Every finding on record at The Village Healthcare Center

Based on observation, interview, and record review, the facility failed to ensure a care plan was developed for resident's discharge plans, for one of three residents reviewed (Resident A).This failure had potential for the staff not to be aware of discharge plans for Resident A.Findings:On January 30, 2026, at 9:15 a.m., an unannounced visit was conducted at the facility to investigate resident discharge.On January 30, 2026, at 12:10 p.m., an interview was conducted with Resident A. Resident A stated she would like to be discharged to her home but is aware she is not ready and prefers to stay longer in the facility to work with the physical therapist. On January 30, 2026, Resident A's record was reviewed. Resident A's admission Record, indicated the resident was admitted to the facility on [DATE], with diagnoses which included aftercare for below knee amputation (removal of a limb).A review of Resident A's Minimum Data Set (MDS - a resident assessment tool), dated January 12, 2026, indicated a BIMS (Brief Interview of Mental Status) score of 15 (cognitively intact).A review of Resident A's Progress Notes, dated January 14, 2026, at 12:15 p.m., indicated discharge plans to home with home health services.A review of Resident A's Order Summary Report, included a physician's order, dated January 29, 2026, which indicated LCD (last covered date) 2/1/26 (February 1, 2026) discharge 2/2/26 (February 2, 2026) home (Resident A's address).Further review of Resident A's care plan indicated there was no care plan related to discharge plans to go home.On January 30, 2026, at 1:05 p.m., an interview was conducted with Social Services Assistant (SSA). The SSA stated the Social Services Director (SSD) is responsible to in developing a care plan related to discharge plans. The SSA stated care plan on discharge is important to help plan where the resident is going to be discharged and what care needs and resources the resident would need before and at discharge.On January 30, 2026, at 1:10 p.m., an interview was conducted with the Administrator (ADM). The ADM stated discharge care plan should be initiated upon admission which included discharge plans and care needs.On January 30, 2026, at 1:15p.m., an interview was conducted with the Director of Nursing (DON). The DON stated there was no care plan developed related to discharge plans for Resident A. The DON stated social services should have initiated a care plan on admission for discharge planning. The DON stated it is important to have a care plan in place to ensure proper care would be provided to the residents to reach the discharge plan goal.A review of the undated facility's policy and procedure titled, Transfer of Discharge Policy, indicated, .When a resident is transferred or discharged , details of the transfer or discharge will be documented in the medical records and appropriate information will be communicated to the receiving health care facility or provider.

Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food preparation and storage practices in the kitchen were observed, when: 1. Dust was found in multiple areas of the kitchen and on several kitchen equipment; 2. Grime buildup was found on the bottom of the cold storage shelves and on the walk in Refrigerator's (Ref) # (number) 1 inner door; and 3. Multiple residents' food items were stored in the nurses' station refrigerator undated and out of date. These failures had the potential to place residents at risk for food-borne diseases (illness that result from ingestion of contaminated food) that can cause sickness and/or death. Findings: 1. On June 9, 2025, at 9:05 a.m., a concurrent observation and interview was conducted with the Food Server Director (FSD) in the kitchen area. The FSD confirmed Ref #4's fan surface was dusty. On June 9, 2025, at 9:07 a.m., a concurrent observation and interview was conducted with the FSD in the kitchen area. The FSD confirmed the black debris on the fan surface of Ref #3 was dust. On June 9, 2025, at 9:08 a.m., a concurrent observation and interview was conducted with Food Server (FS) 2 in the work server area. FS 2 stated the wall above Ref #2 was dusty, and maintenance should have cleaned it. On June 9, 2025, at 9:17 a.m., a concurrent observation and interview with the Dietary Supervisor (DS) was conducted in the kitchen. The DS confirmed the black material in the door frame leading to the assisted living dining room was dusty. On June 9, 2025, at 9:26 a.m., a concurrent observation and interview with the DS was conducted in the kitchen. The DS confirmed the walk in Ref #1s' fan cover was dusty and needed to be cleaned. On June 9, 2025, at 9:29 a.m., a concurrent observation and interview with the DS was conducted in the kitchen. The DS confirmed the inner wall of walk in Ref #1's wall above the door was dusty. On June 10, 2025, at 4:10 p.m., during an interview with the Registered Dietitian (RD), the RD stated the kitchen area should have been cleaned and free from dust, because dust would potentially cause cross contamination. A review of the U.S. Food and Drug Administration's (FDA) Food Code 2022, Section 4-602.13 Nonfood-Contact Surfaces, the Food Code indicated, .The presence of food debris or dirt on nonfood contact surfaces may provide a suitable environment for the growth of microorganisms which employees may inadvertently transfer to food. If these areas are not kept clean, they may also provide harborage for insects, rodents, and other pests . 2. On June 9, 2025, at 8:15 a.m., during a concurrent walk-through observation and interview inside the kitchen with the DS, white grime build up was found on the bottom cold storage shelf inside walk in Ref #1. In addition, there was black grime build up along the rubber gasket in the left upper corner (L-shaped) of the inner surface of the door. In a concurrent interview with the DS, the DS stated the white grime build up was food residue, and the black grime build up in the walk in Ref #1's inner door was dirt and was missed during cleaning by the staff. The DS stated the grime build up found on the bottom shelves, as well as the dirt on walk in Ref #1's inner door should have been cleaned. The DS further stated the grime could cross-contaminate food and cause food-borne illness in the residents. On June 10, 2025, at 4:10 p.m., during an interview with the RD, the RD stated the kitchen area and storage equipment should been cleaned and free from grime, because dirt and grime could potentially could cause cross-contamination and illness. A review of Food code 2022. Annex 3: 4-402.12 Fixed Equipment, Elevation or Sealing indicated, .The inability to adequately or effectively clean areas under equipment could create a situation that may attract insects and rodents and accumulate pathogenic (disease causing) microorganisms that are transmissible through food . A review of the facility's undated policy and procedure titled, What is Food Sanitation? indicated, .The term sanitation means sound and health or clean and whole. It is largely concerned with the removal and effective control of micro-organisms (germs, bacteria, yeasts, mold, etc.) in food and everything that touches food .Sanitation is therefore a way of life and must be practiced around the clock, every day and all year round . 3. On June 10, 2025, beginning at 3 p.m., the nurse's station refrigerator, which contained residents' food, was inspected with the Infection Preventionist (IP). The following were observed: a. One unopened Stringles Organic string cheese seven g (grams-unit of measurement) serving was labeled with room [ROOM NUMBER]A, undated, and with best-by date of February 9, 2025. In a concurrent interview, the IP stated the food item should have been dated when it was received, should not have been in the fridge anymore, and should have been taken out; b. One opened 20-oz (ounce-unit of measurement) plastic bottle of strawberry fruit spread, and with a date of March 6, 2025. In a concurrent interview, the IP stated the strawberry fruit spread was past its storage date and should have been taken out of the fridge; c. One unopened 1.6 oz plastic container of celery sticks was unlabeled and had a best used by date of May 1, 2025. In a concurrent interview, the IP stated the pack of celery sticks was past its storage date, should have been labeled, and should have been taken out of the fridge; and d. One open 16-oz plastic bottle of salad dressing was unlabeled with a best used by date of January 16, 2024. In a concurrent interview, the IP stated the plastic bottle of salad dressing was open, unlabeled, and should have been taken out of the fridge. The IP further stated that for open food items, they could be stored in the fridge for 72 hours, after which they were supposed to be discarded. On June 10, 2025, at 4:10 p.m., during an interview with the RD, the RD stated expired food that were found in the residents' refrigerator should have been tossed to maintain the sanitary condition of the fridge. The RD further stated if food was expired and not monitored, it could cause food-borne illness in the residents. A review of the facility's undated policy and procedure titled, Food from Family, Visitors, Community, indicated, .Food stored for resident should be labeled and dated appropriately and discarded per safe food storage guidelines .

Based on interview and record review, the facility failed to ensure accurate documentation of the residents' wishes regarding their care were maintained, for four of six residents reviewed for Advance Directives (AD - a written instruction relating to the provision of health care when the individual is incapacitated) (Residents 3, 13, 93 , and 26) , when: 1. Resident 3, 13, and 93's ADs were not readily available in their charts; and 2. For Resident 26, there was no documented evidence information was provided to the resident regarding AD formulation. These failures had the potential for the resident's decisions regarding their healthcare and treatment to not be honored. Findings: 1a. A review of Resident 3's record indicated Resident 3 was admitted to the facility on [DATE], with diagnoses which included dementia (memory loss), mild protein calorie malnutrition, and depression. Resident 3's History and Physical Examination, dated [DATE], indicated Resident 3 did not have the capacity to understand and make decisions. Resident 3's Minimum Data Set (MDS - a clinical assessment tool), dated [DATE], indicated Resident 3 had a Brief Interview for Mental Status (BIMS) score of 2 (severe cognitive impairment). Resident 3's Advance Directive Acknowledgement Form, signed by the resident's representative, dated [DATE], indicated Resident 3 had an AD. Further review of Resident 3's record indicated the AD was not available. 1b. A review of Resident 13's record indicated Resident 13 was admitted to the facility on [DATE], with diagnoses which included atrial fibrillation (irregular heart rhythm), hemiplegia (paralysis or loss of voluntary movement on one side of the body) and hemiparesis (weakness on one side of the body) following a stroke, and seizures. Resident 13's History and Physical Examination, dated [DATE], did not indicate if Resident 93 had or did not have the capacity to understand and make decisions. Resident 13's MDS, dated [DATE], indicated Resident 13 had a BIMS score of 8 (moderate cognitive impairment). Resident 13's Advance Directive Acknowledgement Form, signed by the resident's representative, dated [DATE], indicated Resident 13 had a Durable Power of Attorney for Health Care (DPOA-HC- legal document that allows you to appoint someone to make healthcare decisions for you if you are unable to do so yourself). Further review of Resident 13'2 record indicated the DPOA-HC was not available in Resident 13's physical or electronic record. 1c. A review of Resident 93's record indicated Resident 13 was admitted to the facility on [DATE], with diagnoses which included compression fracture of third lumbar vertebra (a break in the bone of the lower spine due to collapse or compression due to pressure), and acute myeloblastic leukemia (a rapidly progressing cancer of the blood and bone marrow), not having achieved remission (reduction or disappearance of cancer signs and symptoms following treatment). Resident 93's History and Physical Examination, dated [DATE], indicated Resident 93 had the capacity to understand and make decisions. Resident 93's MDS, dated [DATE], indicated Resident 93 had a BIMS score of 15 (cognitively intact). Resident 93's Advance Directive Acknowledgement Form, dated [DATE], indicated Resident 93 had an AD. Further review of Resident 93's record indicated the AD was not available in Resident 13's physical or electronic record. On [DATE], at 2:45 p.m., a concurrent interview and record review was conducted with the Director of Nursing (DON). The DON confirmed absence of copies of Residents 3 and 93's AD in their physical and electronic records, as well as the absence of Resident 13's DPOA-HC in the physical and electronic record. The DON stated these documents should have been in the resident's chart. The DON further stated, We may not follow what the AD says on there as the resident wishes, if we do not have them in the chart. A review of the facility's policy and procedure titled, Advance Directives, dated [DATE], indicated .Advance directives are honored in accordance with the state law and facility policy .If the resident or residents representative has executed one or more advance directive(s) .copies of these documents are obtained and maintained in the same section of the residents medical record and are readily retrievable by any facility staff .The residents wishes are communicated to the residents direct care staff and physician by placing the advance directive documents in a prominent, accessible location in the medical record and discussing the residents wishes in care planning meetings . 2. A review of Resident 26's record indicated Resident 26 was admitted on [DATE], with diagnoses which included metabolic encephalopathy (brain function impairment leading to changes in mental status). Resident 26's MDS, dated [DATE], indicated Resident 26 had a BIMS score of 15 (cognitively intact). Resident 26's AD or Advance Directive Acknowledgement Form, was not found in the resident's physical and electronic record. On [DATE], at 2:55 p.m., an interview with the DON was conducted. The DON stated the expectation was if no AD was obtained on admission, a follow up should have been conducted with Resident 26 regarding the AD Acknowledgement Form, and education should be provided to the resident regarding formulation of an AD. If Resident 26 had an AD, a copy should have been obtained and placed in the chart. The DON further stated failure to keep an AD easily available to staff could lead to inappropriate medical actions for the resident such as life saving CPR when not requested. A review of the facility's policy and procedure titled, Advance Directives, dated [DATE], indicated, .The resident has the right to formulate an advance directive, including the right to accept or refuse medical treatment or surgical treatment .The resident or representative is provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so .Written information about the right to accept or refuse medical or surgical treatment, and the right to formulate an advance directive is provided in a manner that is easily understood by the resident or representative .Written information includes a description of the facility's policies to implement advance directives and applicable state laws .

Based on observation, interview, and record review, the facility failed to ensure proper labeling and storage of medical supplies and medication conformed to national standards and the facility policy and procedure when: 1. During medication administration observation, Resident 95's furosemide (medication used to help the body get rid of extra fluid and salt) bubble pack label did not include the blood pressure holding parameters (instructions for when the medication should not be given). This failure had the potential for the medication to be administered outside of holding parameters. 2. During medication storage inspection, the following were observed: a. Three bottles of iron tablets, with expiration dates of April 2025, were stored in the medication cabinet readily available for use; b. One opened container of Metamucil (used to treat constipation), labeled for a discharged resident and with an expiration date of November 2024, was stored in the medication cabinet readily available for use; and c. One open 30-ounce (oz- unit of measurement) bottle of ProStat (a ready-to-drink concentrated liquid protein medical food) was observed stored in the medication cabinet, covered with dried liquid, which had oozed from the top of the bottle. These failures had the potential for the outdated and potentially contaminated medications to be administered to the vulnerable residents of the facility, which could lead to adverse effects from use of these outdated or compromised medications. Findings: 1. On June 12, 2025, at 9:25 a.m., a medication administration observation was conducted with Licensed Vocational Nurse (LVN) 1. LVN 1 prepared medications for Resident 95, including the medication Furosemide 20 mg (milligrams- a unit of measurement), which LVN 1 stated was to be given by mouth two times a day, based on the orders on the electronic medication administration record. LVN 1 further stated the medication was to be held if Resident 95's systolic (upper number) blood pressure (SBP) was less than 110 mmHg (millimeters of mercury- unit of measurement for pressure). The LVN did not administer the medication to Resident 95. A review of Resident the medication's label indicated Furosemide 20MG TAB TAKE 1 TABLET BY MOUTH TWICE DAILY. The medication label did not include the holding parameter on the label, and there was no direction change sticker to indicate any change in the administration of the medication. A review of Resident 95's record indicated Resident 95 was admitted to the facility on [DATE], with diagnoses which included systolic congestive heart failure (heart's left ventricle is too weak to contract effectively, preventing it from pumping enough blood to the body), and atrial fibrillation (irregular heart rhythm). Resident 95's Order Summary Report, included the physician's order, dated June 10, 2025, which indicated, Furosemide Oral Tablet 20 MG .Give 1 tablet by mouth two times a day for CHF (congestive heart failure) HOLD for SBP less than 100. On June 13, 2025, at 9:14 a.m., the Director of Nursing (DON) was interviewed. The DON stated a direction change sticker should have been placed on the Furosemide bubble pack to indicate a change in medication administration instructions. The DON stated she expected the pharmacy to place the correct medication instructions on the label according to the physician's orders. A review of the facility's policy and procedure titled, Medication Labeling and Storage, dated February 2023, indicated, .Labeling of medications and biologicals dispensed by the pharmacy is consistent with applicable federal and state requirements and currently accepted pharmaceutical practices .The medication label includes, at a minimum .appropriate instructions and precautions .Only the dispensing pharmacy may label or alter the label on a medication container or package . 2. On June 12, 2025, at 1:27 p.m., an inspection of the Medication Room was conducted with the DON. The following were found: a. One 30-oz bottle of Prostat was observed in the upper shelf of a five-tier wooden medicine cabinet. Brownish-orange liquid, which had oozed from the top of the bottle, had dried and crusted along one side of the bottle from top to bottom. In a concurrent interview, the DON stated it should not have been in the medication cabinet. Inspection of the medication room was continued with the Infection Preventionist (IP). b. One bottle of Metamucil, which was labeled for Resident 96, had an expiration date of November 2024, was observed in the upper shelf of the five-tier wooden medicine cabinet. A review of Resident 96's record indicated Resident 96 was admitted to the facility on [DATE], and was discharged from the facility on July 4, 2024. c. A built in cabinet was against the back wall of the medication room. On the bottom shelf of the upper cabinets were three bottles of Gericare Iron 27 mg (100 tablets per bottle), with expiration dates of April 2025. On June 12, 2025, at 2:45 p.m., a concurrent observation and interview was conducted with the DON. The DON confirmed the expired status of the Metamucil and iron tablets. The DON stated the medications should not have been kept stored in the medication cabinet. The DON further stated the expired medications could be given to the residents in error and cause adverse reactions. A review of the facility's policy and procedure titled, Medication Labeling and Storage, dated February 2023, indicated .If the facility has discontinued, outdated or deteriorated medications or biologicals (drugs made from living organisms or their components, like proteins or cells), the dispensing pharmacy is contacted for instructions regarding returning or destroying these items .

Based on observation, interview, and record review, the facility failed to ensure the appropriate food texture was provided, for nine of nine residents reviewed (Residents 14, 142, 2, 3, 93, 20, 241, 18, and 17), when: 1. Residents on mechanical soft diet did not receive ground pork and chopped vegetables according to the cook's spreadsheet during lunch on June 9, 2025; and 2. Residents on mechanical soft diet were served with potatoes skin during lunch on June 9, 2025. These failures had the potential for the residents to choke on the food. Findings: 1. A review of the facility's menu spreadsheet for lunch on June 9, 2025, indicated residents on mechanical soft diet were to receive ground pork and chopped vegetables as the main entrée. On June 9, 2025, at 12:18 p.m., during meal tray distribution observation, the pot roast meat was observed to have whole coarse strands of meat which measured approximately one inch in size. There was no ground meat for the pot roast in the trayline. The vegetables were observed to have large chunks similar to vegetables intended for residents on regular diets. In a concurrent interview with the Registered Dietician (RD), the RD confirmed the pot roast meat for the residents on mechanical soft diet was not ground, and was the same texture as the meat for those with regular diet. The RD stated the texture and consistency of meat for mechanical soft diet should be chopped or bite size, and should be smaller than half an inch. The RD stated the vegetables should be in small chunks. The RD further stated if the texture for mechanical soft diet was not followed, residents could choke, which could potentially lead to death. A review of the facility's Diet Type Report, dated June 9, 2025, indicated Residents 14, 142, 2, 3, 93, 20, 241, 18, and 17, had a diet order of mechanical soft ground. A review of the facility's undated diet manual section titled, Dental Soft (Mechanical Soft) Diet, indicated, .Meat is ground or chopped into bite-size pieces (1/2 inch or smaller) .Vegetables are cooked soft .with no large chunks or pieces . 2. A review of the facility's menu spreadsheet for lunch on June 9, 2025, indicated residents on mechanical soft diet were to receive chopped potatoes. On June 9, 2025, at 12:18 p.m., during meal tray distribution observation, residents on mechanical soft texture diet received potatoes with skin. In a concurrent interview with the RD, the RD confirmed the potatoes that were served for residents on mechanical soft diet had potatoes with skin. The RD stated there was no other type of potatoes prepared for lunch and the potatoes should have been served without the skin on. The RD further stated potato skins could cause residents to choke or aspirate (inhale food or liquid in to the lungs), which could potentially lead to death. The undated facility diet manual section titled, LIST OF DIETS AVAILABLE IN THE COMMUNITY, indicated, .MECHANICAL SOFT-GROUND .Cannot have potato skins .

Based on observation, interview, and record review, the facility failed to ensure Food and Nutrition Services staff followed the Cook's spreadsheet when: 1. For Residents 14 and Resident 25, the appropriate dessert was not served during lunch on June 9, 2025; and 2. For Residents 14, 18, and 25, the pot roast meat was not served with gravy during lunch on June 9, 2025. These failures had the potential for residents on oral diets to not receive the adequate nutrition which can further compromise their medical status. Findings: 1. On June 9, 2025, at 12:33 p.m., a concurrent observation of the lunch meal trays of Residents 14 and 25 was conducted with the Director of Staff Development (DSD) in the dining room. The food trays were observed to each contain a cup of cherry crisp. In a concurrent interview, the DSD stated Residents 14 and 25 received a cherry crisp each as dessert. The DSD further stated both Residents 14 and 25 were on CCHO (controlled carbohydrate- less sugar) diet because they were diabetics (with abnormal blood sugar). a. During lunch meal observation on June 9, 2025, Resident 14's tray contained the following: - egg salad sandwich; - chopped/soft fried potatoes; - chopped seasoned red cabbage; - minestrone soup; - soft chopped cherry crisp; - decaf hot tea; - iced tea; and - whole milk/beverage. On June 9, 2025, Resident 14's record was reviewed. Resident 14 was admitted to the facility on [DATE], with diagnoses which included diabetes mellitus type 2 (DM2 - abnormal blood sugar). A review of Resident 14's Physicians Order, dated June 6, 2025, indicated Resident 14 was on a CCHO diet. b. During a lunch meal observation on June 9, 2025, Resident 25's tray contained the following: - pureed Honey Pot roast with gravy; - applesauce; - pureed fried potatoes; -pureed seasoned red cabbage; - pureed seasoned red; - pureed cherry crisp; - diet lemonade-honey thick; and - whole milk. On June 9, 2025, Resident 25's record was reviewed. Resident 25 was admitted to the facility on [DATE], with diagnoses which included DM2. A review of Resident 25's Physicians Order, dated June 6, 2025, indicated Resident 25 was on a CCHO diet. A review of the facility's Diet Spreadsheet, dated Week 2, Day 9-Monday, indicated CCHO residents would receive fruit in place of cherry crisp. The facility was not able to provide a documentation or a logbook regarding changes in the diet menu. There was no posting on the menu board or consumer board regarding the changes in the planned menu for the day. On June 10, 2025, at 3:54 p.m., during an interview with the RD, the RD stated the meal diets of Residents 14 and 25 should have coincided with the cook's spreadsheet. The RD stated Residents 14 and 25 should have received fruits for dessert, according to the cook's spreadsheet. The RD further stated Residents 14 and 15 would be at risk for uncontrolled sugar levels, which could lead to kidney failure and possible hospitalization. 2. On June 9, 2025, at 12:33 p.m., a concurrent dining observation was conducted with the DSD in the dining room. The food items for Residents 14, 18, and 25 were observed to not have gravy on their pot roast meat. In a concurrent interview, the DSD stated there was no gravy on pot roast meats served to Residents 14, 18, and 25. The DSD further stated kitchen did not follow the order listed on the meal tickets, and the list should have been followed. A review of facility's Diet Spreadsheet, dated Week 2, Day 9-Monday, indicated mechanical soft diet residents would receive ground honey pot roast with gravy, and residents receiving pureed texture would receive pureed honey pot roast with gravy. On June 10, 2025, at 3:54 p.m., during an interview with the RD, the RD stated the meal diets of Residents 14, 18, and 25 should have coincided with the cook's spreadsheet. The RD stated the pot roast meats should have been served with gravy. The RD further stated, the gravy would help moisten to the food, thereby preventing choking and aspiration. The RD further stated the absence of gravy could lead to undernourishment and weight loss. A review of the facility's policy and procedure titled, Menu Diet Spreadsheets/Portion Serving Communication Tool, dated 2020, indicated, .Diet spreadsheets are based on the planned menu and reflect serving .for regular and therapeutic diet orders .Therapeutic diets reflected on the spreadsheet correspond to the diet guidelines found in the community's approved diet manual .

Based on observation, interview, and record review the facility failed to ensure Food and Nutrition Services associates were trained and competent to carry out the functions of the department safely and effectively when: 1. Food Service (FS) staff did not use three separate steps (wash, rinse and sanitize) to clean and sanitize work surfaces and soiled equipment, according to the facility's policy and procedure; and 2. FS staff did not follow the manufacturer's guidelines for the length of time required for dipping the test strip into the sanitizer (sanitizing solution used for sanitizing food contact surfaces) when testing the concentration of the sanitizer. These failures had the potential for food utensils and dishes to be improperly sanitized, and may result in food-borne illnesses in the vulnerable resident population. Findings: 1. On June 10, 2025, at 2:11 p.m., during a concurrent observation and interview with FS 1, FS 1 was observed cleaning a dirty meal cart. FS 1 stated she used a blue bucket with soap and water solution to clean the work surfaces of the kitchen or soiled equipment, and then used a red bucket to sanitize them. FS1 further stated she already washed and sanitized them. FS 1 did not mention rinsing the soap and water solution before sanitizing. On June 10, 2025, at 2:16 p.m., during an interview with FS 2, FS 2 stated she cleaned the soiled counter top surfaces using soap and water solution, then the sanitizer solution would be used. FS 2 did not mention rinsing the soap and water solution before sanitizing. On June 10, 2025, at 3:34 p.m., an interview was conducted with the Registered Dietitian (RD). The RD stated the proper steps for dishwashing were: removal of food debris, wash with detergent solution, rinse with water, and lastly, sanitize with sanitizer. The RD further stated if staff did not follow the proper dish cleaning and disinfecting procedures, kitchen equipment surfaces would not be cleaned properly. A review of the facility's policy and procedure titled, Tools for Effective Cleaning, dated 2023, indicated, .Cleaning involves the removal of soil. Water is the main cleaning agent .chemical cleaning compound .The purpose of detergents is to loosen the soil or dirt .The soil must be rinsed off .and sanitized . A review of the U.S. FDA (Food and Drug Administration) Food Code 2022, Annex 3 Section 4-501.18 Warewashing Equipment, Clean Solutions, the Food Code indicated, Failure to maintain clean wash, rinse, and sanitizing solutions adversely affects the warewashing operation. Equipment and utensils may not be sanitized, resulting in subsequent contamination of food .Warewashing means the cleaning and SANITIZING of UTENSILS and FOOD-CONTACT SURFACES of EQUIPMENT . 2. On June 10, 2025, at 10:11 a.m., during a concurrent observation and interview with Kitchen Supervisor (KS), KS was asked to demonstrate how to check the concentration of the sanitizer. KS was observed dipping the test strip into the sanitizer for 10 seconds. KS stated he needed to dip the test strip for 10 seconds to check the concentration of sanitizer. On June 10, 2025, at 2:11 p.m., during a concurrent observation and interview with FS 1, FS 1 was observed dipping the test strip into the sanitizer for 15 seconds to check the concentration of the sanitizer. FS 1 stated she needed to dip the test strip into the sanitizer for 15-20 seconds, and confirmed she dipped the test strip into sanitizer for 15 seconds to check the concentration of sanitizer. A review of the sanitizer manufacturer's guidelines, dated January 2025, indicated, .Procedure .Immerse the strip in sample for 5 (five) seconds . On June 10, 2025, at 3:34 p.m., an interview was conducted with the RD. The RD stated the staff should have followed the manufacturer's guideline for the length of time required for dipping of the test strip into the sanitizer solution. The RD further stated if the test strip was dipped for too long, it would lead to False reading result. A review of the facility's policy and procedure titled, Cleaning and Sanitizing - Basics, dated 2023, indicated, .When cleaning and sanitizing any food contact surface, it is extremely important that: Always refer to manufacturer's recommendation of dilution strength and current Federal/ or a State Food code (using stricter of the two standards) .

Based on observation, interview, and record review, the facility failed to ensure the proper maintenance of essential equipment, when water was found dripping from the condenser unit (removes heat from the refrigerator and cooling it down to a liquid state) of Refrigerator (Ref) #3 . This failure had the potential to place residents at risk for food-borne diseases (illness that result from ingestion of contaminated food) that can cause sickness and/or death. Findings: On June 9, 2025, at 10:10 a.m., during the initial kitchen tour, an observation of Ref #3 was conducted. Inside Ref#3, the condenser unit was located at the top back wall of Ref#3. Water was observed dripping down from the condenser unit into a 1/8 6-inch deep metal pan, which was below the condenser unit and resting on the top shelf of the refrigerator. The metal pan was full to the brim with water, with water overflowing and dripping onto some food items on the lower shelves. In a concurrent interview with the Food Server Director (FSD), the FSD stated the water leak came from the condenser unit, and maintenance should have fixed it. The FSD further stated the water was leaking down towards the shelves and dripped onto the food, so it was not safe due to possible cross-contamination of the food. On June 9, 2025, at 10:14 a.m., during a concurrent observation and interview with the Maintenance Supervisor (MS) inside the kitchen, the MS stated Ref #3's condenser unit had a leak, so the water dripped down to the shelves. The MS further stated, It should have been fixed as soon as possible. On June 10, 2025, at 4 p.m., during an interview with the Registered Dietician (RD), the RD stated any damaged kitchen equipment should have been prioritized and repaired for safe and operable use. The RD further stated water that leaked and dripped on to the food would cause cross-contamination, which could cause residents to have food-borne illnesses. A review of the facility's policy and procedure titled, Maintenance Service, dated December 2009, indicated, .Maintenance service shall be provided to all areas of the building, grounds, and equipment .The maintenance department is responsible for maintaining the buildings, grounds and equipment in a safe and operable manner at all times .

Based on observation, interview, and record review, the facility failed to ensure infection prevention and control practices were implemented, when Licensed Vocational Nurse (LVN) 1 was observed removing one tablet of Metoprolol (a blood pressure medication) from the medicine cup using bare forefinger, during medication administration observation. In addition, LVN 1 was observed not disinfecting the blood pressure (BP) apparatus before and after resident use. These failures had the potential to spread infection among the vulnerable residents of the facility. Findings: On June 12, 2025, at 9:16 a.m., a medication administration observation was conducted with LVN 1. The following were observed: - LVN 1 poured Resident 94's medications, including one tablet Metoprolol 25 mg (milligram- unit of measurement) into one medicine cup on top of the medication cart (med cart). LVN 1 stated the medication was not to be administered if Resident 94's systolic (upper number) blood pressure was less than 110 mmHg (millimeters mercury- unit of measurement for pressure). LVN 1 stated Resident 94's blood pressure, which was taken earlier, was 110/60 mmHg, so he would recheck Resident 94's blood pressure when in the room and before administering the medication; - LVN 1 brought out the BP apparatus from the bottom drawer of the med cart and placed it on top of the med cart. LVN 1 then picked up the medicine cup, picked up the BP apparatus, and proceeded to Resident 94's room. LVN 1 obtained Resident 94's blood pressure using the BP apparatus and a stethoscope which he removed from around his neck. After obtaining Resident 94's blood pressure, the LVN looped the stethoscope back around his neck without disinfecting the stethoscope; - LVN 1 stated Resident 94's BP was 100/59 and the Metoprolol was not going to be administered. LVN 1 returned to the medication cart with the medicine cup and the BP apparatus. LVN 1 identified the Metoprolol tablet and proceeded to remove the medication from inside the medicine cup using his bare right forefinger. The BP apparatus was left on top of the medication cart; and - After administering the medications to Resident 94, LVN 1 was observed to return the BP apparatus to the bottom drawer of the med cart without disinfecting the medical equipment. In a concurrent interview with LVN 1, LVN 1 stated he should not have used his bare forefinger in removing the medication from the medicine cup, and he should have disinfected the stethoscope and BP apparatus before and after use on Resident 94. On June 13, 2025, at 9:03 a.m., the Infection Preventionist (IP) was interviewed. The IP stated LVN 1 should not have removed the medication from the medicine cup using his bare forefinger, and should have disinfected the stethoscope and BP apparatus after use on Resident 94, to avoid the risk of contamination or cross-contamination. On June 13, 2025, at 9:14 a.m., the Director of Nursing (DON) was interviewed. The DON stated LVN 1 should not have used bare hands in handling the medication, and should have sanitized the medical equipment before and after use. A review of the facility's policy and procedure titled, Cleaning and Disinfection of Resident-Care Items and Equipment, dated September 2022, indicated .Resident-Care equipment, including reusable items .will be cleaned and disinfected according to current CDC (Centers for Disease Control) recommendations for disinfection .Non-critical items are those that come in contact with intact skin .items include bedpans, blood pressure cuffs .items require cleaning followed by either low- or intermediate-level disinfection following manufacturers' instructions .performed with an EPA (Environmental Protection Agency)-registered disinfectant labeled for use in healthcare settings .Reusable items are cleaned and disinfected or sterilized between residents (e.g., stethoscopes, durable medical equipment) .

Based on observation, interview, and record review, the facility failed to store, prepare, and serve food in a sanitary manner, in accordance with professional standards for food service safety, when: 1. Stacks of dirty pots, pans, and dishes in the three-sections sink area, several with food on them and more dirty dishes noted on a metal shelf across from the three-section sink, one filled with an egg like mixture. 2. Food particles, crumbs, a cookie, broken eggshells, a plastic bowl, and various wrappers were under the stoves and ovens. This failure had the potential to attract further rodents in the kitchen who could transmit disease to 43 of 44 medically compromised residents by contaminating food and food contact surfaces. Findings: On January 27, 2025, at 9:45 a.m., an unannounced visit to the facility was conducted to investigate a complaint regarding dietary services. On January 27, 2025, at 11:30 a.m., an observation and concurrent interview was conducted with the Dietary Supervisor (DS). The DS stated the kitchen crew cleans the kitchen three times a day, after each meal is completed. During the kitchen tour with the DS, the following were observed: - Stacks of dirty pots, pans, and dishes were observed in the three-compartment sink area, several with food still on them; - Multiple dirty dishes were observed on a metal shelf across the three-compartment sink; - Food particles, crumbs, a whole cookie, broken eggshells, a plastic bowl, and various wrappers were observed under the stoves and ovens. The DS looked under the ovens and stoves, and stated it was very dirty. The DS stated the kitchen staff did not have time to clean up after breakfast. The DS stated the breakfast dishes in the three-comparetment sink would be cleaned up after lunch is served as they were not able to wash the dishes yet. On January 27, 2025, at 12:30 p.m., a review of the pest control service report for the facility, dated November 2024 - January 2025 indicated the following: - November 22, 2024, .mice caught in interior traps in kitchen near exit doors. Doors need to be closed at all times. Rodent activity present .Observation .dead .mice .flies .grease build-up present under cooking stations .Recommendation clean and sanitize area .debris under shelves dry shelves, cooking stations .recommendation remove debris-customer .Trash issue food under employee locker .trash under dry storage in kitchen area .recommendation clean and sanitize area . - December 18, 2024, .Rodent activity present .earwig (nocturnal insects that often hide in small, moist crevices during the day, and are active at night, feeding on a wide variety of insects and plants) activity present .observation .dead .earwigs .kitchen . grease build-up present under cooking stations .Recommendation clean and sanitize area .debris under shelves dry shelves, cooking stations .recommendation remove debris-customer .Trash issue food under employee locker .trash under dry storage in kitchen area .recommendation clean and sanitize area . - January 24, 2025, .Rodent activity present .gnat (a very small flying insect that bites animals and people) and earwig activity present .observation .dead .fungus gnats .kitchen .open actions .grease build-up present under cooking stations .Recommendation clean and sanitize area .debris under shelves .recommendation remove debris-customer .Trash issue food under employee locker .trash under dry storage in kitchen area .recommendation clean and sanitize area . A review of the facility document titled, Cooks Weekly Cleaning List, indicated no documentation cleaning was performed on December 8, 9, 10, 18, 19, 27, 28, and 29, 2024. A review of the facility document titled, Cooks Weekly Cleaning List, dated January 13 to 19, 2025, indicated, the following areas were cleaned on January 25, 2025 (six days after the dates indicated to clean): - .both plate and pellet warmers and floors underneath .; - .convection oven .; and - .Fryers inside, outside, and underneath . A review of the facility document titled, Servers Cleaning List, indicated no documentation cleaning was performed on December 12, 13, 22, 23, 24, and 25, 2024. A review of the facility document titled, Servers Cleaning List, dated January 16 to January 22, 2025, indicated no documentation the following tasks were completed: - .wash dirty plastic containers in dry storage room. (may run containers that fit in dish machine .please make sure you are checking .any loose items on the shelves the containers are on.) .; - .clean black/brown condiment containers that hold the salad dressing & jelly/butter. (run thru dish machine) make sure to put dates . ; - .clean shelf area where blue lids container sit, brown sugar container sits and under tray line shelves. Clean inside and outside of bread warmers. Clean shelves where servers' gloves are under tray line .; - .scrub servers sink, clean walls in sink area, clean trash can, wipe down paper towel and soup (sic-soap) dispenser and clean tan drain box under sink .; - .sweep and mop under cold, dry, juice machine, movable units .; and - .clean and defrost ice cream freezer inside, bottom, sides and run ice cream freezer covers in the dish machine . A review of the facility document titled, Dishwasher and Pot Washer Weekly Cleaning List, indicated no documentation cleaning was performed on December 10, 18, 19, 27, 28, 29, 2024. A review of the facility document titlted, Dishwasher and Pot Washer Weekly Cleaning List, indicated no documentation the following tasks were completed on the following dates: - dated December 30, 2024, to January 5, 2025, .plastic storage/sheet pan and cup rack (with wheels) the wall behind and the floor underneath .garbage disposals . - dated January 6 to 12, 2025, .garbage disposals .all trash cans large and small, take out back and use soap, scrubbie [sic] and hose to clean theses thoroughly . On January 27, 2025, at 4:00 p.m., an interview was conducted with the DS. The DS stated the cleaning lists should represent seven (7) to ten (10) days at a time, if it states daily , it means the cleaning task should be completed every day during the week, the initials or name meant it was done every day. The DS stated she did not know why there were tasks with no names, dates, or initials on them, or if the date listed indicated it was done outside of the weekly cleaning tasks. The DS stated she understands if there was no documentation on the weekly cleaning lists, it looks as if the cleaning was not done, and daily cleaning tasks should contain initials with a date for each day the area was cleaned. The DS stated it could be confusing when looking at the cleaning lists which tasks were supposed to be done weekly and which ones were supposed to be done daily. The DS stated if the kitchen was not being cleaned on a daily and weekly basis it could increase the possibilities of rodents and insects, and may lead to food borne illnesses. A review of the facility's policy titled Sanitization, dated November 2022, indicated, .the food service area is maintained in a clean and sanitary manner .kitchens, kitchen areas .are kept clean, free from garbage and debris, and protected from rodents and insects .manual washing and sanitizing is a three-step process .scrape food particles and wash using hot water and detergent .waste is properly contained in a dumpster/compactor with lids .areas used for garbage disposal are free from odors and waste fats, and maintained to prevent pests .

Based on interviews and record reviews, the facility failed to ensure accurate skin assessments and wound care treatment were provided to promote the healing and prevention of new pressure injuries from developing, for three of 13 residents (Residents A, B, and C). These failures have the potential to result in delayed wound healing. Findings: On January 27, 2025, at 9:45 a.m., an unannounced visit to the facility was conducted to investigate quality of care and treatment complaints. On January 28, 2025, at 2 p.m. an interview was conducted with the Treatment Nurse (TN). The TN stated if a resident develops a pressure ulcer/injury (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence), the Certified Nursing Assistants (CNA) are usually the first ones to notice and would report their findings of the wound to her. The TN stated she would conduct the following procedures when a resident was identified with a pressure ulcer/injury: - Evaluate the resident's skin; - Measure the wound; - Write a description of the wound (color, drainage, odor); - Call the provider to let them know there is a change in the resident and get an order for treatment; - Fill out a change of condition (COC) form, write the change in the communication book for the other licensed nurses to monitor the resident for 72 hours; and - Initiate or revise a care plan for the wound with interventions. The TN stated the admitting nurse does the initial skin assessment when a resident is admitted and then she would perform a secondary skin assessment as a follow up. 1. On January 28, 2025, at 2:45 p.m., a review of Resident A's medical record was conducted. Resident A was admitted on [DATE], with diagnoses which included metabolic encephalopathy (a condition where the brain does not function properly due to an imbalance in the body's metabolism) and septic shock (a widespread infection causing organ failure). A review of Resident A's Skilled Nursing Admission Assessment, dated January 2, 2025, at 6:50 p.m., indicated, .skin .bilateral (both) heels discoloration .bilateral buttocks Pressure stage 1 (one) .coccyx (tailbone) pressure stage 1(one) . A review of Resident A's Admission Summary, dated January 2, 2025, at 9:42 p.m., indicated, .skin assessment .non blanchable (does not fade when pressure is applied) redness to bilateral buttocks and coccyx .RT (right) heel red, maroon and mushy, zero open .Lt (left) heel, red, [NAME] [sic] and mushy, zero open . A review of Resident A's Treatment New Admission Risk Assessment, dated January 3, 2025, at 1:10 p.m., indicated, .pressure ulcer #1 .Coccyx pressure ulcer . stage 1 (one) .treatment repositioning .pressure ulcer #2 .buttocks .stage 1 (one) .treatment repositioning .non blanchable redness noted to bilateral buttocks and coccyx. Redness to bilateral heels also noted. Discussed the importance of repositioning often while in bed . A review of Resident A's Change of Condition Evaluation, dated January 5, 2025, at 5:46 p.m., indicated, .skin wound or ulcer .requires extensive assistance for repositioning .open area .left gluteal (buttocks) fold .right gluteal fold . A review of Resident A's Health Status Note, dated January 5, 2025, at 6:20 p.m., indicated, .asked by CNA (Certified Nursing Assistant) to look at patients [sic] coccyx during AM (morning) shift .redness to coccyx area noted, open areas noted. Triad (a type of ointment for wound care) applie . A review of Resident A's Treatment Nurse Weekly Skin Assessment, indicated the following: - dated January 10, 2025, at 10:52 a.m., indicated, .seen by wound consultant .bilateral buttocks MASD (moisture-associated skin damage-a condition causing skin damage due to prolonged exposure to moisture, such as urine, sweat, or wound drainage) with open areas: has scant serous (clear watery fluid) drainage .clean with NS (normal saline-a fluid containing sodium chloride, used to irrigate wounds), apply barrier cream (a cream applied to the skin to create a protective layer) . - dated January 17, 2025, at 10:48 a.m., indicated, .seen by wound consultant .bilateral buttocks MASD and open areas: 50% slough (a type of dead tissue that forms in wounds) is present in open areas. Has light serous drainage .continue with treatment .clean with NS (normal saline), apply with barrier cream to surrounding area and Santyl (an ointment used to remove damaged tissue from skin ulcers) to open area . - dated January 24, 2025, at 12:16 p.m., indicated, .Coccyx PI (pressure injury), grade 2 (two), 0.5cm x 0.4cm x 0.1cm (centimeter-a unit of measurement) .Right buttock PI grade 3 (three), 0.5cm x 0.6cm x 0.1cm .Sacrum (triangle shaped bone at the base of the spine) PI grade 3 (three), 1.0cm x 0.4cm x 0.2cm .Left Inferior (lower) buttock PI grade 3 (three), 0.7cm x 0.6cm x 0.1cm .Left Superior (upper) buttock PI grade 3 (three), 2.0cm x 2.0cm x 0.2cm . On January 29, 2025, at 3:15 p.m., a concurrent interview and record review was conducted with the Registered Nurse (RN). The RN was the treatment nurse until January 23, 2025. A review of Resident A's treatment note, dated January 9, 2024, indicating non blanchable redness to bilateral buttocks, the RN stated it should have been documented as a stage one pressure injury. The RN stated she put in an order to monitor Resident A's skin, she cannot find documentation of monitoring in the progress notes or the treatment administration record (TAR). 2. On January 29, 2025, at 12 p.m., a review of Resident B's medical record was conducted. Resident B was admitted to the facility on [DATE]. 2024, with diagnoses which included cardiac pacemaker and urinary tract infection. A review of Resident B's Treatment Nurse New Admission Risk Assessment, dated January 9, 2025, at 10 a.m., indicated, .is there a pressure ulcer on admission .No .narrative .non-blanchable redness noted to bilateral buttocks . A review of Resident B's Treatment Administration Record (TAR), dated January 2025, indicated the following: - Bilateral buttocks non blanchable redness; cleanse with NS (normal saline), pat dry, apply triad, leave open to air, start date January 16, 2025. - Sacrococcyx pressure injury unstageable: cleanse with NS, pat dry, apply barrier cream to peri wound (area around the outside), and on open area apply collagen alginate and dry dressing, start date January 18, 2025. - Sacrococcyx unstageable: cleanse with NS, pat dry, apply barrier cream to peri wound and on open area apply Santyl, and dry dressing, start date January 25, 2025. A review of Resident B's Treatment Nurse Weekly Skin Assessment, indicated the following: - dated January 17, 2025, at 2:35 p.m., indicated, .open ulcer .yes .seen by wound consultant .sacrococcyx unstageable measuring 4.9cm x 4.0cm x unstageable with 90% granulation, 10% purple. Moderate serosanguinous drainage, treatment order to cleanse with NS, pat dry, apply barrier cream to peri wound and on open area apply collagen, alginate, and dry dressing . - dated January 24, 2025, at 1:24 p.m., sacrococcyx pressure area 4.5cm x 6.2cm x UTD (undetermined) with 70% granulation, 30% slough. Light Serosanguinous drainage. Treatment orders to cleanse with NS, pat dry, apply barrier cream to peri wound and on open area apply Santyl ointment, and dry dressing. On January 29, 2025, at 3:15 p.m., the RN stated Resident B's admission note for January 9. 2025, indicated there was non-blanchable redness to his bilateral buttocks, this should have been noted as a stage one pressure injury, treatment should have been started when it was initially identified (January 9, 2025), and a care plan should have been created. The RN stated there was still notable non-blanchable redness to Resident B's sacrococcyx area and a treatment was ordered on January 16, 2025 (seven days after it was initially identified). On January 31, 2025, at 2:30 p.m., an interview was conducted with the TN. The TN stated open areas to the buttocks or other pressure areas, changes the classification of a pressure injury. The TN stated open areas need to be measured, and a description, and appropriate treatment orders should be obtained. The TN stated pressure areas with non-blanchable redness is a stage one pressure injury, appropriate treatment includes repositioning, in addition to monitoring closely, to only reposition a resident is not a standard of practice. The TN stated if a stage one pressure injury has an open area, the wound needs to be recategorized to a stage two pressure injury. The TN stated once a skin concern is noted it needs to be addressed in the weekly skin notes and a wound with slough needs to be recategorized as a stage three pressure injury as a standard of practice. The TN stated when using Santyl on a wound, it must be cover with dressing to work as an autolytic (breakdown of cells and tissue by enzymes) for debridement (involved removing dead, infected, damaged tissue from a wound or ulcer), it cannot be left open to air, the medication would not be able to work properly. 3. On January 31, 2025, at 9:00 a.m., a review of Resident C's medical record was conducted. Resident C was admitted to the facility on [DATE], with diagnoses which included quadriplegia (partial or complete paralysis of all four limbs) and pressure injury to his left buttock, stage 4 (four). A review of Resident C's Order Summary Report, indicated: - Foley Catheter (a thin flexible tube inserted into the bladder to drain urine) care every shift with Chlorhexidine Gluconate (a special soap used to clean skin and protect against germs) 2% cloth, cleanse tube from urethral meatus (the external opening where urine comes out) to inner thigh, clean downward every shift, ordered November 23, 2024. - Left buttock, skin bridge wound: cleanse with NS, pat dry, apply dry dressing every day shift, ordered November 1, 2024. - Scrotum cleanse with normal saline, pat dry, apply Nystatin (antifungal medication) cream every shift for redness, ordered December 20, 2024. A review of Resident B's Treatment Administration Record (TAR), for December 2024 and January 2025, indicated no documentation treatments were completed for: - Left buttock pressure injury stage 4 (four), clean with NS, apply triple ABT ointment with collogen powder to wound bed, pack with calcium alginate including the tunneling area, cover with dry dressing, on December 9, 2024. - Foley Catheter care every shift with chlorhexidine gluconate 2% cloth cleanse tube from urethral meatus to inner thigh, on night shift December 7, 2024, January 19, and January 24, 2025. - Scrotum cleanse with normal saline, pat dry, apply zinc cream twice daily and as needed for redness, on December 7, 2024. - Scrotum cleanse with normal saline, pat dry, apply nystatin cream, every shift for redness, started on December 20, 2024, on night shift January 19 and January 24, 2025. -Left buttocks stage 4 (four), skin graft in place, followed by xeroform, gauze, Tegaderm, then border dressing, replace outer dressing if soiled, every shift, started on January 17, 2025, on night shift January 19/2025, night shift. On January 31, 2025, at 4 p.m., the DON stated Resident B is very particular about who he allows to perform his urinary catheter care, his catheter care is important because he gets urinary tract infections often, and it is important to make sure he is receiving wound care consistently. There was no documentation in the TAR that the treatment orders were done. The DON stated the treatments need to be completed as ordered. A review of the facility's Job Description-LVN Treatment Nurse, indicated, .daily assesses the total needs of the resident and develops nursing care plans .prepares, administers, and charts medications according to the physician's order .responsible for interpretation and execution of the physician's orders .accurate observations, evaluations and reporting of resident's symptoms . A review of the facility's policy titled Pressure Ulcers/Skin Breakdown-Clinical Protocol, dated April 2018, indicated, .the nurse shall describe and document/report the following .Full assessment of pressure sore including location, stage, length, width and depth, presence of exudates or necrotic tissue .examine the skin of newly admitted residents for evidence of existing pressure ulcers or other skin conditions .Guide the care plan .especially when wounds are not healing .or new wounds develop despite existing interventions .

Based on interview and record review the facility failed to ensure three (Resident D, E, and F) of 13 residents (Residents D, E, and F), received treatment and care in accordance with professional standards of practice to meet each resident's highest practicable physical, mental, and psychosocial well-being, when: 1. Resident D did not receive antibiotic (used to treat infection) medication as ordered by the physician. In addition, the topical treatments for Resident D's moisture associated skin damage (MASD - skin inflammation that occurs when the skin is exposed to moisture for a long time); 2. Resident E's neurocheck (a series of tests to check the brain, spinal cord, and nerve function) was not conducted according to the physician's order after the resident fell ; and 3. Resident F was not administered medication to address constipation according to the physician's order. These failures have the potential to result in a delay in the care and treatment for Resident D, E, and F, and could have affect their overall health condition. Findings: On January 27, 2025, at 9:45 a.m., an unannounced visit was conducted for complaints of quality of care. 1. January 30, 2025, at 10:15 a.m., a review of Resident D's medical record was conducted. Resident D was admitted on [DATE], with diagnoses which include benign prostatic hyperplasia (prostate gland enlargement that can cause urination difficulty) with urinary tract infections. A review of Resident D's Treatment Administration Record (TAR) for December 2024 and January 2025 indicated the following treatments for Resident D's MASD were not documented as completed: - Triad Hydrophilic (a type of medication for wounds) wound dress external paste, apply to bilateral (both) buttocks every day shift for MASD and fungal; no documentation treatment was completed on the day shift of December 8, and December 13, 2024. - Ciclopirox External Gel 0.77%, apply to sacrococcyx (area below the spine to the tailbone)/buttocks every shift for MASD with fungal dermatitis (inflammation of skin); no documentation treatment was completed on December 8, and December 13, 2024. - Sacral (triangle shaped bone under spine) coccyx (tailbone) and bilateral buttocks MASD: clean with NS (normal saline), pat dry, apply barrier cream, leave open to air every shift, no documentation treatment was completed on January 19, and January 24, 2025. A review of Resident D's Medication Administration Record (MAR) dated December 2024, indicated the following: - Bactrim DS (an antibiotic used to treat an infection) 800-160mg (milligram-a unit of measurement) every 12 hours for a urinary tract infection was ordered to start December 2, 2024. The MAR indicated the dose for Bactrim on December 2, 2024, 9 p.m. dose was not administered as not available; - Bactrim DS 800-160mg every 12 hours, ordered to start December 24, 2024, at 8:00 a.m.; the dose was not given as the medication was unavailable. On January 30, 2025, at 4:15 p.m., an interview and concurrent record review was conducted with the Director of Nursing (DON). The DON stated Resident D has several treatments that were not documented as provided, the DON confirmed they were not completed. The DON stated the treatments should not have been missed and the Bactrim was in the medication room available in the emergency kit and should be given timely. 2. On January 30, 2025, at 11:50 a.m., a review of Resident E's medical record was conducted. Resident E was admitted on [DATE], with diagnoses which included metabolic encephalopathy (a condition where the brain does not function properly due to an underlying metabolic balance) and dementia (a group of thinking and social symptoms that interfere with daily functioning). A review of Resident E's Progress Notes, indicated the following: - dated January 1, 2025, at 10:35 a.m.; .resident is AO (alert, oriented) X 2-3 (2-3 indicates oriented to person, place and time) with forgetfulness & (and) episodes of confusion. Resident was observed laying on the floor in supine (on back) position between her bed and the bathroom, her head was positioned underneath the bed next to a bedside table .resident noted with a knot to the back of her head .resident states she was trying to get into her wheelchair .and grab food from her bedside table and she slipped and fell . - dated January 2, 2025, at 10:27 a.m.; .IDT (Interdisciplinary Team - a group of healthcare professionals) me on 1/2/25 (January 2, 2025) to discuss fall on 1/1/25 (January 1, 2025) .Bump noted at the back of bed (sic) .continue neuro checks per facility protocol . A review of Resident E's Change of Condition Evaluation, dated January 1, 2025, at 10:26 a.m., indicated, .noted resident not in bed .observed resident on floor .resident laying on back on the left side of the bed, head under roommates [sic] wheelchair, naked .brief off .resident stated she was trying to get up for breakfast but unable to answer how she got onto the floor . Further review of Resident E's record indicated there was no documented evidence a neuro check log was completed for Resident E's after the fall on January 1, 2025. On February 4, 2025, at 10:15 a.m., conducted an interview with the DON. The DON stated neuro checks were ordered for Resident E on January 1, 2025, but no documentation of the neurocheck completed could be found. 3. On January 31, 2025, at 3:30 p.m., an interview with Resident F was conducted. Resident F stated she wants to have normal bowel movements; she has been constipated for a long time. On January 31, 2025, a review of Resident F's medical record was conducted. Resident F was admitted to the facility on [DATE], with diagnoses which included Parkinson's dementia (a change in thinking and problems with memory) and psychosis (a mental disorder characterized by a disconnection from reality) with hallucinations (perceiving things that are not actually present, hearing voices, seeing objects). A review of Resident F's Order Sunnary Report, included the following physician's orders to address constipation: - .Milk of Magnesia Oral Suspension (MOM) .Give 30 ml (milliliter - unit of measurement) by mouth as needed .Give if no BM (bowel movement) x (times) 3 (three) days .; date ordered January 1, 2025; - Bisacodyl Rectal Suppository (administered via the rectum/anus) .Insert 1 suppository rectally as needed for Bowel Management if MOM (Milk of Magnesia) is ineffective after 8 (eight) hours give suppository .; date ordered January 1, 2025; and - Fleet Enema Rectal Enema (a [NAME] pe of rectal enema used to relieve constipation and prepare the bowels for medical procedures) .Insert 1 applicator rectally as needed .if suppository is ineffective after 8 hours administer Enema .; date ordered January 1, 2025. A review of Resident F's Care Plans indicated the following: - Alteration in comfort, dated January 2, 2025, Interventions included Hospice nurse to assess resident's bowel movement pattern each visit. - At risk for constipation, dated January 3, 2025, Goal: will have BM (bowel movement) every 2-3 days, interventions: Medication as ordered [Milk of Magnesia, Bisacodyl Rectal suppository, fleet enema]. Monitor for effectiveness of medication. Inform MD (medical doctor) promptly if ineffective. Monitor bowel movements for frequency, amount, and consistency. Monitor for signs of complications related to constipation. Monitor medications to see if causing constipation. A review of Resident F's Tasks: Bowel Continence, dated January 1, to January 31, 2025, indicated no bowel movement documented on January 15, 16, 17, 18, 19, 20, 21, 23, 24, 25, and 26, 2025. A review of Resident F's Medication Administration Record (MAR), for January 2025, indicated MOM, bisacodyl, dulcolax suppository, and fleet enema were not documented as administered to Resident F when the resident did not have BM on several days in January 2025. On January 31, 2025, at 4 p.m., an interview was conducted with the DON. The DON stated Resident F should be having bowel movements every two to three days. The DON stated if Resident F would not have BM for three or more days, the nursing staff should be medicating the resident with milk of magnesia, rectal suppositories or be given an enema. A review of the facility's policy titled Change in a Resident's Condition or Status, dated February 2021, indicated, .changes in the resident's medical/mental condition and/or status .accident or incident involving the resident .significant changes in the resident's physical/emotional/mental condition .specific instruction to notify the physician of change in the resident's condition .impacts more than one area of the resident's health status .requires interdisciplinary review and/or revision to the care plan . A review of the facility's policy titled Administering Medications, dated April 2019, indicated, .medications are administered in accordance with prescriber orders, including any time frame. Medication administration times are determined by resident needs and benefit, not staff convenience. Factors that are considered include .enhancing optimal therapeutic effect of the medication .medication errors are documented, reported, and reviewed by the QAPI committee to inform process changes and or the need for additional staff training .as required or indicated for a medication .the date and time the medication was administered .topical medications used in treatment are recorded on the resident's treatment record (TAR) . A review of the facility's protocol titled Bowel .Disorders-Clinical Protocol, dated September 2017, indicated, .lower gastrointestinal tract conditions .alteration in bowel movements .the nurse shall assess and document/report .presence of fecal impaction .digital rectal examination .all current medications .staff and physician will identify risk factors related to bowel dysfunction .taking medications that are used to treat, or may cause or contribute to dysmotility .identify current medications that are associated with gastrointestinal side effects .antipsychotics and antidepressants .institute a regimen to prevent constipation .monitor the individual's response to interventions .frequency and consistency of bowel movements . A review of the facility's policy titled Wound Care, dated October 2010, indicated, .to provide guidelines for the care of wounds to promote healing .documentation .type of wound care given, the date and time wound care was given .all assessment data .wound bed color, size, drainage .notify supervisor if the resident refuses the wound care .

Based on interview and record review, the facility failed to ensure a thorough investigation of an allegation of physical abuse was conducted, for one of three residents (Resident G), after the facility was made aware of the allegation of abuse. This failure had the potential to result in further abuse for Resident G, which could affect the resident's emotional and psychosocial well-being. Findings: On January 27, 2025, at 9:45 a.m., an unannounced visit to the facility was conducted to investigate an allegation of abuse. On January 28, 2025, at 10 a.m., an interview was conducted with the Infection Preventionist (IP). The IP stated an allegation of abuse was discussed during a stand up meeting on January 24, 2025, that Resident G reported to the licensed nurse at around 9 p.m., on January 23, 2025, a Certified Nursing Assistant (CNA) pushed her. On January 28, 2025, at 4:15 p.m., an interview was conducted with the Director of Medical records (DOMR). The DOMR stated stand-up meetings with all department heads were being conducted daily. The DOMR stated during the stand up meeting on January 24, 2025, Resident G was discussed regarding a change of condition indicating allegations made by the resident, such as no food, and a CNA pushed her. On January 28, 2025, at 4:40 p.m., a review of Resident G's medical record was conducted. Resident G was admitted to the facility on [DATE], with diagnoses which included cerebral atherosclerosis (condition where plaque builds up in the arteries in the brain, narrowing them and reducing blood flow) and depressive disorder (a mental health condition with low moods, loss of interest or pleasure in activities, with symptoms that interfere with daily functioning). A review of Resident G's Minimum Data Set (MDS - a resident assessment tool), dated November 23, 2024, indicated Resident G had a Brief Interview of Mental Status (BIMS) score of 13 (cognitively intact). A review of Resident G's SBAR (situation, background, assessment, recommendation-a communication tool used by healthcare workers when there is a change of condition among residents) Communication Form, dated January 23, 2025, at 9:55 p.m., indicated .behavioral symptoms .false allegations about staff .resident making false allegations, told daughter that she is being locked up, has no food and that the CNA pushed her .recommendation of primary .hospice nurse . A review of Resident G's care plan indicated Resident has been making false accusations toward staff: locking up all the food, not feeding her, not answering call light for over an hour, leaving her in the bathroom for hours, dated January 24, 2025. There was no care plan indicating Resident G's accusation that a CNA pushed her. On January 29, 2025, at 10:15 a.m., an interview was conducted with the MDS Coordinator (MDSC). The MDSC stated she spoke with Resident G on January 27, 2025, to do a follow up about the alleged abuse that she had heard about during the stand-up meeting on January 24, 2025. The MDSC stated Resident G's allegations regarding no food, she was locked up, and was pushed by a CNA, were discussed during the stand up meeting. The MDSC stated she did not agree Resident G's allegation of being pushed by a CNA was a false allegation. The MDSC stated how would the facility know it was a false allegation of being pushed by a CNA unless an investigation was conducted. On January 29, 2025, at 2:10 p.m., an interview was conducted with Resident G and her family member (FM). Resident G stated she received a shower from the hospice nurse last week, and two people she had not met before came in and grabbed her under each arm and pulled her out of bed to take a shower, and she was telling them to stop. On January 29, 2025, at 4:30 p.m., during an interview with the Directof Nursing (DON) and Administrator (ADM), the DON and the ADM stated they were not aware about the allegation of physical abuse by Resident G. The ADM and the DON stated they would have investigated the allegation of abuse by Resident G if they would have known about it. A review of the facility's policy titled Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating, dated September 2022, indicated, .All reports of resident abuse .are reported to local, state, and federal agencies (as required by current regulations) and are thoroughly investigated by facility management. Findings .are documented and reported .if resident abuse .is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law .The administrator or the individual making the allegation immediately reports .suspicion to the following persons or agencies .the state licensing/certification agency .the local/state ombudsman .adult protective services .law enforcement officials .notices include .the type of abuse that is alleged .date and time the alleged incident occurred .the name(s) of all persons involved in the alleged incident .what immediate action was taken by the facility . upon receiving an allegation of abuse .the administrator is responsible for determining what actions (if any) are needed for the protection of residents .All allegations are thoroughly investigated .the investigator notifies the ombudsman that an abuse investigation is being conducted .the ombudsman is notified of the results of the investigation .within 5 business days of the incident, the administrator will provide a follow-up investigation report .

Based on interview and record review, the facility failed to ensure an allegation of physical abuse, for one of three residents (Resident G), was reported to the California Department of Public Health (CDPH - State Agency) immediately or within two hours after the facility was made aware of the alleged abuse. This failure resulted in a delayed investigation by CDPH and had the potential to expose the resident to further abuse. Findings: On January 27, 2025, at 9:45 a.m., an unannounced visit to the facility was conducted to investigate an allegation of abuse. On January 28, 2025, at 10 a.m., an interview was conducted with the Infection Preventionist (IP). The IP stated an allegation of abuse was discussed during a stand up meeting on January 24, 2025, that Resident G reported to the licensed nurse at around 9 p.m., on January 23, 2025, a Certified Nursing Assistant (CNA) pushed her. The IP stated the facility decided not to report to CDPH Resident G's allegation of abuse as it was decided as a false allegation. On January 28, 2025, at 4:15 p.m., an interview was conducted with the Director of Medical records (DOMR). The DOMR stated stand-up meetings with all department heads were being conducted daily. The DOMR stated during the stand up meeting on January 24, 2025, Resident G was discussed regarding a change of condition indicating allegations made by the resident, such as no food, and a CNA pushed her. The DOMR stated it was decided not to report to CDPH Resident G's allegation of abuse. On January 28, 2025, at 4:40 p.m., a review of Resident G's medical record was conducted. Resident G was admitted to the facility on [DATE], with diagnoses which included cerebral atherosclerosis (condition where plaque builds up in the arteries in the brain, narrowing them and reducing blood flow) and depressive disorder (a mental health condition with low moods, loss of interest or pleasure in activities, with symptoms that interfere with daily functioning). A review of Resident G's Minimum Data Set (MDS - a resident assessment tool), dated November 23, 2024, indicated Resident G had a Brief Interview of Mental Status (BIMS) score of 13 (cognitively intact). A review of Resident G's SBAR (situation, background, assessment, recommendation-a communication tool used by healthcare workers when there is a change of condition among residents) Communication Form, dated January 23, 2025, at 9:55 p.m., indicated .behavioral symptoms .false allegations about staff .resident making false allegations, told daughter that she is being locked up, has no food and that the CNA pushed her .recommendation of primary .hospice nurse . A review of Resident G's care plan indicated Resident has been making false accusations toward staff: locking up all the food, not feeding her, not answering call light for over an hour, leaving her in the bathroom for hours, dated January 24, 2025. There was no care plan indicating Resident G's accusation that a CNA pushed her. On January 29, 2025, at 2:10 p.m., an interview was conducted with Resident G and her family member (FM). Resident G stated she received a shower from the hospice nurse last week, and two people she had not met before came in and grabbed her under each arm and pulled her out of bed to take a shower, and she was telling them to stop. On January 29, 2025, at 4:30 p.m., during an interview with the Directof Nursing (DON) and Administrator (ADM), the DON and the ADM stated they were not aware about the allegation of physical abuse by Resident G. The ADM and the DON stated they should have reported the allegation of abuse if they had known about it. A review of the facility's policy titled Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating, dated September 2022, indicated, .All reports of resident abuse .are reported to local, state, and federal agencies (as required by current regulations) and are thoroughly investigated by facility management. Findings .are documented and reported .if resident abuse .is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law .The administrator or the individual making the allegation immediately reports .suspicion to the following persons or agencies .the state licensing/certification agency .the local/state ombudsman .adult protective services .law enforcement officials .notices include .the type of abuse that is alleged .date and time the alleged incident occurred .the name(s) of all persons involved in the alleged incident .what immediate action was taken by the facility . upon receiving an allegation of abuse .the administrator is responsible for determining what actions (if any) are needed for the protection of residents .All allegations are thoroughly investigated .the investigator notifies the ombudsman that an abuse investigation is being conducted .the ombudsman is notified of the results of the investigation .within 5 business days of the incident, the administrator will provide a follow-up investigation report .

Based on observation, interviews, and record reviews the facility failed to ensure, for four of six residents reviewed (Residents A, B, C, and D), wound management to treat pressure ulcers (localized area of skin and tissue damage caused by prolonged pressure on the skin) was provided according to the plan of care, when: 1. For Resident A, there was no comprehensive assessment (indicating measurement, color, tissue appearance, presence of drainage, odor, appearance of surrounding tissue) of the re-opened sacral wound; 2. For Resident B, there was no comprehensive assessment of the wound on the bilateral buttocks upon admission. In addition, there was no weekly re-evaluation of the bilateral buttocks wound the week of September 18 to 20, 2024; 3. For Resident C, there was no treatment provided to the left buttock pressure ulcer. In addition, there was no comprehensive assessment of the left buttocks wound upon admission; and 4. For Resident D, there was no comprehensive assessment of the left buttocks pressure ulcer upon admission. In addition, there was no re-evaluation of the left buttock pressure ulcer on September 25, 2024. These failures had the potential to result in the identification of the resident ' s pressure ulcer condition and could delay appropriate care and treatment. Findings: On October 22, 2024, at 8:45 a.m., an unannounced visit to the facility was conducted to investigate two complaints of quality of care. On October 22, 2024, at 10:38 a.m., an interview was conducted with the treatment nurse (TN). The TN stated there were six residents being provided treatment for skin conditions. 1.On October 22, 2024, at 1:35 p.m., an observation and concurrent interview were conducted with the Treatment Nurse during provision of wound treatment to Resident A. The TN was observed to provide treatment to Resident A ' s necrotic wound on the right foot. The TN stated the treatment for the wound on the coccyx area was also provided earlier in the day. On October 22, 2024, a review of Resident A ' s medical record was conducted. Resident A was admitted on [DATE], with diagnoses which included ischemic infarction (mini stroke-a blood clot, blocks blood supply and oxygen) of muscle, right lower leg, peripheral vascular disease (PVD-a condition in the body in which narrowed blood vessels decrease blood flow to the limbs), and cellulitis (infection to the skin) of right lower leg. A review of Resident A's care plans, dated October 9, 2024, indicated Resident A has a pressure ulcer noted to coccyx, interventions included to measure wound upon admission or wound development and regularly thereafter, observe for compliance with turning and repositioning and inform MD (medical doctor) and document when non-compliance (failure to act in accordance with a wish/commend) is present, perform wound care as ordered, re-evaluate every 7-10 days and PRN (as needed). A review of Resident A's Treatment Nurse New Admission Risk Assessment, dated October 9, 2024, at 4:21 p.m., indicated .right foot .right dorsal foot all toes, diabetic ulcer with necrosis Right lateral knee diabetic ulcer Coccyx old/healed wound . There was no documentation to indicate measurements, a description of the wounds, drainage, or odor on the different wound sites. A review of Resident A's Treatment Nurse Weekly Skin Assessment, dated October 16, 2024, at 11:00 a.m., indicated, .Recurrent stage 4 (four) to sacrococcxy 3 x 2.6 x 0.4 (cm) (centimeter- unit of measurement) . No documentation of Resident A's skin re-opening and the development of a sacrococcyx stage four ulcer was found from Resident A's admitted d October 9, 2024, until October 18, 2024. A review of Resident A's Wound Consultant Progress Note, dated October 18, 2024, indicated, .sacrococcyx, sacral region .pressure ulcer stage 4 (four) .40% slough (dead tissue) .40% granulation/20% epithelial (healthy) tissue .exudate amount (minimal) .erythema (redness to skin) (mild); macerated (softening and break down of skin) (mild) .fat layer exposed .excisional debridement .full thickness .3.0 x 2.6 x 0.4 cm . On October 22, 2024, at 4:25 p.m., an interview was conducted with the TN. The TN stated she knows she should have measured Resident A's wounds on admission and monitor the wounds to track progression of the wounds to determine if it is healing or getting worse. On October 24, 2024, at 9:30 a.m., an interview and concurrent record review was conducted with the TN, regarding Resident A. The TN stated she did not know when Resident A's healed sacrococcyx ulcer re-opened and became a stage four pressure ulcer, she stated she did not measure the wounds when the residents were admitted , and she would wait until the wound consultant sees the residents. The TN stated she did not re-assess Resident A's coccyx area prior to the wound consultant's visit on October 18, 2024, nor write a note or fill out a Change of Condition form after the stage four pressure ulcer to Resident A's coccyx area was discovered. The TN stated she based her weekly skin notes from the wound consultant notes. The TN stated she did not measure the wounds of Resident A on October 16, 2024. The TN stated she did not include a description of the wound bed, odor, amount of exudate or type in the weekly skin notes. The TN stated she did not complete the weekly skin note indicating the measurement or location of the wounds because it was too difficult. The TN stated the assessment of Resident A's sacrococcyx wound was conducted on October 18, 2024, but was documented as October 16, 2024, because it was the date the weekly skin note was due. The TN stated she did not complete a weekly skin note for Resident A on October 23, 2024, as indicated. The TN stated the scarred tissue on the sacrococcyx area was not monitored since admission on October 9, 2024, until October 18, 2024 (date the open wound at the sacrococcyx area was identified). 2. On October 22, 2024, at 11:50 a.m., a review of Resident B's medical record was conducted. Resident B was rea-admitted to the facility on [DATE], with diagnoses which included sepsis (infection in the blood) and diabetes mellitus (abnormal blood sugar). A review of Resident B's undated History and Physical Examination, indicated Resident B had the capacity to understand and make decisions. A review of Resident B's Treatment Nurse New Admission Risk Assessment, dated August 21, 2024, indicated, .incontinent of bowel and bladder .abdominal fold MASD (moisture associated skin damage-caused by prolonged exposure to moisture). Bilateral (both) buttocks MASD . The document did not include description (appearance, size, presence of drainange) of Resident B's MASD on the abdominal fold and bilateral buttocks. A review of Resident B's care plan, dated August 21, 2024, indicated, .At risk for further skin breakdown r/t (related to) Impaired bed mobility .Incontinence .Interventions .Apply barrier (provides the skin protection from irritants) cream as needed .observe for skin improvement or deterioration frequently .Provide prompt and thorough peri-care as needed and especially following episodes of incontinence .Provide treatment per MD (medical doctor) orders . A review of Resident B's Minimum Data Set (MDS - a resident assessment tool), dated October 18, 2024, indicated Resident B was always incontinent (unable to control) of bladder and bowel. A review of Resident B's Treatment Nurse Weekly Skin Assessment, dated August 28, 2024, indicated, .This form should be completed weekly on all residents per facility policy. Any areas of Skin requiring treatment should have a thorough record of documentation .Noted with MASD to bilateral buttock and abdominal folds . The document did not include description of Resident B's MASD on the bilateral buttocks. A review of Resident B's Wound Consultant Progress Note, dated August 29, 2024, indicated, .Left, Buttock .irritant contact dermatitis due to .dual incontinence (MASD) .No Wound Assessment .Superficial .Right, Buttock .No wound Assessment .Superficial . A review of Resident B's Treatment Nurse Weekly Skin Assessment, dated September 4, 2024, indicated, .The MASD to bilateral buttock ongoing . The document did not include description of Resident B's MASD on the bilateral buttocks. A review of Resident B's Wound Consultant Progress Note, dated September 6, 2024, indicated, .left, buttock .irritant contact dermatitis (rash) due to .dual incontinence (MASD) .4.0 x 2.0 x 0.2 cm .100% epithelial tissue .exudate (drainage) amount (minimal) .serosanguinous (blood and fluid) .non selective debridement (surgical removal of dead tissue) .Site 002 .right, buttocks .irritant contact dermatitis due to .dual incontinence (MASD) .2.0 x 2.0 x 0.2 cm (centimeters) .100% epithelial tissue .exudate amount (minimal) . serosanguinous .non selective debridement . A review of Resident B's Treatment Nurse Weekly Skin Assessment, did not include description of Resident B's MASD on the bilateral buttocks, on the following dates: - September 11, 2024; - September 18, 2024; - September 25, 2024; and - October 2, 2024; There was no documented evidence the TN conducted an assessment of the MASD on bilateral buttocks on October 9, 2024. Further review of Resident B's wound consultant progress note, indicated there was no documented assessment conducted by the wound consultant on September 20, 2024. There was no documented evidence a wound assessment of the MASD for Resident B's bilateral buttocks was conducted on the week of September 18 to 20, 2024, either from the treatment nurse or the wound consultant. On October 22, 2024, at 4:25 p.m., an interview was conducted with the TN. The TN stated she did not complete a Treatment Nurse Weekly Skin Assessment for Resident B's MASD on bilateral buttocks, dated October 9, 2024. The TN stated she should have measured the wounds of the residents on admission and weekly to track progress of the wound and to determine if it was healing or getting worst. 3. On October 24, 2024, a review of Resident C's medical record was conducted. Resident C was admitted to the facility October 9, 2024, with diagnoses which include altered mental status and pressure ulcer of left buttock, stage three. A review of Resident C's Treatment Administration Record (TAR), dated October 2024: - .Left buttocks stage III (three), clean with NS, apply triple ATB (antibiotic) ointment, pack with collogen [sic] powder followed by calcium alginate, cover with dry dressing every day shift, start date 10/10/2024 (October 10, 2024) . There was no documentation for treatments were completed on October 10, 2024, October 11, 2024, and October 18, 2024. - .Left buttocks stage III (three), clean with NS, pack with collogen [sic] powder followed by calcium alginate, cover with dry dressing. Zinc to peri-wound every day shift ., start date October 19, 2024, no documentation for treatment were completed on October 23, 2024. A review of Resident C's care plans: - dated October 9, 2024, indicated Resident C was at risk for impaired skin integrity-presence of ulcer stage three, interventions included monitor for signs or symptoms of redness, drainage, fever, foul odor, or purulent (infected discharge from wound) drainage and inform MD if noted, observe for skin improvement or deterioration, provide prompt and thorough peri-care as needed; - dated October 17, 2024, indicated Resident C was at risk for skin breakdown r/t impaired bed mobility, incontinence, admitted with stage 3 pressure ulcer to left buttocks, interventions included observe for skin improvement or deterioration frequently, teach resident about risk factors for developing a pressure ulcer and the healing process once one develops. A review of Resident C's Treatment Nurse New Admission Risk Assessment, dated October 10, 2024, at 3:45 p.m., indicated, .pressure ulcer upon admission .how many pressure ulcers .1 (one) .left buttocks .clean with NS, apply triple ATB (antibiotic) ointment, pack with collogen [sic] powder followed by calcium alginate, cover with dry dressing . The document did not indicate description of the pressure ulcer on the left buttocks which includes measurement, appearance, drainage, odor, and appearance of surrounding tissue. A review of Resident C's Wound Consultant Progress Note, dated October 17, 2024, indicated, .Left, Buttock .pressure ulcer stage 3 (three) .measurement 1.0 x 1.0 x 0.4 cm .wound bed .100% granulation .exudate amount (minimal) .skin erythema (mild); macerated (mild) .non selective debridement .full thickness . A review of Resident C's Treatment Nurse New Admission Risk Assessment, dated October 18, 2024, did not indicate description of the left buttocks stage 3 pressure injury. On October 24, 2024, at 9:45 a.m., an interview and concurrent record review was conducted with the TN. The TN stated she did not measure Resident C ' s wound when assessed on October 10, 2024, measurements we not completed until the wound consultant saw the resident on October 17, 2024. The TN stated she did not measure the stage three ulcer to Resident C's left buttocks within the first seven days the resident was at the facility. The TN stated she changed Resident C's dressing to her wound and did not know why there was no documentation on October 10, 2024, October 11, 2024, or October 18, 2024, she was working those days but did not remember. 4. On October 23, 2024, Resident D's record was reviewed. Resident D was admitted on [DATE], with diagnoses which included quadriplegia (partial or total loss of function in all four limbs), and pressure ulcer stage 4 (four) at left buttock. A review of Resident D's care plan, dated September 20, 2024, indicated, .At risk for further skin breakdown .interventions .Monitor skin for signs and symptoms of redness, drainage, fever, foul odor or purulent drainage .Observe for skin improvement or deterioration frequently . A review of Resident D's Treatment Nurse New Admission Risk Assessment, dated September 18, 2024, indicated, .Left buttocks St4 (stage 4) . The document did not include description of the wound on the left buttocks. A review of Resident D's wound consultant notes, indicated the following assessment for the stage 4 pressure ulcer on the left buttocks on the following dates: - October 2, 2024, .left buttocks .pressure ulcer stage 4 .5.8 cm x 6.7 cm x 1.2 cm .drainage moderate .slough 20%, granulation tissue 80% .; - October 9, 2024, .5.6 cm x 6.3 cm x 1.4 cm .drainage light .slough 20%, granulation tissue 80% .; - October 16, 2024, .6.5 cm x 6.1 cm x 1.7 cm .drainage light .slough 30% granulation tissue 70% . - October 23, 2024, .6.1 cm x 6.3 cm x 1.3 cm . There was no documented evidence Resident D's stage 4 pressure ulcer at left buttocks was re-evaluated on September 25, 2024. On October 24, 2024, at 11:30 a.m., a concurrent interview and record review was conducted with the TN. The TN stated she did not conduct a comprehensive wound assessment of Resident D's pressure injury on the left buttocks on September 17, 2024 (readmission). The TN stated she did not conduct a wound assessment for Resident D's stage 4 at the left buttocks on the following dates: - September 25, 2024; - October 2, 2024; - October 9, 2024; - October 16, 2024; and - October 24, 2024. The TN stated she would rely on the weekly assessment to be conducted by the wound consultant and should have conducted her own assessment weekly thereafter according to the plan of care. On October 24, 2024, at 2:20 p.m., the Administrator (ADM) was interviewed. The ADM stated the wound consultants were independent consultants and do not work for the facility. The ADM stated the wound consultants would see a resident if the facility request them to. The ADM stte they did not know if the TN was truly assessing the resident's skin condition completely. A review of the facility's policy titled, Change in a Resident's Condition or Status, dated February 2021, indicated, .A 'Significant Change' of condition is a major decline or improvement in the resident's status that: will not normally resolve itself without intervention by staff or by implementing .clinical interventions .requires .revision of the care plan .the nurse will make detailed observations and gather relevant and pertinent information .prompted by the Interact SBAR Communication Form . A review of the facility's policy titled, Pressure Injuries Overview, dated March 2020, indicated, .general definitions are derived from the State Operation Manual, Appendix PP: 483.25(b)(1) pressure ulcers (F686) .purposes of staging reference the National Pressure Injury Advisory Panel Classification System .pressure ulcers/injuries occur as a result of intense and/or prolonged pressure or pressure in combination with shear .of soft tissue .may also be affected by skin temperature and moisture, nutrition, perfusion, co-morbidities and condition of soft tissue .'Avoidable' means that the resident developed a pressure ulcer/injury and that one or more of the following was not completed: evaluation of the resident's clinical condition and risk factors .implementation of interventions that are consistent with resident needs, resident goals, and professional standards of practice; monitoring or evaluation of the impact of the interventions .revision of the interventions as appropriate .stage 2 pressure injury: partial thickness skin loss with exposed dermis .granulation tissue, slough and eschar are not present .this stage should not be used to describe moisture-associated skin damage including continence-associated dermatitis, intertriginous dermatitis . A review of the facility's procedure titled Wound Care, dated October 2010, indicated, .provide guidelines for the care of wounds to promote healing .verify that there is a physician's order .review the resident's care plan to assess for any special needs of the resident .dressing material, as indicated .place disposable cloth next to resident (under the wound) to serve as a barrier to protect the bed linen and other body sites .wear sterile gloves when physically touching the wound or holding a moist surface over the wound .the following information should be recorded in the resident's medical record .type of wound care given .date and time wound care was given .position in which the resident was placed .any changes in the resident's condition .all assessment data (i.e., wound bed color, size, drainage, etc.) .how the resident tolerated the procedure .problems or complaints made by the resident related to the procedure . A review of the facility's job description titled Treatment/Quality Assurance Nurse, dated October 2020, indicated, .primary purpose of this position is to assist the Director of Nursing in planning, organizing, developing and directing the day-to-day functions of the using service department in accordance with current federal, state and local standards, guidelines and regulations that govern the facility .ensuring that residents obtain their highest practical physical, mental and psychosocial well-being .meet the current standards of nursing practice, comply with state and federal regulations .perform administrative duties such as completing medical forms, reports, evaluations, studies, charting .participate in regularly scheduled reviews of weights, wounds, clinical updates .participate in Care Plan Committee meetings .make rounds with physicians and wound consultants .treatments are provided as scheduled .provide direct nursing care, including treatments and assessments .perform and teach proper documentation strategies for recording of nursing services .participate in the preliminary and comprehensive assessments of the nursing needs of each resident .participate in the development of a written person-centered treatment and medical care plan for each resident that identifies the problems/needs of the resident, indicates the care to be given, goals to be accomplished and which professional service is responsible for each element of care .make daily rounds of the nursing services department to ensure that all nursing services personnel are performing their work assignments in accordance with acceptable nursing standards .prioritize and schedule tasks to be on a daily/weekly/monthly basis .must be knowledgeable of nursing and medical practices and procedures as well as laws, regulations and guidelines that pertain to nursing care facilities .must possess the ability to plan, organize, develop, implement and interpret the programs, goals, objectives, policies, procedures .for providing quality care .

Based on observation, interview, and record review, the facility failed to implement a comprehensive systemic approach, to ensure effective monitoring and systems to maintain acceptable parameters of nutritional status, for two of three sampled residents (Resident 17 and 28), when: 1.The facility's Registered Dietitian (RD) failed to: a. Follow the facility's policy titled, Nutritional Assessment, to assess Resident 17's nutritional status; and monitor the effectiveness of nutritional interventions for Resident 17; and b. Follow the facility's policy titled, Weight Assessment and Intervention, to identify an unplanned severe weight loss in a timely manner for Resident 17. These failures resulted in Resident 17 to experience a severe weight loss of seven (7) pounds (lbs - unit of measurement) (6.3%) in three (3) weeks, and 10 pounds (8.8%) in 1 month which placed the resident at risk for further decline in health. 2. The facility's Registered Dietitian failed to follow the facility's policy titled, Nutrition Assessment, to assess Resident 28's nutritional status. This failure resulted in Resident 28 to experience a severe weight loss of nine (9) pounds (4.5%) in (one) 1 week and 17 pounds (8.5%), a severe weight loss, within 3 weeks which placed the resident at risk for further decline in health. Findings: According to a review of the web article titled American Academy of Family Physicians, published on February 15, 2002, .Involuntary weight loss can lead to muscle wasting (thinning or loss of muscle tissue) .depression (mood disorder) and an increased rate of disease complications. Various studies demonstrated a strong correlation between weight loss and morbidity (having a disease or a symptom of disease) and mortality (death). One study showed that nursing home patients had a significantly higher mortality rate in the six months after losing 10 percent of their body weight, irrespective of diagnoses or cause of death. In another study, institutionalized elderly patients who lost 5 (five) percent of their body weight in one month were found to be four times more likely to die within one year . According to a review of the web article titled Journal of the American Dietetic Association (currently called the Academy of Nutrition and Dietetics), published October 2010, .Unintended weight loss is defined as a gradual, unplanned weight loss that may occur slowly over time or have a rapid onset. In older adults, a 5% or more unplanned weight loss in 30 days often results in protein-energy undernutrition as critical lean body mass is lost . 1. On May 20, 2022, at 4:02 p.m., an interview was conducted with Resident 17. Resident 17 stated the food was always salty and she had not been eating. Resident 17 stated she had lost weight since she was admitted to the facility a month ago. During a review of the Resident 17's Admission Record, indicated Resident 17 was admitted to the facility on [DATE], for rehabilitation with a diagnosis of status post open reduction and internal fixation (ORIF- puts pieces of a broken bone into place using surgery) left and right patella fracture (a break of the knee cap). During a review of Resident 17's Minimum Data Set (MDS - a standardized assessment tool), dated April 30, 2024, the MDS indicated Resident 17 had a BIMS (Brief Interview for Mental Status) score of 14 which indicated cognitively (thought process) intact. The MDS indicated Resident 17 actively participated in the assessment process and goal setting. During a review of Resident 17's weights, the following indicated: - April 24, 2024; 112 lbs; - April 30, 2024; 108 lbs (4 lbs weight loss; 3.57% weight loss in a week from April 24, 2024); - May 9, 2024; 107 lbs (1 lb weight loss in a week from April 30, 2024; 5 lbs weight loss [4.46% weight loss in 2 weeks from April 24, 2024]); - May 14, 2024; 105 lbs (2 lbs weight loss in a week from May 9, 2024; 7 lbs weight loss [6.25% weight loss in 3 weeks from April 24, 2024]); and - May 21, 2024; 102 lbs (3 lbs weight loss in a week from May 14, 2024; 10 lbs [8.93% weight loss in a month from April 24, 2024]). During a review of Resident 17's physician's orders, dated May 22, 2024, it indicated the following dieet orders: - Diet: No added salt (no salt package with meals), order dated April 23, 2024; and - Snack of resident's choice two times a day (BID) for supplement, order dated May 4, 2024. During a review of Resident 17's snack intake for the past 30 days (April 24, 2024 to May 22, 2024), there was no documented amount of intake for the snacks at 10 a.m. and 2:00 p.m. During a review of Resident 17's Initial Nutrition Assessment, dated April 25, 2024, completed by the Registered Dietitian (RD), indicated, .Admission weight (wt.) 112# (lbs), Current wt. 108#, Diet order: NAS (no added salt - no salt packet in the meal tray) .intake 51 -100% .Snacks between meal two times per day, Skin: integrity: skin tear, no edema (swelling) .Comments: left hand 4th finger skin tear, scabs to right hand .and 4th finger, right hand middle finger, scabs to left thumb and middle finger .Assessment: Resident new admit, s/p (status post) ORIF patella (knee bone) .Current diet ordered meets estimate needs, intake fair to good. -4# (4 lbs weight loss) since admission; note on Lasix (diuretic - medication to treat fluid retention), likes to snack. Snacks added BID (twice a day) .weight monitored weekly x (times) 4 (four) weeks .Will continue to monitor and consult IDT (Interdisciplinary team - a group of health care professionals all working toward a common goal), as needed. Goal: Maintain stable weight with no significant changes, maintain intake average >/ (more than or equal to) 75 % . During a review of Resident 17's IDT weight variance progress note, dated May 3, 2024, completed by the RD, indicated, .Resident reviewed with IDT with current wt. 108#, -4 # (4 lbs weight loss) this week .Current diet: NAS (no added salt - no salt packet in meal tray), intake: 26 -100 %. Meds: on Lasix 20 mg (milligram - unit of measurement). Contributing Factors: Resident admitted with some edema (swelling), which is resolving. Resident likes to snack. RECOMMENDATIONS: Provide snacks BID (twice a day) between meals. Continue weekly weights . On May 22, 2024, at 9:19 a.m., a follow up interview was conducted with Resident 17 at Resident 17's bedside. Resident 17 stated she had poor appetite due to a dislike of the provided foods as she did not like the herb, spices, and the food was too salty. Resident 17 stated she reported her food dislikes to the facility staff. Resident 17 stated sometimes she did not touch any of her meals. Resident 17 stated nobody from the facility visited her and discussed her usual weight, poor appetite, unplanned weight loss, goal weight, nutritional interventions (i.e. snacks between meals two times per day) for her weight loss or plan of nutrition care. Resident 17 stated she was unaware of the physician's order for snacks between meals BID. Resident 17 stated sometimes she received snacks, sometimes she did not. She stated she ate the snacks and sometimes she disliked them. Resident 17 stated I do not know how I am going to obtain my goal weight of 125 lbs. On May 22, 2024, at 10:13 a.m., a concurrent interview and medical record review with the Registered Dietitian of Resident 17's Initial Nutrition Assessment, dated April 25, 2024, IDT Weight Variance Progress Note, dated May 3, 2024, and Resident 17's weight history review was conducted. The RD stated residents who triggered at IDT weight variance were those residents who experienced weight loss of 3 lbs for 1 week, 5% for 1 month, 7.5% for 3 months and 10 % for 6 months. The RD stated she focused on Resident 17's weekly weights which did not trigger for weight loss. The RD stated Resident 17 triggered for severe weight loss from admission weight on April 24, 2024. The RD admitted she should have an IDT weight assessment after May 14, 2024, when Resident 17 had a weight loss of 6.25% in 3 weeks. On May 22, 2024, at 10:25 a.m., a follow-up interview and concurrent medical record review for Resident 17 with the RD was conducted. The RD stated she could not locate documentation of a discussion with Resident 17 regarding her usual body weight (UBW), a description reviewing Resident 17's meal intake and appetite, discussion of weight loss interventions by providing snacks two times per day. The RD stated she placed a general goal of Maintain stable weight with no significant changes, without asking Resident 17's weight goal. The RD stated she was unaware of what kind of snacks Resident 17 received, and she stated she did not observe Resident 17's meal or snack intake. The RD stated she relied on nursing staff to gather meal intake information. The RD stated she was unable to locate the documentation of snacks intake in Resident 17's medical record. The RD admitted she was unable to determine whether the snacks given to Resident 17 was effective without monitoring the snacks intake. The RD admitted it was important to get Resident 17's UBW as a baseline and asked what was Resident 17's weight goal so she could have personalized the nutrition care plans to assist Resident 17 toward her weight goal. On May 23, 2024, at 8:24 a.m., a concurrent observation of meal intake and interview was conducted with Resident 17 at bedside. Resident 17 stated she received 2 sausage links, 2 pieces of waffle, half banana and 8 ounce (oz- a unit of measurement) 2% milk. Resident 17 only consumed 1 piece waffle (10 %) and 8 oz 2% milk (15 %) with total 25 % food intake which indicated poor oral intake. On May 23, 2024, at 10:00 a.m., a concurrent interview and record review with the Director of Nurses (DON) was conducted. The DON stated per the facility's policy on Weight Assessment and Intervention, Resident 17 was triggered for a severe weight loss. The DON stated the RD should have completed a weight loss assessment, evaluation, and intervention for Resident 17 after May 14, 2024, for severe weight loss. The DON could not locate any additional documentation to reflect the severe weight loss on May 14, 2024. The DON stated the RD did not follow the Weight Assessment and Intervention policy to monitor the weight loss. On May 23, 2024, at 11:36 a.m., a concurrent interview and record review of Resident 17's Initial Nutrition Assessment, dated April 25, 2024, and IDT weight variance, on May 3, 2024, and Nutrition Assessment policy was conducted with the Director of Nursing (DON). The DON stated the RD only interpreted the information from Resident 17's electronic medical record instead of visiting Resident 17 to collect nutritional information. The DON stated she could not find Resident 17's UBW, weight goal, food preference for nutritional intervention. The DON reviewed Resident 17's meal intake was 26 -100 % in the IDT weight variance progress notes and stated the broad amount intake range did not reflect the real appetite (the amount of Resident 17's meal intake) of Resident 17 which could not reflect whether Resident 17 consumed sufficient nutrition she needed. The DON stated Resident 17's weight loss may be due to not liking the food and not eating enough. The DON stated Resident 17's weight loss could have been preventable if the RD visited Resident 17, obtained the resident's UBW, Resident 17's appetite, and interventions of the food Resident 17 wanted to eat, and monitored the effectiveness of the snacks as a nutritional intervention. On May 23, 2024, at 5:57 p.m., an observation was conducted with Resident 17's finished meal tray. Resident 17 received Shepherd's pie, chicken noodle soup, spinach, and caramel pear pudding. Resident 17 only consumed 5% Shepherd's pie, 5% spinach, 5% caramel pear pudding which indicated poor food intake . 2. During a review of Resident 28's Admission Record, Resident 28 was admitted to the facility on [DATE], for rehabilitation with a diagnosis right proximal femur fracture (refers to a type of fracture that occurs in the hip region) status post ORIF. During a review of Resident 28's Minimum Data Set (MDS), dated [DATE], indicated Resident 28 had a BIMS score of 13 which indicated cognitively intact. The MDS indicated Resident 28 actively participated in the assessment process and goal setting. During a review of Resident 28's Weight and Vitals Record, indicated the following weights: - April 29, 2024; 201 lbs; - May 7, 2024; 199 lbs (2 lbs weight loss in a week from April 29, 2024); - May 14, 2024, 190 lbs (9 lbs [4.5%] weight loss in a week from May 7, 2024; 11 lbs [5.4%] weight loss in 2 weeks from April 29, 2024); and - May 21, 2024; 184 lbs (6 lbs [3.15%] weight loss in a week from May 14, 2024; 17 lbs [8.45%] severe weight loss in 3 weeks from Aptil 29, 2024). During a review of the Resident 28's physician's orders, revised May 17, 2024, indicated, Fortified (Regular food items with foods added to boost the calories and protein content of meals) No added salt diet; During a review of Resident 28's Initial Nutrition Assessment, dated April 29, 2024, completed by the RD, indicated, .Admission weight wt. 201#, Current wt. 201#, Diet order: NAS .intake 26 -100% Skin: Integrity: No edema (swelling) documents. Surgical incision. Skin tear to right arm .Surgical incision present on left hip .3 separate surgical incisions .Calories Needs: Based on current wt. 201 # 2250 -2500 calories .Assessment: Resident new admit, s/p fall .Current diet order meets estimate needs, intake fair to good .weight monitored weekly x 4 weeks .Recommend to continue current POC (Plan of Care) for now. Will continue to monitor and consult IDT, as needed. Goal: Maintain stable weight with no significant changes, maintain intake average >/ 75 % . During a review of Resident 28's IDT weight variance progress note, dated May 17, 2024, completed by the RD, indicated, .Resident reviewed by IDT, with current wt. of 190 #, -9 # (9 lbs weight loss) this week .Current diet: NAS, intake: 0-100 % .Contributing Factors: Variable intake. Resident adjusting to facility. RECOMMENDATIONS: Fortify current diet order. Continue weekly weights . On May 21, 2024, at 12:48 p.m., an interview was conducted with Resident 28. Resident 28 stated his usual body weight was 200 lbs and he lost his appetite since hospitalization 27 days ago. Resident 28 stated c urrently most foods taste terrible for me, and he did not know how much weight he lost. Resident 28 stated nobody from the facility visited him and discussed with him regarding his usual weight, his poor appetite, unplanned weight loss, goal weight and nutrition intervention (fortified diet) for his weight loss and get him involved in his nutrition care plan. Resident 28 was happy he received health shake (nutrition drinks with high calories used by facility as fortified food item) with his lunch meal. Resident 28 stated t his is my first time get shake and it taste so good. Resident 28's finished meal intake was concurrently observed with the following food consumed: 10 % chicken (~ [approximate] 20 calories), 5 % dessert (~ 5 calories); finished 8 oz 2 % milk (~ 120 calories); and finished 8 oz shake (~ 240 calories). Surveyor did an estimation calories Resident 28 was observed to consume total of ~ 385 calories . On May 22, 2024, at 11:06 a.m., a concurrent interview and record review of Resident 28's Initial Nutrition assessment, dated on April 29, 2024, and IDT wt. variance note, dated May 17, 2024 was conducted with the RD. The RD stated she could not locate documentation discussed with Resident 28 regarding his usual body weight (UBW), a description of visiting Resident 28 regarding his meal intake and appetite. The RD admitted she relied on nursing information regarding Resident 28's meal intake. The RD admitted she never observed Resident 28 during dining and was unaware Resident 28 had poor an appetite. The RD recommended to a fortified diet as an intervention for Resident 28's unplanned weight loss of 9 lbs on May 17, 2024. The RD stated she was unaware of the type of fortified food items the Food and Nutrition Services sent to Resident 28. The RD admitted she did not observe the acceptance and intake of fortified food items for Resident 28. The RD stated she just put a general goal or statement for Resident 28 as indicated, Goal: Maintain stable weight with no significant changes in the Initial Nutrition Assessment, on April 29, 2024, without asking Resident 28 what was his goal weight. The RD admitted she needed to obtain the UBW as baseline for nutrition care and asking Resident 28 what his weight goal so there would be a personalized nutrition interventions worked toward his goal. The RD admitted without monitoring the fortified food items intake, there was no way to evaluate the effectiveness of the intervention. On May 23, 2024, at 8:59 a.m., an interview was conducted with Certified Nursing Assistant (CNA) 2. CNA 2 stated Resident 28 did not have good appetite and his usual meal intake were 30 -45 % with breakfast and lunch. Each food items Resident 28 consumed was discussed with CNA 2. There were two sausage links served. CNA 2 stated Resident 28 only consumed 1/2 sausage link and the other sausage link was untouched (5% ~ 50 calories), 10 % waffle (~10 calories), finish half banana (~ 60 calories), and finished 8 oz whole milk (~ 150 calories), for a total estimated calories Resident 28 consumed ~ 270 calories with his breakfast. On May 23, 2024, at 11:36 a.m., a concurrent interview and review of Resident 28's Initial Nutrition Assessment, on April 29, 2024, and IDT weight variance on May 17, 2024, and facility's policy of Nutrition Assessment was conducted with the DON. The DON stated the RD only interpreted the information from Resident 28's electronic medical record instead of visiting Resident 28 to collect nutritional information. The DON reviewed the meal intake on IDT Weight variance progress note on May 17, 2024, the amount intake range: 0 -100 % and stated this meal intake range was so broad that it would not reflect the appetite of the Resident 28 and unable to interpret whether the Resident consumed sufficient nutrition. The DON stated it was important for the RD to visit Resident 28 got a baseline of UBW, know Resident 28, catering Residents 28 with his preference nutrition interventions and created a personalized nutrition care plan for Resident 28 worked toward his goal. The DON stated Resident 28's weight loss could have been preventable if the RD went to visit Resident 28, obtained UBW, weight goal, be aware of the poor appetite, catering the nutritional interventions Resident 28 wanted . On May 23, 2024, at 5:46 p.m., an observation was conducted with Resident 28's finished meal tray inside Resident 28's room. Resident 28 only consumed 50 % caramel pear pudding (~ 50 calories), finished 8 oz while milk (~ 150 calories), and finished 8 oz health shake (~ 240 calories). Surveyor did an estimate calories Resident 28 ate ~ 440 calories. During a review of Resident 28's Initial Nutrition Assessment, dated April 26, 2024, completed by the RD, indicated, Resident 28 needs 2250 -2500 calories. Resident 28 consumed the following food intake with estimated calories observed on the following dates: - May 21, 2024: Lunch: 385 calories; - May 23, 2024: Breakfast: 270 calories; - May 23, 2024: Dinner: 440 calories. - Total calories: 1095 calories. Resident 28 only consumed 46 % estimated nutrition needs based on 2375 calories. During a review of the facility's policy and procedure titled, Nutritional Assessment, revised October 2017, indicated, .Policy Statement: As part of the comprehensive assessment, a nutrition assessment, including current nutritional status and risk factors for impaired nutrition, shall be conducted for each resident .Policy interpretation and Implementation .As part of the comprehensive assessment, the nutrition assessment will be a systematic, multidisciplinary process that includes gathering and interpreting data and using that data to help define meaningful interventions for the resident at risk for or with impaired nutrition .The nutritional assessment will be conducted by the multidisciplinary team and shall identify at least the following components .Usual body weight .A description of the resident's usual intake and appetite .Usual meal and snack patterns .Food preferences and dislike (including flavors .Dietitian .whether the resident's current intake is adequate to meet his or her nutritional needs .Sources of information for the resident nutritional assessment may include the following .Observation .Resident and family interviews .Once current conditions and risk factors for impaired nutrition are assessed and analyzed, individual care plans will be developed that address or minimize to the extent possible the resident's risks for nutritional complications. Such interventions will be developed within the context of the resident's prognosis and personal preferences .Individualized care plans shall address to the extent possible .The identified causes of impaired nutrition .The president's personal preferences .Goals and benchmarks for improvement .Time frames and parameters for monitoring and reassessment . During a review of the facility's policy and procedure titled, Therapeutic Diets, revised October 2017, indicated, .Policy Statement .Therapeutic diets are prescribed by the physician to support the resident's treatment and plan of care and in accordance with his or her goals and preferences .Policy Interpretation and Implementation .Diet will be determined in accordance with the resident's informed choices, preferences, treatment goals and wishes .The dietitian, nursing staff, and attending physician will regularly review the need for, and resident acceptance of, prescribed therapeutic diet .The dietitian and nursing staff will document significant information relating to the resident's response to his/her therapeutic diet in the resident's medical record .Snacks will be compatible with the therapeutic diet . During a review of the facility's policy and procedure titled, Weight Assessment and Intervention, revised March 2022, indicated, .Policy Statement: Resident weights are monitored for undesirable or unintended weight loss or gain .Policy Interpretation and Implementation Weight Assessment .The threshold for significant unplanned and undesired weight loss will be based on the following criteria .One month - 5% significant loss, greater than 5% severe loss .Three month - 7.5% significant loss, greater than 7.5% severe loss .Six months - 10% significant loss, greater than 10% severe loss .

Based on observation, interview, and record review, the facility failed to ensure the temperature in the medication refrigerator was monitored twice daily, according to the facility's protocol. This failure had the potential for the medications stored in the medication refrigerator to not be stored in a proper temperature to maintain its efficacy and/or full therapeutic effects in which can lead to unsafe administration of medications to residents. Findings: On May 20, 2024, at 9:46 a.m., during a concurrent interview and inspection of the facility's medication room with Registered Nurse (RN) 1, the medication refrigerator was observed to have contained vaccines, insulin products, a refrigerated emergency kit (medications for use in the emergency), and other refrigerated medications. RN 1 stated the medication refrigerator temperatures were expected to be checked and documented on the Temperature Log by the licensed nurse twice daily at each shift. A review of the medication refrigerator temperature logs from September 2023 to May 2024, indicated they were incomplete and/or inconsistently monitored twice daily, and as follows: - For October 2023, there were 3 missing temperature recordings (October 23, 27, and 30, 2023); - For November 2023, temperature log was missing; - For December 2023, there were 41 missing temperature recordings; 17 days without any recordings; - For January 2024, there were 4 missing temperature recordings; - For February 2024, there were 12 missing temperature recordings; and - For March 2024, there were 31 missing temperature recordings; 31 days without any morning shift recordings. On May 21, 2024, at 3:46 p.m., during an interview with the Director of Nursing (DON), the DON stated licensed nurse were expected to check and document the medication refrigerator temperature on the temperature log twice daily at each shift. On May 22, 2024, at 2:14 p.m., during a follow-up concurrent interview and record review with the DON, the medication refrigerator temperature logs from September 2023 to May 2024 were reviewed. The DON verified the temperature logs were incomplete and were not monitored consistently twice a day for October 2023, December 2023, January 2024, February 2024, and March 2024. The DON verified the temperature log was missing for November 2023. During a review of the facility's policy and procedures (P&P), titled Medication Labeling and Storage, dated February 2023, indicated, .The facility stores all medications and biologicals in locked compartments under proper temperature .The nursing staff is responsible for maintaining medication storage and preparation areas in clean, safe, and sanitary manner .

Based on observation, interview, and record review, the facility failed to ensure the food service employees were able to carry out the functions of food and nutrition services safely and effectively when: 1. Prep [NAME] did not document the cooling process for tuna salad made on May 20, 2024; 2. Prep [NAME] and [NAME] 2 were unable to demonstrate the cooling process for tuna salad; 3. [NAME] 2 did not know how to calibrate thermometer; 4. Dishwasher 2 did not know how long kitchenware need to immerse into sanitizer; 5. Dishwasher 1 and Dishwasher 2 did not follow manufacturer guideline instruction time length for dipping test strip in sanitizer to check the concentration of sanitizer; 6. [NAME] 1 prepared grainy broccoli for two Residents (Resident 135 and 281) who had physician prescribed pureed diet texture (the food texture should be smooth for residents who have difficulty chewing and/ or swallowing ability) during lunch on May 21, 2024. (Cross referred F 805). These failures had the potential to cause foodborne illness for 37 out of 37 sampled residents who received foods from the kitchen and aspiration (accidentally inhaling food or liquid into the lungs) and choking for 2 Residents (Resident 135 and 281). Findings: 1. On May 20, 2024, at 3:46 p.m., an observation was conducted at walk-in refrigerator. There was a container of tuna salad labeled with prep (prepared) date: 5/20/24 (May 20, 2024) and used by date: 5/27/24 (May 27, 2024). Checked the temperature of the tuna salad indicated 56.7 degrees Fahrenheit. On May 20, 2024, at 3:50 p.m., the cooling log record review was conducted in the kitchen. Tuna salad made on May 20, 2024, was not documented in the cooling log. On May 21, 2024, at 10:14 a.m., an interview was conducted with the Prep Cook. She stated the tuna salad was made yesterday around 10 a.m. and she forgot to document in the cooling log. On May 21, 2024, at 10:34 a.m., an interview was conducted with the Food Service Director (CDM). Reviewed the temperature taken for the tuna salad on May 20, 2024, at 3:46 p.m. at 56.7 degrees Fahrenheit with the CDM. The CDM confirmed the tuna salad temperature was in the danger zone (more than 41 degrees F) for more than 4 hours. On May 23, 2024, at 4:57 p.m., an interview was conducted with the CDM. She stated her expectation was food service employees need to follow policy and procedure and documenting cooling process for potential hazard foods in cooling log for food safety handling practices. During a review of the job description Prep Cook, indicated, Responsibilities .Consistently follows policies and procedures .within the individual department . During a review of the facility's policy and procedure (P&P) titled, Rapid Cooling of Food, revised dated November 2022, the P&P indicated, Policy Statement: Food and nutrition services employees prepare, distribute, and serve food in a manner that complies with safe food handling practices .Policy Interpretation and Implementation: General Guidelines: - The danger zone for food temperature is above 41 degrees Fahrenheit (a unit of measurement) and below 135 degrees Fahrenheit. This temperature range promotes the rapid growth of pathogenic microorganisms that cause foodborne illness. - Potentially hazardous foods (PHF) include meats, poultry, seafood, cut melon, egg, milk, yogurt, and cottage cheese. - The longer foods remain in the dangerous zone the greater the risk for growth of harmful pathogens. Therefore PHF must be maintained at below 41 degrees Fahrenheit or at above 135 degrees Fahrenheit. - Potentially hazardous foods held in the danger zone for more than 4 hours (if being prepared from ingredients at room temperature) .may cause foodborne illness . Rapid Cooling . - Facility staff may utilize a Cooling Log for documentation of temperature measurements/times. 2. On May 21, 2024, at 10:06 a.m., an interview was conducted with the Prep Cook. She was asked to demonstrate the monitoring cooling process for tuna salad. She stated tuna salad needed to reach below 41 degrees Fahrenheit between 4 to 6 hours. On May 21, 2024, at 11:19 a.m., an interview was conducted with the CK 2. He was asked to demonstrate the monitoring cooling process for tuna salad. He stated tuna salad need to reach below 41 degrees Fahrenheit within 5 hours. On May 21, 2024, at 4:44 p.m., an interview was conducted with the CDM. She stated food service employees needed to cool down tuna salad below 41 degrees Fahrenheit within 4 hours. On May 23, 2024, at 4:57 p.m., an interview was conducted with the CDM. She stated her expectation was food service employees needed to follow policy and procedure cooling process for potential hazard foods for food safety handling practices. During a review of the job description Prep Cook, indicated, Responsibilities: .Consistently follows policies and procedures .within the individual department. During a review of the job description Cook, indicated, Responsibilities: .Consistently follows policies and procedures .within the individual department . During a review of the facility's policy and procedure (P&P) titled, Rapid Cooling of Food, revised dated November 2022, the P&P indicated, Policy Statement: Food and nutrition services employees prepare, distribute, and serve food in a manner that complies with safe food handling practices .Policy Interpretation and Implementation General Guidelines . - Potentially hazardous foods ( .seafood .) held in the danger zone for more than 4 hours (if being prepared from ingredients at room temperature) .may cause foodborne illness . 3. On May 21, 2024, at 11:19 a.m., an interview was conducted with CK 2. He was asked to demonstrate how to calibrate thermometer. He placed the digital thermometer into a bowl of ice cube cold water and stated he needed to calibrate the thermometer at 36 degrees Fahrenheit. On May 21, 2024, at 4:44 p.m., an interview was conducted with the CDM. She stated the digital thermometer needed to be calibrated at 32 degrees Fahrenheit. The CDM stated it was important the cook know how to calibrate the thermometer, so the cook could get the accurate temperature when they checked the food temperature. The CDM stated her expectation was for the cook to follow policy and procedure to calibrate thermometer. During a review of the facility's policy and procedure (P&P) titled, Thermometer Calibration, dated 2020, the P&P indicated, Guideline: All temperatures of food will be recorded using a bimetallic stem type or digital thermometer . Procedure: 2 .hold and adjust thermometer head with an appropriate tool and turn head so pointer reads 32 degrees Fahrenheit . During a review of the job description Cook, indicated, Responsibilities: .Consistently follows policies and procedures .within the individual department . 4. Reviewed the manufacturer guideline directions for sanitizer poster posted above 3 compartment sink indicated, . immersion until thoroughly wet for at least 60 seconds . On May 20, 2024, at 3:02 p.m., an interview was conducted with Dishwasher (DS) 2 and the CDM in front of the 3 compartment sink. The DS 2 stated she need to submerge kitchenware into the sanitizer for 30 seconds. The CDM stated the kitchenware need to be submerged into the sanitizer for 1 minute (60 seconds). During a review of the job description Dish Washer, indicated, Responsibilities .Consistently follows policies and procedures .within the individual department . 5. Reviewed the manufacturer guideline directions for sanitizer poster posted above 3 compartment sink indicated, .Dip test strip for 5 seconds in test solution . On May 21, 2024, at 9:54 a.m., an interview was conducted with Dishwasher (DS) 2 in front of the 3-compartment sink. She stated she needed to dip the test strip for 10 seconds in the test solution (sanitizer) to check the concentration of the sanitizer. On May 21, 2024, at 9:56 a.m., an interview was conducted with DS 1 in front of the 3-compartment sink. He stated he needed to dip the test strip for 10 to 15 seconds in the sanitizer to check the concentration of sanitizer. On May 23, 2024, at 4:57 p.m., an interview was conducted with the CDM. She stated the dishwashers needed to follow the manufacture's guideline time length to dip test strip for 5 second to check the concentration of sanitizer. The CDM explained dishwashers did not follow the manufacturer's guideline time length testing sanitizer and could lead to inaccurate reading of the sanitizer concentration. 6. On May 21, 2024, at 11:39 a. m., a noon prep pureed meal observation was conducted with [NAME] (CK) 1. [NAME] 1 prepared grainy broccoli for two Residents (Resident 135 and 281) who had physician prescribed pureed diet. On May 21, 2024, at 1:25 p.m., a test tray (to evaluate the quality of a meal during a meal service and identify any areas for improvement) of pureed foods was conducted with the CDM. She stated the pureed broccoli was not smooth and contained small pieces broccoli. On May 23, 2024, at 4:57 p.m., an interview was conducted with the CDM. She stated her expectation was for the cooks to follow the puree diet menu and recipes. During a review of the job description Cook, indicated, Responsibilities: Prepares all foods according to the menu and the standardized recipes in a safe efficient .Ensures the proper preparation .and serving of foods as indicated on .the recipes .

Based on interview and record review, the facility failed to ensure: 1. Three of five emergency kits (e-kit; a kit/box containing medications and supplies for immediate use during a medical emergency) were not replaced timely after being opened. This failure had the potential for emergency medication to be unavailable when needed. 2. Controlled substance medications (medication with a high potential for abuse and addiction) were accurately accounted for on the Medication Administration Record (MAR) and the Drug Control Receipt Record/Disposition Form (count sheet - an inventory sheet that keeps record of the usage of controlled medications), for two of four residents reviewed (Residents 17 and 19). This failure had the potential to not have an accurate accountability of controlled medications and the potential for abuse or misuse of these medications. In addition, both failures had the potential for not meeting the residents' therapeutic (related to healing of a disease) needs or worsening of their medical conditions. Findings: 1. On May 20, 2024, at 9:46 a.m., during an inspection of the Medication Storage room with Registered Nurse (RN 1), the oral medication e-kit and the intramuscular (IM, a technique used to deliver a medication deep into the muscles) medication e-kit were observed to be sealed with yellow locks. RN 1 confirmed the yellow lock indicated the e-kits had been opened by the nursing staff. RN 1 described the e-kit process and the expectation from the nursing staff to do the following when the e-kit was open - Should fill out the medication slip; - Leave one copy of the slip in the log book and one copy of the slip inside the e-kit; - Reseal the e-kit with a yellow lock; - The nursing staff should immediately call the pharmacy to reorder the e-kit; and - The pharmacy should replace the e-kit on the same day/evening or within 72 hours. During an inspection of the opened oral medication e-kit, two slips of paper were observed inside. The slips of paper indicated the oral medication e-kit was opened two times as follows: - On May 15, 2024, two amoxicillin (antibiotic to treat infections) 250 mg (milligram - a unit of measurement) tablets were removed and; - On May 16, 2024, one Augmentin (antibiotic to treat infections) 500 mg tablet was removed. In a concurrent interview with RN 1, RN 1 confirmed the oral medication e-kit had not been replaced since May 15, 2024, and acknowledged it should have been replaced. During an inspection of the IM e-kit, two slips of paper were observed inside. The slips of paper indicated the IM e-kit was opened two times as follows: - On April 4, 2024, one Toradol (medication used for pain) 30 mg one milliliter (ml - unit of measurement) vial was removed and; - On April 10, 2024, one Glucagon kit (used for low blood sugar) was removed. In a concurrent interview with RN 1, RN 1 confirmed the IM e-kit had not been replaced since April 4, 2024, and acknowledged it should have been replaced. On May 20, 2024, at 10:25 a.m., during an inspection of Medication Cart A with RN 1, the narcotic e-kit inside Medication Cart A was observed to be sealed with a yellow lock, which indicated it had been opened by the nursing staff. During an inspection of the narcotic e-kit, three slips of paper were observed inside. The slips of paper indicated the narcotic e-kit was opened three times as follows: - On May 15, 2024, one hydrocodone-acetaminophen (a potent controlled medication for pain) 10-325 mg tablet was removed; - On May 17, 2024, one hydrocodone-acetaminophen (a potent controlled medication for pain) 5-325 mg tablet was removed at 5 p.m. and another tablet was removed at 10:06 p.m. for two different residents. In a concurrent interview with RN 1, RN 1 confirmed the narcotic e-kit had not been replaced since May 15, 2024, and acknowledged it should have been replaced. On May 21, 2024, at 9:37 a.m., during an interview with Licensed Vocational Nurse (LVN) 1, regarding the e-kit process, LVN 1 stated she would have called the pharmacy for a replacement of the e-kit immediately after it was opened and the e-kit would have been replaced by pharmacy on the same night or by the following morning. On May 21, 2024, at 3:46 p.m., during an interview with the Director of Nursing (DON), the DON stated the nursing staff were expected to call the pharmacy for a replacement as soon an e-kit was opened and the pharmacy was expected to replace opened e-kits within 72 hours. During a review of the facility's policy and procedure (P&P), titled Emergency Medications, dated November 2022, indicated, .The facility shall maintain a supply of medications typically used in emergencies . 2. The count sheets for controlled medications for four random residents receiving PRN (as-needed) controlled medications were requested for review during the survey and indicated the following: a. Resident 17 had a physician's order, dated May 9, 2024, for Norco (hydrocodone-acetaminophen) 10/325 milligram tablet, 1 tablet by mouth every 6 hours as needed for moderate to severe pain 6 - 10. On May 20, 2024, at 10:55 a.m., during a concurrent interview and record review with RN 1. Resident 17's Drug Control Receipt Record ., for Norco 10/325 mg indicated, one tablet was signed out on May 17, 2024, at 8 p.m. The MAR did not indicate the nursing staff's initials to demonstrate the hydrocodone - acetaminophen 10/325 mg was administered to Resident 17 on May 17, 2024. RN 1 stated the licensed nurses were expected sign the narcotic count sheet and document on the MAR immediately after administration. RN 1 acknowledged the nursing staff signed out one hydrocodone - acetaminophen 10/325 mg tablet on the count sheet for Resident 17, but did not document the medication administration on the MAR for May 17, 2024, at 8 p.m. On May 21, 2024, at 3:36 p.m., during an interview with the DON, regarding the administration of narcotics, the DON stated the nursing staff should have removed the medication from the bubble pack, signed the count sheet and documented in the MAR at the same time. The DON stated the documentation on the count sheet should match the MAR. On May 21, 2024, at 4:03 p.m., during a concurrent interview and record review with the DON, the DON reviewed the discrepancy between the count sheet for Resident 17's hydrocodone - acetaminophen 10/325 mg tablet and the MAR dated May 2024. The DON confirmed the discrepancy and acknowledged the lack of documentation. b. Resident 19 had a physician's order, dated April 8, 2024, for Percocet (oxycodone-acetaminophen - a potent controlled medication for pain) 10/325 mg tablet, 1 tablet by mouth every 6 hours as needed for moderate to severe pain 4 - 10. On May 20, 2024, at 3:19 p.m., during a concurrent interview and record review with LVN 2, LVN 2 stated Resident 19's count sheet for oxycodone-acetaminophen 10/325mg tablet and the MAR dated May 2024, indicated, one tablet was signed out on the narcotic count sheet but was not signed in the MAR on the following dates and times : - May 7, 2024, at 1 a.m.; - May 8, 2024, at 10:58 p.m.; - May 9, 2024, at 8:07 p.m.; - May 10, 2024, at 1:40 a.m.; - May 10, 2024, at 6:07 a.m.; - May 10, 2024, at 8:55 p.m.; - May 11, 2024, at 9 p.m.; - May 12, 2024, (time illegible); - May 13, 2024, at 8 p.m.; - May 14, 2024, at 8 p.m.; - May 15, 2024, at 9 p.m.; - May 16, 2024, at 8:16 p.m.; - May 17, 2024, at 8 p.m.; - May 18, 2024, at 9 p.m.; and - May 19, 2024, at 9 a.m. LVN 2 described the controlled medication administration process and stated nurses should have signed the narcotic out on the count sheet and documented the administration in the MAR immediately after administration. LVN 2 acknowledged the nursing staff signed out one oxycodone - acetaminophen 10/325mg tablet on the count sheet, but did not document the medication administration on the MAR on the dates and times listed above. On May 21, 2024, at 4:07 p.m., during a concurrent interview and record review with the DON, the DON reviewed the lack of documentation between the count sheet for Resident 19's oxycodone - acetaminophen 10/325 mg tablet and the MAR dated May 2024. The DON confirmed the discrepancies and acknowledged the missing documentations in the MAR for the dates and times as listed above. During a review of the facility's P&P titled Administering Medications, dated April 2019, indicated, .The individual administering the medication initials the resident's MAR on the appropriate line after giving each medication .the individual administering the medication records in the resident's medical record .the date and time the medication was administered; the dosage; the route of administration .the signature and title of the person administering the drug . During a review of the facility's P&P, titled Controlled Substances, dated November 2022, indicated, An individual resident controlled substance record is made for each resident who will be receiving a controlled substance .The record contains: name of the resident; name and strength of the medication .time of administration; method of administration .signature of nurse administering the medication .

Based on interview and record review, the facility failed to ensure informed consent was obtained from the resident or resident representative for the use of psychotropic (medications that affect the mind, emotions, and behavior) medications, for four of five residents reviewed for unnecessary medications (Residents 12, 15, 17, and 19),when the facility's informed consent forms were not properly completed and signed by the resident or resident representative and the physician who obtained the informed consent. This failure resulted in the resident and/or resident's representative to not be informed of the risk and benefits of the proposed care and treatment regarding the use of the psychotropic medications. Findings: 1. During a review of Resident 12's Admission Record, indicated Resident 12 was admitted to the facility on [DATE], with diagnoses of depression (a mental health disorder). During a review of Resident 12's Minimum Data Set (MDS - an assessment tool), dated May 3, 2024, indicated a BIMs (Brief Interview for Mental Status) score of 15 (cognitively intact). A review of Resident 12's physician orders indicated the following: - Venlafaxine (medication to treat depression) Oral Tablet 37.5 mg (milligram - unit of measurement) Give 1 (one) tablet by mouth two times a day for depression m/b (mainfested by) irritability (a feeling of agitation), dated April 30, 2024; and - Bupropion ER (XL) (medication to treat depression) Oral Tablet Extended Release 24-hour 150 mg .Give 1 tablet by mouth one time a day for depression m/b verbalization of sadness, dated May 2, 2024. During a review of Resident 12's medical record, the facility form titled Informed Consent (IC - the process in which the health care provider educates a patient about the risks, benefits, and alternatives of a given procedure or intervention), for venlafaxine did not indicate the dose and frequency of the medication. Resident 12's IC form did not include a signature from the physician who obtained the informed consent for the use of venlafaxine. During a review of Resident 12's medical record, there was no documented evidence an informed consent was obtained from Resident 12 with the use of of bupropion 150 mg daily. 2. During a review of Resident 15's Admission Record, indicated Resident 15 was readmitted to the facility on [DATE], with a diagnosis of major depressive disorder (mood disorder). During a review of Resident 15's Minimum Data Set, dated dated [DATE], indicated a BIMs score of 12 (moderately impaired cognitively). A review of Resident 15's physician orders indicated the following: - Sertraline Oral Tablet 100 mg Give 1 tablet by mouth one time a day for mood disorder ( a major health condition taht primarily affects your emotional dstatus) m/b self isolation (the act of separating oneself from others), dated May 16, 2023. During a review of Resident 15's document titled Informed Consent, the documentation did not include the frequency of the medication and the date Resident 15 signed the informed consent form. 3. During a review of Resident 17's Admission Record, indicated Resident 17 was admitted to the facility on [DATE], with a diagnosis of depression. During a review of Resident 17's Minimuim Data Set, dated April 24, 2024, indicated a BIMs score of 14 (cognitively intatct). A review of Resident 17's physician orders indicated the following: - Sertraline HCL (medication to treat depression) Tablet 50 MG Give 1 tablet by mouth one time a day for Depression NOS (not otherwise specified) m/b verbalization of sadness. During a review of Resident 17's Informed Consent, did not indicate the dose and frequency for sertaline. The document did not indicate the physician's signature to indicate the physician obtained the informed consent from the resident with the use of sertraline. 4. During a review of Resident 19's Admission Record, dated May 22, 2024, indicated Resident 19 was admitted to the facility on [DATE], with a diagnosis of anxiety disorder (a mental heatlh disorder characterized by feelings of worry or fear that interferes with ones daily activities). During a review of Resident 19's Minimum Data Set, dated dated [DATE], indicated a BIMs score of 15 (cognitively intact). A review of Resident 19's physician orders indicated the following: - Escitalopram Oxalate (medication to treat depression) Oral Tablet 10 mg, Give 1 tablet by mouth one time a day for Depression m/b verbalizations of sadness, dated February 12, 2024. - Zoloft Oral (medication to treat depression) Tablet 50 mg .Give 50mg by mouth one time a day for Depression m/b verbalization of sadness. - Xanax (medication to treat anxiety)Oral Tablet 0.5 mg (Alprazolam), Give 0.5 mg by mouth every 8 hours as needed for anxiety m/b verbalization of feeling anxious. During a review of Resident 19's medical record, there was no documented evidence an informed consent was obtained from Resident 19 for the use of escitalopram, Zoloft, and Xanax (new dose). During an interview on May 22, 2024, at 3:19 p.m., with the Director of Nursing (DON). The DON stated the Resident should be aware of the psychotropic medicatons being administered and the Resident should be infomred of the use of psychotropic medications. During an interview on May 22, 2024, at 3:40 p.m., with the DON, she stated the informed consent form for Residents 15. 17, and 19 were incomplete for the use of psychotropic medications. The DON stated the informed consent form should have been completed so the residents would know what medications they are consenting to. During an interview on May 23, 2024, at 10:20 a.m., an interview and concurrent record review was conducred with the Director of Staff Development (DSD). The DSD stated the informed consent form for the use of venlafaxine for Resident 12 was incomplete and there was no documented ICF obtained from Resident 12 for the use of bupropion. The facility policy and procedure titled, Requesting, Refusing and/or Discontinuing Care or Treatment, revised 2021, indicated, .Policy .Residents/representatives are inforomed (in advance) of .the care that will be furnished .the risks and benefits of the proposed care, treatment .

Based on observation, interview, and record review, the facility failed to ensure nutritional care and services were provided, for one of three residents reviewed for nutrition (Resident 22), when: 1. Weekly weights monitoring were not completed as ordered by the physician; and 2. There was no assessment and interventions initiated to address Resident 22's continued poor food intake and weight loss. In addition, there was no follow up assessment conducted by the Registered Dietitian (RD) to address Resident 22's poor food intake and weight loss. These failures resulted in Resident 22 to have a weight loss of 16.1 pounds (lbs.)/10% (percent) from December 16, 2021 to January 12, 2022 (27 days), which could subsesquently cause further decline in the health status of Resident 22. Findings: On January 10, 2022, at 1:01 p.m., Resident 22 was observed lying in bed. Resident 22's lunch meal was observed on top of the bedside table, untouched. In a concurrent interview with Resident 22, she stated ,I did not eat my lunch because I don't have an appetite. On January 12, 2022, Resident 22's medical record was reviewed. Resident 22 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the untitled facility document , dated December 16, 2021, indicated a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility document titled, Weights and Vital Summary, indicated the following weights for Resident 22: - December 16, 2021; 161 lbs.; - December 29, 2021; 154.8 lbs; weight loss of 6.2 lbs/3.85% in 13 days; and - January 12, 2022; 144.9 lbs; weight loss of 9.9 lbs/6.4% in 13 days and 16.1 lbs/10% (severe weight loss) in 27 days. There was no documented evidence Resident 22 was weighed weekly on December 22, 2021 and January 5, 2022. (The physician ordered for a weekly weight). The facility document titled, Nutrition Assessment, dated December 16, 2021, indicated, .Some weight fluctuation (changes) anticipated r/t (related) resolving [CONDITION(S)] (a condition in the body having low salt), resolving [CONDITION(S)] (swelling due to fluid in the body) BLE (bilateral [both] lower extremities) and diuretic (medication to treat water retention) Tx (treatment). Patient newly admitted . No labs for review. Excoriated (damage to the skin surface) coccyx (tailbone) .Current nutrition POC (plan of care) seems appropriate at this time . There was no documented evidence a follow up nutrition assessment was conducted by the RD for Resident 22 after December 16, 2021. A review of Resident 22's food intake record dated December 16, 2021 to January 13, 2022, indicated an average of 25 % food during breakfast, lunch, and dinner. The record indicated the resident had 24 episodes of refusing meals, in various mealtimes. A review of the care plan titled, At risk for altered nutrition, dated December 16, 2021, indicated, .Goal .Will maintain hydration and nutrition to resident's comfort and tolerance .Interventions .Encourage resident to eat 75% of meals and snacks .RD assessment/review PRN (as needed) . The Progress Notes, indicated the NP was informed of Resident 22's poor food intake on December 29, 2021, January 1, 2022, and January 5, 2022. The record indicated the NP did not have new orders. There was no documented evidence the facility initiated further interventions to address continued poor food intake including referral to the RD for further recommendations, after December 16, 2021. A review of the laboratory results indicated the following: - December 19, 2021; protein (nutrient that is essential to building body mass); 4.7 (low; normal range 6.4 to 8.9), and [MEDICATION(S)] (main protein in the body); 2.6 (low; normal range 3.5 to 5.7); - December 30, 2021; protein level at 4.0 (low) and [MEDICATION(S)] level at 2.4 (low); and - January 13, 2022; protein level at 3.8 (low), and [MEDICATION(S)] level at 2.3 (low). The laboratory results indicated Resident 22's protein and [MEDICATION(S)] level progressively decreased from December 19, 2021 to January 13, 2022. There was no documented evidence the low levels of protein and [MEDICATION(S)] were referred to the RD. The Progress Notes, dated December 18, 2021, at 11:49 a.m., indicated, .resident having nausea with vomiting . The Progress Notes, dated December 18, 2021, indicated the Nurse Practioner (NP) ordered for [MEDICATION(S)] (medication to treat nausea). The Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The Progress Notes, dated December 24, 2021, at 1:26 p.m., indicated, .call out to dr (physician) due to [MEDICATION(S)] not helping resident with nausea, resident continues to report nausea stating that her stomach is very upset and because she is so nauseated she does not wish to eat . The document indicated the NP ordered to change [MEDICATION(S)] to [MEDICATION(S)] (another medication to treat nausea). The Progress Notes, dated January 1, 2022, at 9:18 p.m., indicated, .(Family Member) (name of family member) called wanting update on (resident). Requesting [CONDITION(S)] tests because [MEDICATION(S)] (medication to treat [CONDITION(S)] [overactive [CONDITION(S)] gland]) was started 3 (three) days before hospitalization so resident did not see endocrinologist (a doctor that deals with the endocrine system, which controls the hormones in your body) .Also requesting endoscope (procedure to view the inside of a person's body) to see if hospital missed something because of her being nauseated and gagging every time they talk to her .Left message for (name of NP) for Dr. [NAME] . A review of the record indicated Resident 22 was administered medication to treat nausea from December 18, 2021 to January 11, 2022 (25 days) and continued to complain of nausea despite of the medication. There were no documented evidence further interventions were initiated by the facility staff to address Resident 22's continued complaints of nausea despite medication not until Resident 22's family member requested for it to be re-evaluated on January 1, 2022. On January 12, 2022, at 9:10 a.m., Licensed Vocational Nurse (LVN) was interviewed. The LVN stated Resident 22 did not have an appetite to eat and had been consuming 25% of her meals on average for about two weeks. She stated Resident 22 had episodes of refusing her meals. She also stated Resident 22 had episodes of nausea and currently had medication when she needed it. She stated the doctor was aware of Resident 22's nausea and poor food intake. She stated there were no other recommendations from the doctor other than her medication for nausea. On January 12, 2022, at 9:50 a.m., the Food Service Director (FSD) was interviewed. The FSD stated if a resident had weight issues, it should be discussed during the Nutrition at Risk (NAR) Committee meeting on a weekly basis. She stated, the RD would coordinate the meeting along with another LVN. She stated the RD usually would come to the facility every Thursday and would conduct the NAR meeting. She was not sure if RD came to the facility for the past weeks. On January 12, 2022, at 10:13 a.m., the Administrator (ADM) was interviewed. She stated she was not sure if the RD came to the facility recently to address Resident 22's weight loss issue. She agreed that if RD came to the facility that she would have identified Resident 22's weight loss. On January 12, 2022, at 11:05 a.m., the RD was interviewed. She stated Resident 22's last weight was recorded on December 29, 2021 and did not trigger on the report for weight loss. The RD stated she was not aware of Resident 22's poor food intake. The RD stated she should have been informed of the resident's poor food intake. The RD stated if a resident had a 2% weight loss in a week, it would trigger in the report. She stated the report did not trigger a weight loss because there were some weekly weights missing. She stated she should have evaluated the weight loss if it was trending down even though not considered significant. She stated she was not notified of Resident 22's weight loss on December 29, 2021. On January 12, 2022, at 2:56 p.m., Certified Nurse Assistant (CNA) 1 was interviewed. She stated Resident 22 did not eat breakfast or lunch today. She stated Resident 22 was like this since admission. On January 13, 2021, at 3:46 p.m., an interview with the Director of Nursing was conducted. She stated the residents should be weighed upon admission and weekly for one month. She stated Resident 22 was noy weighed as ordered by the physician, on December 22, 2021 and January 5, 2022. The DON stated the RD evaluated Resident 22 on December 16, 2021. However, she stated there were no other follow up evaluation conducted by the RD on Resident 22. She stated the RD should have evaluated Resident 22's nutritional needs on a weekly basis after December 16, 2021, since Resident 22 had poor food intake and weight loss of 6.2 lbs/3.85% on December 29, 2021. The DON stated Resident 22 had poor food intake (average 25%) for several weeks. She stated no other interventions were done other than to continue to monitor. She stated the RD should have been consulted on December 29, 2021, to address Resident 22's nutritional needs, due to continued poor food intake, and the low protein and [MEDICATION(S)] levels. On January 14, 2021, at 2:06 p.m., an interview with the NP was conducted. He stated he was aware of Resident 22's poor food intake and complaint of nausea. He stated Resident 22 was given medications but continued to be nauseated. The NP stated Resident 22 should have been referred to the RD, to assess the nutritional needs, prior to initiating medications for poor food intake. The facility's policy and procedure titled, Weight Assessment and Intervention, dated September 2008, was reviewed. The policy indicated, .Weight Assessment .The nursing staff will measure resident weights on admission, the next day and weekly for two weeks thereafter .Any weight change of 5% or more since the last weight assessment .nursing will immediately notify dietician in writing .The dietitian will respond within 24 hours of receipt of written notification .Negative trends will be evaluated by the treatment team whether or not the criteria for significant weight changes has been met .1 month - 5% weight loss is significant; greater than 5% is severe .Assessment information shall be analyzed by the weight committee team and conclusion shall be made regarding .the approximate calorie, protein, and other nutrient needs compared with resident's current intake; the relationship between current medical condition or clinical situation and recent fluctuations in weight; and whether and to what extent weight stabilization or improvement can be anticipated .The physician and the weight committee team will identify conditions and medications that may be causing .weight loss or increasing the risk of weight loss .Individualized care plans shall address .the identified causes of weight loss .Interventions for undesirable weight loss shall be based on careful consideration of the following .Resident choice and preference .Nutrition and hydration needs of the resident .The use of supplementation and/or feeding tubes .

Based on observation, interview, and record review, the facility staff failed to effectively assess, manage, and treat the pain for two of ten sampled residents (Residents 31 and 14). These failures resulted in Resident 31's pain not being addressed for three days, and Resident 14's pain not being addressed for approximately 24 hours. In addition, Resident 31 self-administered medications brought from home for pain relief, without staff knowledge. This posed a risk for adverse drug interactions for Resident 31. In addition, the unsecured medications put other residents, who might obtain the medications, at risk for adverse drug interactions and injury or death from a medication overdose. Findings: 1. During the initial tour of the facility, on November 3, 2014, at 9:35 a.m., Resident 31 was observed with a gauze bandage over her right knee and a bruise on her right elbow. During a concurrent interview, Resident 31 stated she fell at home and was in the facility for rehabilitation. On November 3, 2014, a medical record review was conducted for Resident 31. The resident was admitted to the facility from an acute hospital on October 23, 2014, with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS; a standardized assessment tool), dated October 23, 2014, was reviewed. The MDS indicated Resident 31 was able to make herself understood, able to understand others, and had no cognitive impairment. The MDS indicated, on admission, Resident 31 had no complaints of pain for the last five days. The document titled, "Physicians Transcribed Order," dated October 23, 2014, at 6:57 p.m., was reviewed and included an order for [REDACTED]. If resident is experiencing pain, make sure to document what intervention you used to alleviate pain." The nurse's notes dated October 23, 2014, through October 27, 2014, were reviewed and included: - An admission note dated October 23, 2014, at 8:18 p.m., indicated, "Pt (patient) is A/O (alert/oriented) to person, place, time, and event. Able to make needs known. Calm and friendly ...shows no s/s (signs/symptoms) of distress and discomfort at this time." - A nurse's note dated October 24, 2014, at 4:28 a.m. indicated, "C/O of generalized mild pain and discomfort, but aware MD (physician) does not want to order any pain meds, therefore requested staff to try to contact MD in am (morning) with 2nd (second) request to MD ... " There was no documentation to reflect any type of intervention the facility provided to alleviate the resident's pain. There was no indication to reflect the MD was notified of the resident's complaint of pain. - A nurse's note dated October 24, 2014, at 5:33 a.m., indicated, "C/O mild pain, no order from MD, MD confirmed no pain meds upon admission 10/23 pm shift, less than 24 hours ago, will contact MD again today during day per resident request." There was no documentation to reflect any type of intervention the facility provided to alleviate the resident's pain. There was no indication to reflect the MD was notified of the resident's complaint of pain. - A nurse's note dated October 24, 2014, at 3:58 p.m., indicated Resident 31's primary physician, "...does not want to prescribe pain medication for pt as she has hx (history) of falls." There was no documentation to reflect any type of intervention the facility provided to alleviate the resident's pain. There was no indication to reflect the MD was notified of the resident's complaint of pain. - A nurse's note dated October 24, 2014, at 5:01 p.m., indicated, "... Res (resident) is requesting pain meds/explained that MD doesn't want to prescribed any pain meds/res is upset...Resident stated she had changed to another doctor." There was no documentation to reflect any type of intervention the facility provided to alleviate the resident's pain. There was no indication to reflect the MD was notified of the resident's complaint of pain. - A nurse's note dated October 24, 2014, at 11:50 p.m., indicated, "Res (resident) requested pain meds during shift. Explained that MD won't prescribed (sic) any pain meds d/t (due to) history of fall." There was no documentation to reflect any type of intervention the facility provided to alleviate the resident's pain. There was no indication to reflect the MD was notified of the resident's complaint of pain. - A nurse's note dated October 25, 2014, at 4:48 p.m., indicated, "...rt (right) shoulder pain especially when turning/ (the resident) stated (the pain measured) 10/10 (a pain screening tool from 0-10, 0 being no pain and 10 being the worst possible pain)." There was no documentation to reflect any type of intervention the facility provided to alleviate the resident's pain. There was no indication to reflect the MD was notified of the resident's complaint of pain. - A nurse's note dated October 25, 2014, at 8:30 p.m., indicated, "...CNA (Certified Nurse Assistant) found a bottle of [MEDICATION NAME] (a prescription medication used to treat anxiety) 2 mg (milligrams) and a bottle [MEDICATION NAME](an over the counter pain relief medication). Husband visited earlier, didn't notify nursing about the meds. At this time, res is very drowsy and lethargic, responsive, stated she took a pill, didn't tell what was it (the resident did not identify what medication she took), (Resident 14) asked how much she took, stated one (pill)." There was no documentation indicating the physician was notified of Resident 31's self medication, the two medications the resident might have taken, or the increased pain level which prompted the resident to self medicate. - A nurse's note dated October 26, 2014, at 4:26 p.m., indicated, "...res stated always have pain/MD aware." There was no documentation to reflect any type of intervention the facility provided to alleviate the resident's pain. - A nurse's note dated October 26, 2014, at 10:18 p.m., indicated, "...Res is requesting meds to help her relax at night but doesn't want me to call her physician because she will be changing to another doctor." There was no documentation to reflect any type of intervention the facility provided help the resident relax at night. There was no indication to reflect the MD was notified of the resident's complaint of pain. - A nurse's note dated October 27, 2014, at 7:37 a.m., indicated, "...Pt verbalized distress to CNA's regarding pain and not being able to sleep. Pt verbalizes pain 10/10 (pain scale with one being very mild pain and ten equaling severe pain) to rt hip that radiates to back and pain to rt hip 7/10, and also unable to sleep. Pt states that MD does not want to prescribe her any medication so she would like to change doctors. Report given to day nurse to follow up on MD and medications for pt. Pt had verbalized wanting to die to CNAs, pt asked if this was true and if she had a plan, pt stated she is frustrated but does not have a plan to hurt herself." There was no documentation reflecting actions taken by the licensed nurse to assist Resident 31 after the resident expressed her frustration and desire die. There was no documentation to reflect any type of intervention (such as repositioning, cool compresses, relaxation techniques) the facility provided to alleviate the resident's pain. There was no indication the MD was informed of the resident's statements of frustration, pain, and desire to die. There was no documentation to reflect the MD was informed of the resident's complaints of pain. The nurse's notes did not indicate non-pharmacological interventions were provided for Resident 31's pain. There was no indication nursing management and/ or the facility's Medical Director was notified of and asked to intervene in behalf of Resident 31. Further review of the Resident 31's record, indicated: A "Physicians Telephone Order" dated October 27, 2014, indicated an order for [REDACTED]. "[MEDICATION NAME] ([MEDICATION NAME]/ [MEDICATION NAME], opiod/ narcotic pain medication) tablet, 5-325 mg: Give 2 Tablets By Mouth As needed every four hours, For severe pain; [MEDICATION NAME] tablet, 5-325 mg: Give 1 Tablet By Mouth As needed every four hours, For moderate pain; and TYLENOL, Tablet, 325 mg: Give 2 Tablets By Mouth As needed every six hours, For mild pain." The nurse's note dated October 27, 2014, at 8:47 a.m., indicated, "Phoned primary physician re (regarding) residents c/o (complain of) Bilateral hip pain. New orders noted for [MEDICATION NAME] (a narcotic) 5/325 1 tab (tablet) p.o. (by mouth) q (every) 4 hours moderate pain and 2 tabs p.o q 4 hours PRN (as needed) severe pain and Tylenol 325 mg 2 tabs p.o q 6 hours PRN Mild pain." The document titled, "PRN MEDICATION ADMINISTRATION REPORT FROM: 10/24/14 TO: 11/4/2014," was reviewed. The document indicated Resident 31 was first medicated for pain 78 hours after the resident initially complained of pain. There was no documentation to explain the two hour wait after the order was received before the resident received the pain medication. On November 6, 2014, at 9:50 a.m., an interview was conducted with Resident 31. Resident 31 stated she was in "a lot" of pain when she arrived at the facility after the fall. Resident 31 stated her physician would not let her have anything for pain, so she wanted to change doctors. Resident 31 stated she had pain medication brought in from home that she took without telling anyone. Resident 31 stated, "I slept so good that night." On November 6, 2014, at 2:05 p.m., an interview was conducted with Licensed Vocational Nurse (LVN) 3. LVN 3 stated she was not the nurse on duty when Resident 31 reported the pain, but if a resident was having pain, "I would get a hold of the doctor right away." LVN 3 stated if the physician had said "no" to ordering pain medication, and the resident still was having pain, she would call the physician back again. If the physician continued to say "no" to ordering a pain medication after the second time, she would "notify the DON, or charge nurse and medical director, if necessary." An interview was conducted with the DON, on November 4, 2014, at 4 p.m. The DON stated the nurses told her they were working on getting Resident 31 pain medication. The DON stated she did not know the nurses were having trouble getting an order for [REDACTED]. The DON stated the facility's practice was to follow the facility's chain of command when a resident's primary physician would not address a resident's request for pain medication. The document titled, " Policy and Procedure: Pain Management, Revised: 8/1/14," was reviewed. The facility's policy indicated, "...The primary physician will be alerted via telephone if any of the following issues arise: 1) Acute onset of pain, 2) New or changing pain, 3) No pain medications are ordered and the resident is in significant pain." The facility's failure to notify the physician of Resident 31's pain, obtain an order for [REDACTED]. 2. On November 4, 2014, at 10 a.m., during a medication pass observation, Resident 14 told LVN 1 his left shoulder was hurting. LVN 1 presented her back to the resident and asked him to show her where the pain was and the resident pointed to her left upper back area. LVN 1 stated she would have the desk nurse call the physician to obtain an order for [REDACTED]. (by mouth) pain medication ordered. LVN 1 did not look at Resident 14's stated pain site or further question the resident regarding the level or characturistics of the pain. The Surveyor asked LVN 1 if Resident 14 complainted of pain before November 4, 2014, at 10 a.m. LVN 1 stated he had not. The LVN stated the resident had an order for [REDACTED]. On November 4, 2014, a review of Resident 14's clinical record indicated he was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. On November 4, 2014, a review of Resident 14's MDS (Minimum Data Set, a standardized assessment tool), dated October 20, 2014, indicated the resident was cognitively intact and required extensive assistance with all activities of daily living. A concurrent review of the skilled nurses notes dated October 20, 2014, through November 4, 2014, indicated Resident 14 frequently requested pain medication for pain in his right shoulder. There was no documentation to reflect the resident making a statement he had pain in his left shoulder prior his complaint on November 4, 2014, at 10 a.m. During a record review conducted on November 4, 2014, at 3:50 p.m., for Resident 14's, there was no documentation of the resident's complaint of pain in his left shoulder, nor was there any documentation indicating the physician was notified of the resident's left shoulder pain. On November 5, 2014, at 9:30 a.m., LVN 1 stated she asked the desk nurse (nurse stationed at the nursing station desk to handle telephone calls and physician's orders [REDACTED]. On November 5, 2014 at 9:37 a.m., during an interview conducted with Resident 14, this surveyor asked him if he was still having pain in his left shoulder, Resident 14 nodded his head, "Yes," and stated, "A little bit." During an interview conducted with LVN 2 on November 5, 2014, at 9:40 a.m., LVN 2, stated she was the desk nurse and had been the desk nurse on duty the day before. When asked if she knew about Resident 14's pain, the LVN stated, "I know he has pain in his right shoulder, we put a wrap on it for his pain. I did not know about the pain in his left shoulder. I will call the physician and get an order for [REDACTED]. LVN 2 was observed for an additional twenty minutes. The LVN did not leave the desk area to assess possible causes of Resident 14's pain during that time. On November 6, 2014 at 11:10 a.m., a review of Resident 14's clinical record indicated a physicians order was obtained for Tylenol (a pain medication) approximately twenty four hours after Resident 14 first complained of pain in his left shoulder. During an interview conducted with the DON on November 6, 2014, at 10 a.m., the DON stated, if a resident complained of a new pain, she would expect the nurses to assess the severity of the pain and the length of time the resident had the pain, then notify the physician. On November 6, 2014, a review of the facility's Pain Management policy, dated August 1, 2014, indicated all residents should be assessed for pain on admission, at the time of new onset pain, and regularly thereafter. The policy indicated the assessment should include location, duration, intensity, affect of the pain on functional status, and any other symptoms associated with the pain.

Based on observation, interview, and record review, the facility failed to ensure one of twelve sampled residents (Resident 16) received respiratory therapy/treatments as ordered by the physician, in a safe manner, and in accordance with the plan of care and acceptable standards of practice when; 1. Treatments were administered more than one and one half hours late and without evidence of a pre and post treatment assessment; 2. PRN (as needed) respiratory treatments were not administered when needed; 3. PT (Physical therapy) was done when the resident was having respiratory difficulty; 4. Concurrent therapy was routinely done by the RT (respiratory therapist); and, 5. The resident's respiratory status was not assessed and communicated to the physician. These failed practices resulted in the decompensation of the resident's respiratory status, respiratory distress, and [MEDICAL CONDITION]. Findings: During the facility environmental tour on October 24, 2013, at 1 p.m., several facility staff members and EMS (emergency medical service) personnel were observed entering the room where Resident 16 was located. Staff was observed pushing the facility crash cart (a cart stocked with equipment and supplies necessary to treat an emergency condition) into the room. The record for Resident 16 was reviewed on October 25, 2013. Resident 16 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The History and Physical dated October 17, 2013, indicated Resident 16 had pneumonia while in the hospital which was resolved. The RT evaluation, completed October 18, 2013, at 6 a.m., indicated Resident 16 had decreased breath sounds in the base of her lungs posterior and lateral (when listening from the side and the back), she had crackles on inspiration and expiration (caused by blocked airways opening suddenly), with rhonchi in the upper lobes (a rattling sound caused by secretions in the airways), and was on continuous oxygen at 2 LPM (liters per minute) via NC (nasal cannula) for shortness of breath with a SpO2 (a measurement of the body's ability to carry oxygen to the tissues) of 93% (normal is 96-100% without oxygen). A physician's orders [REDACTED]. p.m. The order indicated the treatment was to be given by the RT and documented by the nursing staff, unless the RT was not available. Then the treatment was to be given by the nursing staff. In addition to the routine RT order, the EMAR (electronic medication administration record) included an order for [REDACTED]. The Care Plan included a problem identified as, "Cough," initiated October 23, 2013. The goal was for the resident to have no S/S (signs or symptoms) of respiratory distress. The interventions included assess lung sounds every shift, assess for SOB/easily fatigued/cyanosis (blue colored skin indication poor oxygenation), and respiratory treatments as ordered. The EMAR for October, 2013, was reviewed on October 25, 2013. The record indicated the RT treatments were given as ordered and signed off by nursing on October 18, 19, 20, 21, and 22, 2013. There was no documentation to determine whether the treatment was given by the RT or the nurse. There was no evidence in the record an assessment of the resident's respiratory status was performed before, during, or after any of the treatments. The EMR (electronic medical record) progress notes dated October 23, 2013, at 1:56 a.m., indicated Resident 16 was unable to take her 5 p.m. medications on October 22, 2013, due to her cough. The EMR indicated the nurse informed the physician, and he ordered a CXR (chest X-ray) to be done the following day. There was no evidence on the EMAR that additional Abutter treatments were given to the resident. There was no evidence a respiratory assessment was performed by a nurse or a RT and communicated to the physician during the conversation. The detail notes in the EMAR indicated on October 23, 2013, the 10:30 a.m. breathing treatment was given at 12:16 p.m. (one hour and 46 minutes late). There was no documentation to determine whether the treatment was given by the RT or the nurse. There was no evidence in the record an assessment of the resident's respiratory status was performed before, during, or after the treatment. There was no indication the late treatment was reported to the physician. A CXR report, faxed to the facility from the diagnostic lab on October 23, 2013, at 2:06 p.m., indicated Resident 16 had a mild infiltrate in the RLL (right lower lobe) that may represent pneumonia. The report contained a written note indicating to hold off on antibiotics, but advising the facility to do IS (a device that encourages deep breaths to help keep the lungs inflated) 10 times every hour. There was no evidence in the record the IS was ever started. The EMR progress notes dated October 23, 2013, at 4:34 p.m., indicated Resident 16 was complaining of a productive cough, and a CXR was done with results pending. There was no evidence the nurse was aware of the results of the CXR. There was no evidence a respiratory assessment was performed by a nurse or a RT. The EMR progress report dated October 24, 2013, at 8:26 a.m., indicated the nurse called the physician's office to update him on, "resident's deteriorating condition." There was no evidence a respiratory assessment was performed by a nurse or a RT and communicated to the physician during the conversation. There was no evidence in the EMAR that additional [MEDICATION NAME] treatments were given to the resident. The PT Treatment notes dated October 24, 2013, indicated the Resident had PT that day. The notes indicated she reported feeling weak and SOB and refused to do gait training (walking with the therapist), but agreed to sit up at the edge of the bed for leg exercises. According to the notes, the nurse was made aware of her SOB and weakness. The EMR progress notes dated October 24, 2013, at 9:13 a.m., indicated the nurse called the physician's office to discuss the CXR results from the previous day. There was no evidence a respiratory assessment was performed by a nurse or a RT and communicated to the physician during the conversation. There was no evidence in the EMAR that additional [MEDICATION NAME] treatments were administered to the resident. The detail notes in the EMAR indicated on October 24, 2013, the 10:30 a.m. RT treatment was given at 12:05 p.m. (one hour and 35 minutes late). There was no documentation to determine whether the treatment was given by the RT or the nurse. There was no evidence indicating an assessment of the resident's respiratory status was performed before, during, or after the treatment. There was no indication the late treatment was reported to the physician. The EMR progress notes dated October 4, 2013, at 1:30 p.m., indicated the resident complained to the CNA that she was feeling short of breath. The record indicated 911 was called, and the resident was noted to have agonal respirations (gasping type breathing) with a cyanotic color (turning blue) and no pulse. Chest compressions were initiated and the resident was transferred to the hospital. During an interview with LVN 5 on October 29, 2013, at 1:15 p.m., the LVN stated the note written on the CXR fax report should have been taken as an order to initiate IS, and the IS should have been started. During an interview with LVN 5 on October 29, 2013, at 1:25 p.m., the LVN stated the RT came in daily to do treatments. She stated the nurses had to chart the treatments in the computer. She stated the RT would get the medications for the treatment from the nurse, and the nurse would document the treatment. She stated she did not know if the RT documented the treatments anywhere in the record, but, "he should." She stated he might have a form under the, "rehab," tab in the paper record. The, "rehab," tab in the paper record for Resident 16 was reviewed on October 29, 2013, at 1:30 p.m. The tab contained an initial RT evaluation, but no evidence of RT treatments that had been given to the resident. During an interview with the DON on October 29, 2013, at 3 p.m., the DON stated the RT had a book that should have documentation of the treatments he provided. The RT book was requested for review. On October 29, 2013, at 3 p.m., the DON was observed searching through multiple binders located on shelves in the nurse's station. The DON was unable to locate a book that contained the RT treatment documentation. RT Log #1 - The Respiratory Care Service Log was reviewed on October 29, 2013. The log included the number four in multiple boxes that coincided with patient names and treatments. RT Log #2 - The Respiratory Therapist Log was reviewed on October 29, 2013. The log contained in and out times by date. The log indicated the RT was in and out at the exact same times every day, seven days a week. RT Log #3 - The Respiratory Therapy report for October, 2013, was reviewed on October 29, 2013. The report included initials in boxes indicating an evaluation had been done on a resident, as well as hash marks indicating the units allocated per resident for each day. During an interview with the RT on October 30, 2013, the RT stated the documents reviewed were all for billing purposes. He stated those were the documents he forwarded to accounts payable, and they paid him based on the information in the documents. He stated he did treatments on residents, but he did not document them anywhere. He stated he did not document pre, during, or post assessments, or education of the resident during the treatment. He stated he got the medications from the nurses before he started, and told the nurses when he was done. He stated he would do all of the resident treatments at the same time (if two, three, or four residents were due for treatments, he would start them one after the other, and all residents would be receiving their treatments concurrently). He stated he used to chart assessments and treatments, but with the new EMR he was not given access to do documentation, so he could not chart them. The RT declined to answer questions regarding the timeliness of treatments or nursing documentation of treatments. According to the AARC (American Association for Respiratory Care) Clinical Practice Guideline Assessing Response to [MEDICATION NAME][MEDICATION NAME] Therapy at Point of Care (indicated for extended care or skilled care facilities): a. To guide patient management, the resident's baseline condition and changes from baseline must be determined prior to therapy, during therapy, and following therapy. This is done by assessing the vitals signs, breath sounds, and lung function; b. Monitoring the resident throughout the therapy assists in determining the presence or absence of a desirable response to breathing treatments; and, c. Documentation should include the resident's response to the treatment (medication type/dose/time received, vital signs, breath sounds, and lung function) and the resident's progress toward goals. Further review of the logs indicated concurrent therapy was being done by the RT as follows: 1. October 1, 2013 - three residents at 6:30 a.m., 10:30 a.m., 2:30 p.m., and 6:30 p.m. (including Resident 16); 2. October 2, 2013 - three residents at 6:30 a.m., 10:30 a.m., 2:30 p.m., and 6:30 p.m. (including Resident 16); 3. October 3, 2013 - three residents at 6:30 a.m., 10:30 a.m., 2:30 p.m., and 6:30 p.m. (including Resident 16); 4. October 18, 2013 - two residents at 6:30 a.m., 10:30 a.m., and 2:30 p.m. (including Resident 16); 5. October 19, 2013 - two residents at 6:30 a.m., 10:30 a.m., and 2:30 p.m. (including Resident 16); 6. October 20, 2013 - two residents at 6:30 a.m., 10:30 a.m., and 2:30 p.m. (including Resident 16); 7. October 21, 2013 - two residents at 6:30 a.m., 10:30 a.m., and 2:30 p.m. (including Resident 16); 8. October 22, 2013 - two residents at 6:30 a.m., 10:30 a.m., 2:30 p.m., and 6:30 p.m. (including Resident 16); and, 9. October 23, 2013 - two residents at 6:30 a.m. and 10:30 a.m. (including Resident 16). According to the AARC: "Concurrent therapy," in Respiratory Care is defined as rendering simultaneous inhaled medication aerosols, to more than one patient, in unmonitored patient care areas, by one therapist. Having completed comprehensive research into the practice of "Concurrent Therapy," aside from declared disaster, there is no compelling medical, ethical, or safety rationale for the continuation of this practice. The CSRC (California Society for Respiratory Care) takes the position concurrent therapy should rapidly be abandoned in the interest of patient safety, [MEDICATION NAME] efficacy, and the ethical practice of Respiratory Therapy. According to an article published in ADVANCE for Health Professionals, "Doing More With Less Does Not Mean Concurrent Care," November 29, 2012, Author: Stan Holland, MS, RRT, FAARC; Just because side effects (of breathing treatment medications) are infrequent does not mean (concurrent therapy) is safe. The appropriate administration of respiratory therapy involves assessing and monitoring the patient. Assessment and monitoring include the need for therapy, administration of medications, the type of medication delivery device, patient education, patient tolerance, patient coordination, and outcomes documentation. Concurrent therapy may encourage the elimination of one or more of these essential elements and could result in medical errors.

Based on observation, interview, and record review, the facility failed to ensure measures were taken to prevent recurrent UTIs (urinary tract infection) for one of twelve sampled residents (Resident 19) when the resident's [MEDICATION NAME] bag was maintained in an unsanitary manner, and the resident was not encouraged to drink fluids as necessary for prevention of UTI. These failed practices resulted in the resident developing a UTI in September and October 2013. (A UTI after an ileoconduit is an infection in the urinary tract caused by bacteria that makes its way into the ureters (the tubes that carry urine from the kidneys to the urine collection pouch that is made and placed in the abdominal wall during surgery). It is important to prevent the urine that empties into the pouch or the collection bag from backing up, or "refluxing," into the ureters, as this may lead to a urinary tract or kidney infection. It is also important to drink plenty of fluid, as this helps to flush bacteria or germs out of the ureters, dilutes the bacteria, and promotes an acidic environment to help prevent the growth of bacteria) Findings: During the initial tour of the facility, accompanied by CNA 5 (certified nursing assistant), on October 22, 2013, at 10 a.m., Resident 19's room was entered and noted to have a strong urine odor. A Foley drainage bag (used to drain urine when attached to a catheter) was observed hanging on the side of the bed, with the tubing looped and the end piece sticking up and open to air. The bag contained 300 ml (milliliters) of amber colored urine. There was no cap on the end of the tubing. The CNA stated the resident had a [MEDICATION NAME] bag that she emptied into the foley bag. On October 23, 2013, at 9 a.m., Resident 19 was observed sitting in bed in her room that continued to have a strong urine odor. The Foley bag, stained from previous urine, continued to hang at the bedside, now with a small amount of amber colored urine in it. The end of the tubing was open to air with nothing covering it. The resident stated she used the Foley bag to empty her urine from her [MEDICATION NAME] bag into, mostly when she went to [MEDICAL TREATMENT]. She stated sometimes she took the Foley bag (with the end of the tubing attached to the [MEDICATION NAME] bag) with her to [MEDICAL TREATMENT]. There was no label or date on the Foley bag to indicate when the bag was placed at bedside for the resident's use. On October 24, 2013, the following occurred: 1. At 10:20 a.m., Resident 19's room was observed with the Foley bag hanging at the bedside with amber colored urine in the bag and clear yellow urine in the loop of the tubing. The end of the tubing was covered with a thin clear plastic bag. The cord used to hang the Foley bag on the bed was also wrapped around the end of the plastic bag holding it in place on the tubing. There was no label or date on the Foley bag to indicate when it was placed bedside for the resident's use. 2. During an interview with LVN (licensed vocational nurse) 4 at 10:45 a.m., the LVN stated Resident 19's Foley bag was hanging at the bedside, and it did not go with the resident to [MEDICAL TREATMENT]. The LVN stated sometimes the resident took the Foley bag with her to [MEDICAL TREATMENT], and sometimes she did not. The LVN stated sometimes the urine from the [MEDICATION NAME] bag got emptied into the foley bag, and sometimes it was emptied into the toilet. The LVN stated the CNAs should be measuring the I&O (intake and output) on the resident, including the urine from the [MEDICATION NAME] bag and the Foley bag in the output. She stated she did not know how the resident was doing with her fluid status (intake vs. output). She stated, "I would have to look;" and, 3. At 2:30 p.m., Resident 19 was observed returning from [MEDICAL TREATMENT]. The [MEDICATION NAME] bag had clear yellow urine in it. With LVN 4 present and observing, the resident hooked the [MEDICATION NAME] bag tubing to the Foley bag tubing and emptied the urine into the foley bag tubing. She did not clean her hands or either of the tubings before hooking them together. The LVN stated she did not know how often the Foley bag was changed. She stated sometimes the resident had the Foley bag tubing hooked to the [MEDICATION NAME] bag at night while she slept, and she was mobile in bed and moved around. The LVN looked into the end of the Foley tubing and stated the tubing did not have any valve that could prevent back flow of old urine from the Foley tubing into the [MEDICATION NAME] bag (potentially coming into contact with the ureters and resulting in reflux of old urine). She stated it was an, "open tubing." The record for Resident 19 was reviewed on October 23, 2013. Resident 19 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The record indicated Resident 19 had a history of [REDACTED]. The resident was on [MEDICAL TREATMENT] (a method of cleansing the blood using an artificial kidney) and had a [MEDICATION NAME] (an opening in the abdomen where urine leaves the body) with a bag attached to the skin for collecting and draining urine. The record included physician's orders [REDACTED]. 1. [MEDICATION NAME] care every shift and as needed; 2. [MEDICAL TREATMENT] three times a week; and, 3. Fluid restriction of 1500 ml (milliliters) daily. The care plan included the following: A. Altered Urinary Elimination, with a goal of no complications related to the [MEDICATION NAME], and an intervention to empty the drainage bag every shift and as needed. There was no specific procedure mentioned for emptying the bag; and, B. UTI, with a goal of resolution of the infection, and interventions to assess the urine for odor, monitor the effectiveness of antibiotic therapy, monitor for S/S (signs and symptoms) of dehydration, and offer and encourage fluids. The IDT (interdisciplinary team) Care Plan Conference Summary dated July 6, 2013, identified the resident was at risk for UTI related to her [MEDICATION NAME] and kidney disease, and the care plan in place was appropriate. The IDT Care Plan Conference Summary dated October 29, 2013, indicated the resident was on a 1500cc fluid restriction, with a goal to remain free from dehydration. There was no indication the team discussed the recurrent UTIs or care of the [MEDICATION NAME]. The summary indicated the care plan in place was appropriate. The EMR (electronic medical record) progress notes indicated the following: a. September 12, 2013, the resident completed antibiotics for treatment of [REDACTED]. b. September 20, 2013, the resident's son complained of her urine having a very strong odor. The physician was notified and he ordered a UA (urinary analysis) with a C&S (a test to see if bacteria is in the urine and what antibiotic will treat it); c. September 23, 2013, lab results for the urine C&S indicated the bacteria [MEDICATION NAME] was growing in the resident's urine. There was no evidence the physician was notified, and no antibiotics were started; d. September 25, 2013, the physician was notified of the results of the urine C&S, and a seven day course of antibiotics was ordered; e. September 26, 2013, the resident was on oral antibiotics for a UTI, with no adverse effects from the antibiotics. The physician ordered the duration of the antibiotics to be increased to ten days. Extra fluids were encouraged by the staff; f. September 27, 2013, increased fluid intake was encouraged by the staff; g. September 28, 2013, the resident remained on antibiotic therapy for a UTI. Extra fluids were given by the staff; h. September 29 and 30, 2013, the resident remained on antibiotic therapy for a UTI. Fluids were encouraged by staff; i. October 5, 2013, the resident's urine was clear and light yellow in color. The last dose of antibiotic for UTI was completed in the morning; j. October 11, 2013, per [MEDICAL TREATMENT] center, the resident was placed on a fluid restriction of 1500cc per day; k. October 14, 2013, the resident's urine had become cloudy with a foul smell. A urine test and C&S were done; l. October 15, results were received from the urine test, and a culture was indicated (due to evidence of a UTI). The physician was notified, and wanted to wait for the culture results before considering new orders; m. October 19, 2013, the urine culture showed evidence of a UTI, with the bacteria [MEDICATION NAME] growing in the urine. The physician ordered antibiotics to treat the infection. The resident was on a 1500cc fluid restriction, and was tolerating, "extra," fluids well; and, n. October 20, 21, 21, and 23, 2013, the resident was taking antibiotics for a UTI. She was taking fluids well when offered. During an interview with the DON (Director of Nursing) on October 25, 2013, at 12:40 p.m., the DON stated she had not seen the [MEDICATION NAME]/foley set up used by Resident 19 and the staff caring for her. During the interview, the policy regarding [MEDICATION NAME] care was requested. During an interview with the DON on October 25, 2013, at 3:20 p.m., the DON stated she evaluated the set up for Resident 19, and she explained to the resident that they were going to change her plan of care. She told the resident staff would have her empty her [MEDICATION NAME] bag into a graduate (a plastic container that is emptied each time it is used) in the future to prevent UTIs. The DON stated she was not able to locate a facility policy regarding [MEDICATION NAME] care. The I&O record for October 2013 was reviewed on October 29, 2013. The record indicated the resident's daily fluid balance was as follows: October 1 - 440 cc intake, with 2500 cc output; October 2 - 600 cc intake, with 1300 cc output; October 3 - 450 cc intake, with 1700 cc output; October 4 - 1010 cc intake, with 1400 cc output; October 5 - 1240 cc intake, with 1750 cc output; October 6 - 780 cc intake, with 1090 cc output; October 7 - 960 cc intake, with 900 cc output; October 8 - 660cc intake, with 1750 cc output; October 9 - 960 cc intake, with 800 cc output; October 10 - 960 cc intake, with 1350 cc output; October 11 - 990 cc intake, with 800 cc output; October 12 - 380 cc intake, with 500 cc output; October 13 - 890 cc intake, with 1200 cc output; October 14 - 660 cc intake, with 1075 cc output; October 15 - 240 cc intake, with 900 cc output; October 16 - 640 cc intake, with 1300 cc output; October 17 - 450 cc intake, with 540 cc output; October 18 - 990 cc intake, with 650 cc output; October 19 - 640 cc intake, with 1200 cc output; October 20 - 830 cc intake, with 650 cc output; October 21 - 1060 cc intake, with 1550 cc output; October 22 - 810 cc intake, with 500 cc output; October 23 - 1110 cc intake, with 850 cc output; October 24 - 570 cc intake, with 750 cc output; October 25 - 900 cc intake, with 850 cc output; October 26 - 450 cc intake, with 500 cc output; October 27 - 690 cc intake, with 300 cc output; and, October 28 - 480 cc intake, with 1400 cc output. For the month of October 2013, the resident had a negative fluid balance less intake than output on 19 days. Although the care plan indicated fluids needed to be encouraged, and the progress notes indicated the staff was encouraging fluids, the intake never reached the maximum amount allowed of 1500 cc. The facility policy titled, "Intake and Output," was reviewed on October 25, 2013. The policy indicated the following: 1. The purpose was to evaluate the resident's fluid balance; 2. I&O records were significant in monitoring residents on fluid restriction and residents on [MEDICAL TREATMENT]; and 3. The charge nurse was responsible for knowing who was on I&O and making sure they were complete, accurate, and recorded. The policy did not include any information regarding fluid differences that were expected or that may cause concern, or what, if anything, regarding fluid balance to report to the physician. The policy did not provide parameters to enable nurses to assess if the resident needs for intake and output were being met. The facility staff failed to take actions to prevent the recurrence of UTIs in Resident 19 when they repeatedly used unsanitary practices in caring for the resident's [MEDICATION NAME] bag, and allowed negative fluid balances for multiple days at a time, and increased the potential for Resident 19 to become dehydrated.

Based on observation, interview, and record review, the facility failed to promote care that maintained the dignity and respect for one of twelve sampled residents (Resident 45), when her call light went unanswered for an extended period of time causing her to soil herself, and CNA 1 (certified nursing assistant) argued with her and refused to change her sheets and blanket. This failed practice resulted in mental anguish for Resident 45, and affected her psychosocial (comfort interacting with others) well being when she was left soiled for an extended period of time, and then was treated disrespectfully by the staff that was supposed to be helping her. Findings: On October 22, 2013, during the initial tour of the facility, Resident 40 stated her roommate (Resident 45) had a horrible experience on their first day at the facility. Resident 40 stated she felt so bad about how her roommate had been treated by CNA 1 on the night shift. Resident 40 stated CNA 1 was disrespectful to Resident 45 by being rude and refusing to changed the soiled bed after Resident 45 requested the bed be changed. Resident 40 stated the way the CNA acted was not right and she had to say something about it. The record review for Resident 40, conducted on October 23, 2013, indicated Resident 40 was alert, oriented (to person, time, and place), verbal, and able to understand with her cognitive status intact. A record review was conducted for Resident 45, on October 24, 2013. Resident 45 was admitted to the facility on [DATE], at 9:13 a.m., with [DIAGNOSES REDACTED]. The progress note dated October 18, 2013, at 4:30 p.m., indicated that Resident 45 was transferred from the hospital after having left hip surgery. Resident 45 had an incision 19 cm long with 40 staples. Resident 45 was alert, oriented (to person, time, place, and event), with her cognitive status intact, and able to make her needs known. Resident 45 came to the facility for skilled nursing services and rehabilitation. The admission nursing assessment, dated October 18, 2013, indicated Resident 45 was always continent of bowel and bladder. An interview was conducted with Resident 45, on October 22, 2013, at 10 a.m., Resident 45 stated she was admitted to the facility on [DATE]. She was in pain and was told by the nurses that they did not have her medications ready. Resident 45 stated she went hours without receiving any pain medication. Resident 45 stated after about eight hours, she was finally given her pain medications and was able to sleep for a few hours. Resident 45 stated she woke up at 4 a.m., and needed to use the restroom, so she pressed her call light. She stated nobody came to her room. She stated she waited and pressed the call light several times over and over, but still nobody answered her call for help. Resident 45 stated she had to go to the restroom really bad and was not able to hold it any longer. Resident 45 stated she ended up soiling herself, which was "very difficult" for her to go through. Resident 45 stated it was humiliating and very upsetting. She stated she was an independent woman who took care of herself and did not have to rely on anyone to use the restroom. Resident 45 stated, after waiting two hours for staff to respond, she decided to call for help using her phone. At 6 a.m.( two hours later), Resident 45 used her cell phone to call the main facility number for assistance. She stated the facility operator answered and transferred the call to the Skilled Nursing unit. She stated at that point, two staff members came to her room (LN 1 and CNA 1). Resident 45 stated CNA 1 had a look on her face as if she was bothered she had to clean the resident. "The CNA looked like she hated her job." She stated the CNA was very uncaring and began arguing with the resident about changing her sheets. The CNA stated she did not have to change the sheets or bedding because it was not wet. Resident 45 told the CNA the sheets were wet and she did not want to lay back down on the dirty sheets. She stated CNA 1 insisted she did not have to change the sheets, until Resident 45's roommate (Resident 40) yelled out, "Just change her sheets. It doesn't matter whether they are wet or not. Just change her sheets!" Resident 45 stated CNA 1 seemed upset about changing the sheets, and was very rude to her. Resident 45 stated she was very upset that on her first day, when she was already anxious about staying the night at a new facility, she was treated rudely by CNA 1. Resident 45 became tear- eyed and her voiced cracked from emotion as she told her story. Resident 45 stated she just had surgery, and came to the facility to get better. Resident 45 stated she needed to be at a place that could take care of her needs while she recovered, and not to be ignored and treated with no respect or [MEDICATION NAME]. Resident 45 stated LN 1 later apologized for how CNA 1 treated her. Resident 45 stated she was so concerned and nervous that she might have to deal with CNA 1 again. She stated it was upsetting that she might have to see or have to rely on CNA 1 for help. Resident 45 stated she reported the incident to the DSD and DON. An interview was conducted with the DSD on October 23, 2013, at 9:45 a.m. The DSD stated Resident 45 reported that she had to wait an hour for someone to answer her call light and she soiled her underwear. The DSD stated Resident 45 was continent of bowel and bladder. The DSD stated Resident 45 did not give any specific details about the incident. The DSD stated that Resident 45, "Only said it took one hour to get her call light answered and CNA was rude, but no specifics." The DSD stated she had completed her investigation for this incident. The DSD further stated she gave CNA 1 a verbal and written formal counseling for her job performance for not answering the call lights timely. A copy of the disciplinary report was requested for review. The DSD stated she could not find it in her office and would have to get a copy of it from Administration. At 10:31 a.m., the DSD stated the written counseling was not given to CNA 1. The disciplinary form was written, but CNA 1 had not been into the facility to sign the written disciplinary form. The DSD further stated that CNA 1 was not taken off the schedule and worked last night (October 22, 2013) from 11 p.m. to 7 a.m. The DSD stated she was going to have the CNA come in during the day on Monday (October 28, 2013) to sign the written disciplinary form. The DSD stated she had received several complaints from residents about CNA 1's bad attitude, body language, and rudeness. The DSD stated they decided to discipline CNA 1 for not answering call lights because they had received several complaints about CNA 1's behavior in the past. CNA 1's personnel file was requested. CNA 1 was hired in February 10, 2011, and had four written disciplinary/counseling notices regarding inappropriate behavior, and poor standards of conduct (April 2, 2012, June 12, 2012, December 31, 2012, and May 6, 2013). On December 31, 2012, the DON gave CNA 1 a counseling notice for poor standards of conduct. A resident complained about CNA 1's attitude. The December 31, 2012, employee write up indicated, "Resident states employee 'acts like she doesn't want to take care of any patients.' The resident also stated that employee has, on different occasions, walked in her room, turned off call light, and states she will come back, but never does." The employee's written response was to the December 31, 2012, write-up included, "Employee stated that she had forgotten to take this resident off the bedpan, but had texted day shift employee to follow up once she arrived home." A second disciplinary action, dated June 12, 2012, was given for poor attitude and lack of consideration when turning a resident. The resident had complained that CNA 1 turned her too quickly and abruptly. The resident indicated she was concern the employee had been in her closet with a flashlight. There was no current performance evaluation, abuse training, or evidence of criminal or background check in CNA 1's personnel file. The DSD was asked to provide evidence that the abuse training, evidence of criminal or background check and a performance evaluation was completed for CNA 1. As of October 31, 2013, the day of the survey exit, no documentation was provided to show abuse training, evidence of criminal and/or background checks, and current perforamance evluations were completed for CNA 1. On October 29, 2013, at 10 a.m., during an interview with the DSD, she stated CNA 1 did not come in to meet with her as scheduled to sign the disciplinary notice on Monday, October 29, 2013, so she was going to do it on Thursday, October 31, 2013. The DSD stated CNA 1 had been to work since the incident with Resident 45 occurred. The DSD further stated that Resident 45 was aware of the facility's grievance process, was satisfied about how the complained had been handled, and did not want to put her complaint in writing. An interview was conducted with Resident 45, on October 29, 2013, at 11 a.m. Resident 45 stated she was not aware of the facility's grievance/complaint process, and that no one from the facility had explained the procedure to her. Resident 45 stated she reported the incident in great detail to the DSD and DON and was wondering how her complaint was handled. Resident 45 stated she was very upset about not being given this information, and felt as if the facility was not taking her complaint seriously. "They are trying to sweep it under the rug." Resident 45 stated she is alert and "with it," and able to express herself, but her concern was for those residents who have been or will be treated poorly by CNA 1 and are not able to voice their experiences. The facility's policies and procedures for Patient's Rights and Dignity were requested. The DON stated the facility did not have a policy and procedure for Patient's Rights or Dignity. The DON did provide a copy of what was given to the patients on admission regarding their rights. The Patient's Right's form given to the residents indicated the residents at the facility had the right , "To be treated with consideration, respect and full recognition of dignity and individuality, including privacy in treatment and in personal care..." The facility failed to treat Resident 45 with consideration, respect and full recognition of dignity and individuality. The facility failed to promote care that maintained the dignity for Resident 45 when her call light went unanswered for an extended period of time, causing Resident 45 to soil herself. The facility failed to provide care with respect to Resident 45 when CNA 1 argued with the resident and refused to change her sheets and bedding after the resident had soiled herself. These actions caused mental anguish to Resident 45, and affected her psychosocial well-being, when she was left soiled for an extended period of time and treated disrespectfully by the staff member who was suppose to be helping her.