, LVN 3 stated an initial assessment of the unstageable pressure sore located at the top of the right ear measured 0.7 centimeters (cm) in length by 0.6 cm width and depth that was undeterminable, and described as light brown scab. LVN 3 stated the unstageable pressure sore on top of the right ear of Resident 11 should have been identified, assessed, and treated to prevent risk for worsening of tissue necrosis (death of tissue cells) and infection. During record review of the document titled, Change of Condition SBAR (Situation-Background-Assessment-Recommendation, a form of communication between members of the health care team) - Pressure Ulcer, dated 5/12/16, for Resident 11, indicated a new unstageable pressure sore of the right upper ear. b. During an observation of skin treatment at 9:50 a.m. on 5/12/16, Resident 11 had a Stage 2 pressure sore located at the lower portion of the right ear, just above the ear lobe (according to facility's documents, referring to the helix of the right ear) that was pinkish red color. During a concurrent interview, LVN 3 stated that the right ear helix pressure sore was a scab that reopened to a Stage 2 (partial thickness skin loss involving epidermis, dermis, or both (top layers of the skin)). LVN 3 stated the ulcer was superficial pressure sore developed at the facility on 4/26/16. During an observation of skin treatment at 10:15 a.m. on 5/12/16, Resident 11 had an unstageable pressure sore located on the right lateral lower leg. During a concurrent interview, LVN 3 stated the pressure sore located on the right lateral (on the side) lower leg began as an excoriation (Stage 2 pressure sore) and progressed to an unstageable pressure sore at the facility. During an observation of skin treatment at 10:30 a.m. on 5/12/16, LVN 3 and certified nurse assistant (CNA 2) repositioned Resident 11's head and body to lie on her right side. Resident 11 stated her right ear was starting to hurt. Resident 11's head remained lying on the right side as CNA 2 repositioned the pillow underneath her head while Resident 11 continued to complain of right ear pain. LVN 3 provided treatment to Resident 11's Stage 4 pressure sore located at the left buttock that was pink and exposed muscle. During a concurrent interview, LVN 3 stated the pressure sore to the left buttock started as a blister at the facility and progressed to unstageable pressure sore. LVN 3 stated a fluid filled blister would be considered as a Stage 2 pressure sore. During an observation of skin treatment at 11 a.m. on 5/12/16, Resident 11 had a Stage 4 pressure sore located on the sacrum (lower back). During a concurrent interview, LVN 3 stated bone could be felt on the pressure sore. On 5/12/16 at 12:35 p.m., during an interview and concurrent review of Resident 11's document titled, Change of Condition SBAR- Pressure Ulcer, dated 4/26/16, LVN 3 stated Resident 11 developed a new Stage 2 pressure sore located at the right ear helix (referring to the above the ear lobe pressure sore) at the facility. LVN 3 stated the right ear helix pressure sore began as a scab and advanced to Stage 2 pressure sore at the facility. LVN 3 was unable to provide documentation of routine assessment and monitoring of the right ear helix scab. LVN 3 stated that when the right ear helix was a scab, it should have been assessed and documented weekly. LVN 3 stated the intervention to offload (remove direct pressure) the right ear was to place a pillow underneath Resident 11's head and LVN 3 stated that the intervention was not effective to offload the right ear and there were no other implemented interventions to prevent further deterioration of the right ear helix pressure sore. On 5/12/16 at 12:35 p.m., during an interview and concurrent review of a document titled, Wound Evaluation Flow Sheet for Resident 11's right ear helix pressure sore, LVN 3 confirmed: 1. On 4/27/16, initial assessment of a Stage 2 pressure sore of the right ear helix pressure sore that measured 1.5 cm in length by 0.5 cm in width by 0.2 cm in depth. 2. On 5/11/16, a Stage 2 pressure sore of the right ear helix that measured 1.5 cm in length by 0.4 cm in width by 0.2 cm in depth. On 5/12/16 at 12:35 p.m., during an interview and concurrent review of Resident 11's document titled, Change of Condition SBAR- Skin Condition, dated 4/9/16, LVN 3 stated that Resident 11 developed a new onset of right lateral lower leg redness (Stage 1 pressure sore) at the facility. On 5/12/16 at 12:35 p.m., during an interview and concurrent record review of Resident 11 ' s document titled, Change of Condition SBAR- Skin Condition, dated 4/10/16, LVN 3 stated that Resident 11 developed a new onset of skin excoriation (superficial skin injury) to the right lateral lower leg. On 5/12/16 at 12:35 p.m., during an interview and concurrent review of Resident 11's document titled, Change of Condition SBAR- Pressure Ulcer, dated 5/6/16, LVN 3 stated that Resident 11 developed new unstageable pressure sore to the right lateral lower leg. A review of Resident 11's document titled, Wound Evaluation Flow Sheet for the right lateral lower leg indicated: 1. On 5/6/16, initial assessment of an unstageable pressure sore to the right lateral lower leg measuring 1.5 cm in length by 1.0 cm in width and depth was undeterminable. 2. On 5/13/16, an unstageable pressure sore to the right lateral lower leg described as eschar (a black, dry, thick, and leathery dead tissue) measuring 1.5 cm in length by 1.0 cm in width and depth that was undeterminable. On 5/12/16 at 12:35 p.m., during an interview and concurrent review of Resident 11's document titled, Change of Condition SBAR- Pressure Ulcer, dated 1/1/16, LVN 3 stated that Resident 11 developed a new Stage 1 pressure sore to the left buttock at the facility. On 5/12/16 at 12:35 pm., during an interview and concurrent review of Resident 11's document titled, Change of Condition SBAR- Pressure Ulcer, dated 1/4/15, LVN 3 stated that Resident 11 developed deep tissue injury to the left buttock at the facility. A review of Resident 11's document titled, Wound Evaluation Flow Sheet for the left buttock indicated: 1. On 1/1/16, initial assessment of a Stage 1 pressure sore to the left buttock measuring 5 cm in length by 3.5 cm in width and described as non-blanchable redness (redness that would not go away when pressed). 2. On 1/8/16, deep tissue injury to the left buttock measuring 5 cm in length by 3.5 cm in width and described as reddish, purplish discoloration. 3. On 1/27/16, initial assessment of an unstageable pressure sore to the left buttock measuring 3.5 cm in length by 3.5 cm in width and depth that was undeterminable. The wound bed was described as eschar and necrotic (tissue changed color from red to brown or black/purple). 4. On 3/30/16, initial assessment on re-admission indicated a Stage 4 pressure sore to the left buttock measuring 3 cm in length by 3.3 cm in width by 2 cm in depth with slough (soft, moist yellow tissue). 5. On 5/11/16, a Stage 4 pressure sore to the left buttock measuring 3 cm in length by 3 cm width by 1.3 cm in depth with granulation (pink/red moist comprised of new blood vessels) and slough. A review of Resident 11's document titled, Wound Evaluation Flow Sheet for the sacrococcyx (area at the bottom of the spine or tail bone) of pressure sore indicated: 1. On 10/5/15, a Stage 4 pressure sore to the sacrococcyx measuring 6.5 cm in length by 7 cm in width by 2.5 cm in depth with undermining (erosion under the wound edges that results in a large wound with a small opening) was described as pink with moderate serosanguinous (bloody drainage) consistency. 2. On 12/31/15, there was no indication of the stage or type of wound. The sacrococcyx was measuring 7.5 cm in length by 4.5 cm in width by 1 cm in depth with undermining, and described as red color with moderate serosanguineous consistency. 3. On 4/27/16, a Stage 4 pressure sore to the sacrococcyx measuring 6 cm in length by 6 cm in width by 1.8 cm in depth with undermining and moderate serous (clear or straw colored drainage from a wound) consistency. 4. On 5/11/16, a Stage 4 pressure sore to the sacrococcyx measuring 5 cm in length by 5 cm in width by 1.6 cm in depth with moderate serous consistency. During an interview at 12:35 p.m. on 5/12/16, LVN 3 stated Resident 11 was last seen by a wound specialist last year. LVN 3 stated Resident 11 was not currently under the care of a wound specialist for pressure sore assessment; monitoring for the progression of the pressure sores; specialized consultation of appropriate treatment for [REDACTED]. LVN 3 was not able to provide a reason for not referring a wound specialist to provide care for Resident 11. On 5/13/16, a review of Resident 11's document titled, Wound Care Assessment, indicated Resident 11 had not been seen by a wound care specialist since 10/14/15, for seven months, as verified by LVN 3. 2. During an observation, at 8:20 a.m. on 5/12/16, Resident 18 had a purple colored skin area at the left elbow and left bony prominence of the wrist. During a concurrent interview with LVN 1, she stated that Resident 18's left elbow and left wrist were not previously identified, assessed, treated, and monitored. LVN 1 stated Resident 18's left elbow and left wrist should have been identified and treated. A review of a Resident 18's Face Sheet indicated Resident 18 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the MDS, dated [DATE], indicated Resident 18 had short-term and long-term memory problem, and required extensive assistance with staff for bed mobility. A review of Resident 18's document titled, Wound Evaluation Flow Sheet, dated 5/12/16, indicated initial assessment of suspected deep tissue injury to the left wrist measuring 1.3 cm in length by 1.1 cm in width and described as purplish discoloration. The Wound Evaluation Flow Sheet indicated the current treatment was [MEDICATION NAME] (topical treatment to reduce bacteria that can cause skin infection) and to off load the area as a preventative intervention. A review of Resident 18's document titled, Wound Evaluation Flow Sheet, dated 5/12/16 indicated initial assessment of suspected deep tissue injury to the left elbow measuring 1.5 cm in length by 1.5 cm in width an described as purplish discoloration. According to the facility's policy and procedure titled, Pressure Ulcers/ Skin Breakdown Prevention and Monitoring dated October 2014, residents at risk for development of pressure ulcers will be placed on a pressure ulcer prevention program which include: use pillows, wedges or other off-loading devices to keep bony prominences from touching each other and to float heels; routinely assess and document the condition of the resident's skin for any signs and symptoms of irritation or breakdown; and report any signs of developing pressure ulcer to the physician and inform resident and/or responsible party. According to John(NAME)Medicine, best outcomes for wound and pressure sore management are generated by dedicated, well-educated personnel from disciplines working together for the common goal of holistic patient care. Proper skin care is crucial and involves inspecting skin daily. An assessment of the wound should be done and used to drive treatment decisions. Wound assessment includes: location, class/stage, size, base tissues, exudates (any fluid, pus-like or clear fluid that leaks out) odor, edge/perimeter, pain and an evaluation for infection. http://www.hopkinsmedicine.org/gec/series/wound_care.html