Every finding on record at University Retirement Community at Davis

Based on observation, interview, and record review, the facility failed to ensure call light systems were accessible for two of 17 sampled residents (Resident 23 and Resident 25) when:1. Resident 25's call light was observed under the bed and not within reach; and2. Resident 23's shower room call device did not have a string to operate.These failures had the potential to negatively affect Resident 23 and Resident 25's safety by preventing the residents from communicating requests for assistance when needed.Findings:1. During a review of Resident 25's admission records, the records indicated Resident 25 was admitted to the facility in April 2023 with diagnoses that included palliative care (care focused on providing relief of pain and other symptoms of a serious illness), osteoporosis (weak and brittle bones), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and dementia (a progressive state of decline in mental abilities). Resident 25's Minimum Data Set (MDS, a federally mandated resident assessment tool) indicated Resident 25 had severe cognitive impairment and was dependent on staff for toileting and personal hygiene.During a review of Resident 25's care plan, initiated 4/25/23, the care plan indicated, [Resident 25] has high risk for falls r/t [related to] poor safety awareness due to cognitive deficits and weakness.Keep resident's call light within reach and encourage the resident to use it for assistance as needed. The resident needs prompt assistance to all requests for assistance.During an observation on 9/16/25 at 9:55 a.m. in Resident 25's room, Resident 25 was observed lying in bed, eyes closed, respirations even and unlabored. Resident 25's call light was observed under the bed and not within reach.During a concurrent observation and interview on 9/16/25 at 10:12 a.m. with Resident 25 in her room, call light was still observed under the bed. Resident 25 stated she used the call light if she needed assistance. Resident 25 was observed moving her right hand to search for the call light.During a concurrent observation and interview on 9/16/25 at 10:14 a.m. with Licensed Nurse 1 (LN 1), LN 1 confirmed Resident 25's call light was under the bed and not within reach and stated, .It [call light] should be within reach, so they [residents] have access if they need help.2. During a review of Resident 23's admission records, the records indicated Resident 23 was admitted to the facility in February 2024 with diagnoses that included Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), cerebral infarction (a condition where blood flow to the brain is interrupted, leading to tissue damage), and psychotic disorder with delusions (disorder that cause abnormal thinking and perceptions). Resident 23's MDS indicated Resident 23 had severe cognitive impairment.During a review of Resident 23's care plan, initiated on 2/23/24, the care plan indicated, The resident is high risk for falls r/t Hx [history] of falls.Be sure The resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance.The resident needs a safe environment.a working and reachable call light.During an observation on 9/16/25 at 9:22 a.m. in Resident 23's shower room, the call device was observed installed approximately five feet from the floor, and missing the string to operate it.During a concurrent observation and interview on 9/18/25 at 8 a.m. with Certified Nursing Assistant 1 (CNA 1) in Resident 23's shower room, CNA 1 stated Resident 23 used the room for showers and confirmed the call light did not have a string. CNA 1 stated call lights are important in cases of emergency and that the missing call light string should have been reported to the maintenance department immediately.During a concurrent observation and interview on 9/18/25 at 8:10 a.m. with LN 2, LN 2 stated call lights should always be accessible and within reach .because residents' needs should always be attended to. LN 2 stated call lights should be present in the bathrooms and showers and must be accessible to residents and to the staff, especially during emergencies. LN 2 confirmed Resident 23's shower area had a call light but no string to pull in case the resident was on the floor. While checking Resident 23's belongings inside the bathroom, LN 2 found the missing call light string mixed with Resident 23's bathroom items. LN 2 stated, .it must have been pulled out and no one reported it to the maintenance.During a concurrent observation and interview on 9/18/25 at 8:20 a.m. with the Maintenance Staff (MS), MS confirmed Resident 23's shower room call light had no string or cord attached to the call device. The MS stated Resident 23 or the staff will need the cord in case of emergency or if someone fell on the floor and stated, .we don't want anyone crawling on the floor to reach the closest call light which was about 10 feet away. The MS further stated the expectation was for staff to report to maintenance if there was anything that needed repair especially call lights because those are really important especially in cases of emergencies.During an interview on 9/18/25 at 8:30 a.m. with the Director of Nursing (DON), the DON stated call lights should be within reach at all times and should be available in bathroom and shower areas. The DON further stated all rooms should be equipped with call lights with cords so residents or staff can pull the device in case they need help. The DON added that residents can also go to bathroom or shower area by themselves and if the residents needed help, they could use the call light to alert staff. When the photo of Resident 23's call device was shown, the DON confirmed the call device did not have a string on it and stated Resident 23 will not be able to call for help in case of emergency. The DON also confirmed the call device was also high and that it would be hard to reach without a string or if the resident was on the floor.During a review of the facility's policy and procedure (P&P) titled Call Lights, revised 2/2023, the P&P indicated, It is the policy of the Company to assure that residents always have a method of calling for assistance and that staff answers the residents' calls in a timely and professional manner.

Based on observation, interview, and record review, the facility failed to maintain a safe and secure storage of medications for two of 17 sampled residents (Resident 8 and Resident 20), for a census of 36 when:1a.Resident 8's unlabeled medication was left at bedside;1b.Resident 8's discontinued controlled medications were stored in the medication cart;2. Resident 20's expired medication was stored in the medication room; and,3. Two bottles of expired vitamins were stored in the medication room.These failures increased the potential for medications to be accessible to other residents, increased the potential for drug diversion, and administration of vitamins with decreased effectiveness. Findings: 1a. During a review of Resident 8's admission records, the records indicated Resident 8 was admitted in May 2025 with diagnoses that included displaced fracture of lateral malleolus of left fibula (a break in the small bone on the outside of the ankle joint), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and anxiety disorder (a condition characterized by excessive worry and fear that can interfere with daily life). Resident 8's Minimum Data Set (MDS, a federally mandated resident assessment tool) indicated Resident 8 had moderate cognitive impairment. During a concurrent observation and interview on 9/16/25 at 9:28 a.m. with Resident 8 in her room, an unlabeled medication cup containing white powder was observed on top of Resident 8's nightstand. Resident 8 stated, .that's the powder that goes under my breast for itching. During an observation on 9/16/25 at 2:41 p.m. in Resident 8's room, Resident 8 was observed alert, sitting in wheelchair, and reading newspaper. The unlabeled medication cup with white powder was still observed at bedside. During a concurrent observation and interview on 9/16/25 at 3:09 p.m. with the Infection Preventionist (IP) in Resident 8's room, the IP stated a resident can be allowed to keep medications at bedside if the physician assessed that the resident could self-administer the medication. The IP confirmed the observation of the unlabeled medication containing white powder on top of Resident 8's nightstand and stated, .it doesn't say what it is, and since it doesn't have label, we don't know when it was prepared. The IP further stated, .It [powder] should not be here.The roommate does have cognitive issues.We don't know if roommate will take it or mix it with fluids. During a review of the facility's policy and procedure (P&P) titled MEDICATION STORAGE IN THE FACILITY, revised 5/16/18, the P&P indicated, Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. Resident-specific medication supplies are accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. 1b. A review of the admission Record indicated Resident 8 was initially admitted [DATE] with diagnosis including low back pain and generalized muscle weakness. A review of Resident 8's discontinued medications indicated, the physician order for Tramadol (a controlled substance used to treat moderate to severe pain) HCL (hydrochloride) 50 mg (milligram, unit of measurement) 1 tab by mouth every 8 hours as needed for pain was discontinued on 2/10/25. During a concurrent interview and record review with the Director of Nursing on 9/17/28 at 12:08 p.m., the DON stated Resident 8's Tramadol order was discontinued sometime February and the two bubble packs, each bubble pack containing 28 pills were stored in the narcotic drawer along with the active controlled medications inside the medication cart. The DON further stated the medication bubble packs should have been given to the DON. A follow up interview with the DON was conducted on 9/18/25 at 8:58 a.m. The DON stated all discontinued medications should be taken out from the active supply to prevent medication errors. The DON further stated there is a potential for drug diversion when discontinued controlled medications are not removed from the medication cart. 2. During a concurrent observation and interview on 9/17/25 at 1:35 p.m. inside the medication room with the Director of Staff Development (DSD). Two bottles of Vitamin E softgels, each bottle containing 100 softgels with an expiration date of 8/31/25 were stored inside the medication room with other over the counter medications. The DSD confirmed the 2 bottles of Vitamin E were expired. 3. During a concurrent observation and interview on 9/17/25 at 1:54 p.m. inside the medication room with the DSD. A box of biotene mouth spray for Resident 20 with an expiration date of 8/27/25 was stored in the bottom drawer with other medications. The DSD confirmed the moisturizing spray was expired. In an interview on 9/19/25 at 7:37 a.m., the DON confirmed she was made aware of the expired medications and the DON stated this was unacceptable. The DON further stated the night shift nurse should be checking the medications in the medication room at least once a week. A review of the facility's P & P revised 1/1//23 and titled, Controlled Substance Storage indicated, Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, disposal, and recordkeeping in the facility .Controlled substance inventory is regularly reconciled to the Medication Administration Record (MAR) and Form: CONTROLLED SUBSTANCE RECORD .Completed accountability records are submitted to the director of nursing [sic] .Controlled substances remaining in the facility after the order has been discontinued .are retained in the facility in a securely locked area with restricted access until destroyed .Accountability records for discontinued controlled substances are maintained with the unused supply until it is destroyed or disposed of . A review of the facility's policy & procedure (P & P) revised 6/2024 and titled, Medication Administration: Disposition of Discontinued Medications indicated, It is the policy of the Company to manage the disposition, destruction and disposal of discontinued and/or out-of-date medications in accordance with the Federal and State regulations and in a manner that ensures maximum safety for residents .Discontinued medications include physician-ordered discontinued medications (prescription and/or over-the-counter (OTC) .expired medications and out-of-date house stock medications .Give the discontinued controlled medication or narcotic to Director of Nursing . A review of the facility's P & P revised 1/1/2023 and titled, Storage of Medications indicated, .Outdated .medications .are immediately removed from inventory, disposed of according to procedures for medication disposal .All expired medications will be removed from the active supply and destroyed in the facility .

Based on observation, interview and record review, the facility failed to store and prepare food in accordance with professional standards for food service safety for a census of 36 when: 1.Food items in the refrigerator were observed to be uncovered; and,2. Potentially hazardous food (food that requires time/temperature control for safety to limit the growth of organisms capable of causing a disease) had inaccurate labeling.These failures had the potential to result in foodborne illnesses. Findings: During a concurrent observation and interview, on 9/16/2025 at 8:18 a.m. of the walk-in refrigerator #8, with the Nutritional Services Supervisor (NSS), a large plastic bin of dark orange sauce was observed on the refrigerator shelf uncovered. The NSS confirmed all food items are to be covered. During a concurrent observation and interview, on 9/17/2025 at 9:33 a.m. of the walk-in refrigerator #8, with the NSS, a steel container of cooked lentils was observed on refrigerator shelf partially covered with plastic wrap. The NSS confirmed everything is to be covered. During a review of the facility's policy titled, Refrigerated Storage Standards, revised 5/03 indicated, Prepared Foods: Once foods are prepared, portioned and ready for service, caution should be taken to assure that they are stored properly to retain color, quality and moistness for eating.Covered foods.prevent items from falling into product. 2. During the dining observation on 9/16/25 at 12:23 p.m. in the dining hall, tuna salad was observed on a plastic container covered with a plastic sheet and was served for lunch. The label on the tuna salad indicated, .PREPARED: Tue [Tuesday] 09/16/25 1:27 PM. During a concurrent observation and interview on 9/16/25 at 12:26 p.m. with the Director of Dining Services (DDS) and the Nutrition Services Supervisor (NSS), the DDS and the NSS confirmed the tuna salad had an inaccurate label and that the preparation time was labeled in advance. The DDS stated, .That's interesting, maybe it's east coast [time].Tuna is good for four hours.If the tuna salad exceeded the four-hour danger zone, at that point, the food is on danger zone and potential for bacteria.The label is the basis when counting the danger zone time. During a follow-up observation and interview on 9/16/25 at 12:45 p.m. with the DDS and the NSS in the kitchen, the machine used to print labels indicated that the time was set at 2:46 p.m., which indicated the machine was set two hours ahead of the actual time. Three other label machines were inspected and all the machines indicated inaccurate times. The NSS stated that if the preparation time was not accurate, .we don't know the safe time zone, we don't know if it [food] is still good. During a review of the facility's policy and procedure (P&P) titled Data Code Genie (DCG) Food Labeling Standard, revised 4/2024, the P&P indicated, Food date marking should incorporate identified standards and criteria to ensure all food items are kept safe for consumption within a specific amount of time to minimize bacteria growth and spoilage. During a review of the facility's P&P titled General Food Storage Standards, revised 1/2023, the P&P indicated, .16. All potentially hazardous foods must be labeled with a date sticker as soon as the package is opened or the item is prepared.

Based on observation, interview, and record review, the facility failed to maintain and follow an effective infection prevention and control program for a census of 36 when:1.Resident 40's CPAP (continuous positive airway pressure- ensures uninterrupted breathing and oxygen) mask and distilled water used for the treatment were not properly stored;2. Staff did not consistently follow transmission-based precautions (TBP) for Resident 37;3. Resident 20's distilled water used for CPAP treatment was observed unlabeled and on the floor; 4. Dirty linens were observed on the floor of the laundry room; and5. The facility management was not informed of positive Legionella (a type of bacteria found in [NAME] that can cause a serious type of lung infection) testing results. These failures increased the potential for Resident 40 and Resident 20 to develop respiratory infections, and decreased the facility's potential in preventing transmission of diseases among residents and staff.Findings: 1. A review of the admission Record indicated Resident 40 was admitted [DATE] with diagnosis including Parkinson's disease (a brain disorder causing problems with movement and balance) with dyskinesia (involuntary, uncontrolled, & repetitive muscle movements) and obstructive sleep apnea (intermittent airflow blockage during sleep). A concurrent observation and interview was conducted on 9/16/25 at 9:41 a.m. inside Resident 40's room. Resident 40 confirmed the CPAP machine at bedside belonged to him. The CPAP mask was not covered and there was an opened, unlabeled 1 gallon container of distilled water on the floor. A follow up observation and interview was conducted on 9/16/25 at 10:43 a.m. inside Resident 40's room with Certified Nursing Assistant 2 (CNA 2). The CNA 2 stated when she came in this morning Resident 40 was off his CPAP. The CNA 2 further stated the CPAP mask should be inside the bag. The CNA 2 showed a black mesh bag located near the CPAP machine on top of the nightstand. The CNA 2 confirmed the container of distilled water was on the floor, opened and unlabeled, and used for Resident 40's CPAP. The CNA 2 stated the container of distilled water should be on the counter, inside the cabinet or on top of the nightstand. A review of Resident 40's physician orders on 9/16/25 did not include orders for CPAP mask cleaning. A concurrent interview and record review was conducted on 9/18/25 at 12:01 p.m. with the Director of Nursing (DON). The nurse surveyor showed the photos taken on 9/16/25 with the DON. When the DON saw the photos of Resident 40's CPAP mask and distilled water, the DON stated, that's an infection control issue. The DON further stated the CPAP mask should be inside the bag and the distilled water should have been dated and should not be on the floor. The DON stated the CPAP mask cleaning should have been placed on admission. The DON confirmed there was no documented evidence the CPAP mask was cleaned since admission. A review of the facility's policy and procedure revised 8/2024 and titled, Aerosol Generating Procedures (AGPs)- BIPAP [or bi-level positive airway pressure]/CPAP indicated, The purpose of this policy is to guide prevention of infection associated with respiratory treatment tasks and equipment .AGPs among ALL residents and staff .'CPAP', or continuous positive airway pressure, is a respiratory therapy intervention used to provide a patent airway during periods of sleep apnea. It uses air pressure generated by a machine, delivered through a tube into a mask that fits over the nose or mouth .Sterile distilled water used in respiratory treatments must be dated and initialed when opened .Clean reusable equipment with mild soap and water once treatment is completed . 2. A review of Resident 41's medical record indicated Resident 41 was admitted to the facility in September of 2025 with diagnoses of Malignant Neoplasm of Anus (Anal cancer), Enterocolitis due to Clostridium Difficile (c-diff; an inflammation of the small and large intestines caused by the bacterium Clostridium Difficile), and resistance to multiple antimicrobial drugs [a medication used to treat and prevent infections caused by microorganisms such as bacteria, viruses and fungi]. Resident 41's Minimum Data Set (MDS, a federally mandated resident assessment tool) indicated Resident 41 had no cognitive impairment. During an observation and interview on 9/16/25 at 3:30 p.m. with Resident 41 and Resident 41's family member, it was observed that Resident 41 had an isolation cart outside of her room, and signs labeled, Contact Precautions [transmission based precautions used to prevent the spread of infectious agents spread through contact] and Droplet Precautions [transmission based precautions used to prevent the spread of infectious agents spread through droplet; such as when coughing] taped to the wall next to the room entrance. Resident 41's room door was observed to be open. When asked about the reason for being on contact and droplet isolation, Resident 41 stated she is a cancer patient who has a cough and diarrhea. Per Resident 41's family member, .we were told that everyone who enters this room has to wear a gown, mask and wear gloves. you should not have washed your hands in her bathroom .staff told us that we have to wash our hands at the nurse's station. During an observation on 9/16/25 at 4:30 p.m., Licensed Nurse 4 (LN 4) was observed entering Resident 41's room and left the door open while providing care. During a follow up observation on 9/16/25 at 4:35 p.m., the door of Resident 41's room remained open. LN 4 was observed removing her PPE [personal protective equipment] in the room at the trashcan by the door. LN 4 was not observed washing her hands with soap and water after removing her PPE. LN 4 used hand sanitizer and walked down the hall to the nurse's station. During an interview on 9/16/25 at 4:40 p.m. with LN 4, LN 4 stated Resident 41 is on contact and isolation precautions due to having c-diff and a cough. LN 4 confirmed she did not wash her hands in Resident 41's room and that she washed her hands at the nurse's station after caring for Resident 41. During an interview and observation on 9/17/25 at 9:55 a.m. with Certified Nursing Assistant 3 (CNA 3), CNA 3 stated that Resident 41 is on contact and droplet precautions. CNA 3 confirmed the door to Resident 41 was open. During an observation on 9/17/25 at 10:00 a.m., a Housekeeper (HK) was observed in Resident 41's room. The door to Resident 41's room was left open while HK cleaned the room. The HK was observed removing PPE in the room, at the trashcan by the door, and left the room without washing her hands with soap and water. The door to Resident 41's room was left open. During an interview on 9/18/25 at 8:45 a.m. with Infection Preventionist (IP), the IP stated Resident 41 was on contact precautions due to a c-diff diagnosis. The IP stated Resident 41 was on droplet precautions due to . she also has MDRO [multidrug-resistant organism] in her respiratory track and has an active cough. IP confirmed that she educated staff to wash their hands in Resident 41's room after removing their PPE and to use a paper towel to turn off the water. IP stated that . because some of them don't feel comfortable with using her [Resident 41] bathroom because of the c-diff. they walk with their hands up so people know their hands are dirty and they will wash hands at the nursing station with soap and water. During an interview on 9/18/25 at 8:45 a.m. with the Director of Nursing (DON), the DON stated that her expectation for proper hand hygiene after taking care of a patient that is on contact precautions for c-diff is that they wash their hands with soap and water in the patient's room prior to exiting the room. The DON stated her expectation for someone who is on droplet precautions is that the door to their room be kept closed to prevent spread of the infection. A review of the facility Policy and Procedure (P&P) last revised 5/2023 titled Clostridioides Difficile Associated Disease, the P&P indicated in . When caring for residents with diarrhea or fecal incontinence, staff will maintain vigilant hand washing with soap and water, rather than alcohol-based hand rubs, for mechanical removal of Clostriduim difficle spores from hands. the Resident will have their hands washed thoroughly prior to leaving their room. Hand Hygiene is CRITICAL for staff and residents; (spores are NOT killed by hand sanitizers) . A review of the facility Policy and Procedure (P&P) last revised 7/2025 titled Infection Control Precautions- Categories of Transmission Based Precautions indicated, . Resident Placement During Droplet Precautions: Place the resident in a private room with the door closed . 3. During a review of Resident 20's admission records, the records indicated Resident 20 was admitted to the facility in August 2025 with diagnoses that included sleep related hypoventilation (breathing becomes abnormally slow or shallow during sleep), and sleep apnea (breathing repeatedly stops and starts). During a review of Resident 20's physician order, dated 8/30/25, the order indicated, CPAP: Apply at Factory setting 9mmH2O [millimeters of water, a unit of pressure measurement] with heated humidification [adding moisture to the air] at bedtime – remove in the morning. During an observation on 9/16/25 at 10:39 a.m. in Resident 20's room, two jugs of one-gallon distilled water were observed on the floor, one jug was closed, and the other one was observed opened, unlabeled and contained approximately 100ml (milliliters, a unit of measurement). During a concurrent observation and interview on 9/16/25 at 2:30 p.m. with Resident 20 in his room, the two jugs were still observed on the floor. Resident 20 stated, I use CPAP every night. The staff are putting the water on the CPAP. During a concurrent observation and interview on 9/16/25 at 3:42 p.m. with the Infection Preventionist (IP), the IP confirmed the observation of the two jugs on the floor and stated distilled water used for CPAP should not be on the floor because of the risk of contamination and spilling. During an interview on 9/18/25 at 2:48 p.m. with the Director of Nursing (DON), the DON stated, .For CPAP supplies, water should be labeled and dated, stored on the shelf, not on the floor. 4. During a concurrent observation and interview on 9/17/25 at 1:12 p.m. with the Environmental Services Manager (ESM) in the laundry room, two dirty linens were observed on the floor at the back of one of the washers. The ESM stated, I'm in the process of getting the washer fixed, water shoots up and spill on the floor, linens were used to not flood the room.It's been doing that for about a week. The ESM further stated the linens should have been picked up from the floor already and confirmed it was not sanitary. During an interview on 9/18/25 at 3:25 p.m. with the IP, photo of the linens on the floor was shown. The IP confirmed the linens on the floor were not sanitary and stated, .they [linens] are on the floor, it shouldn't be there, looking at the discoloration, that is a growth, it could be rusty or bacteria harboring. During a review of the facility's policy and procedure (P&P) titled Laundry & Linen, revised 4/2017, the P&P indicated, The purpose of this procedure is to provide a process for the safe and aseptic handling, washing, and storage of linen. During a review of the facility's P&P titled Laundry Services: Linens SNF [Skilled Nursing Facility], revised 11/2017, the P&P indicated, It is the policy of the Company to assure that laundry services are provided in a manner that meets State and Federal regulations, follow standard guidelines of Center for Disease Control and Prevention, and meets residents' needs.Linens are to be transported and stored by methods that ensure cleanliness, and protect from dust and soil during intra/inter-facility loading, transport, and unloading and to prevent the spread of infection and cross contamination. 5. During a review of the Legionella testing summary report provided by the facility, dated 5/1/25, the report indicated two of the three sampled sources tested positive for Legionella. The report indicated the Theoretical Detection Limit Legionella was 1 CFU/mL (colony forming units per milliliters, a unit of measurement), and the sample taken from PWH [Potable Water Hot] Healthcare HW [Hot water] Distal had a Total Legionella of 6 CFU/mL and the sample taken from PWH Healthcare HW Near, had a Total Legionella of 5 CFU/mL. During a review of the facility provided document titled Legionella Analytical, dated 2021, the document indicated, Analytical results are reported as colony forming units (CFU) of Legionella per milliliter of sample if Legionella are detected. According to OSHA [Occupational Safety and Health Administration] guidance for Legionellosis [type of pneumonia caused by Legionella].positive sampling results indicate that Legionella is growing in the sampled water system or part of the sampled water system.Analytical results are reported as Total Legionella, which includes all detected species.The presence of any species of Legionella warrants corrective action.when the bacterium is identified in a water system, the US-CDC (United States Centers for Disease Control and Prevention) recommends determining the source and cause for growth, and that corrective action be taken to remove the bacteria from the water, known as remediation.The decision to implement remedial action lie with the facility owner or the management team. During an interview on 9/18/25 at 3:25 p.m. with the IP, the IP stated the maintenance department monitored Legionella and that she did not review Legionella testing reports and stated, If anything comes up, they let us know. The IP stated there were no positive Legionella results reported to the facility. During an interview on 9/19/25 at 9:07 a.m. with the Facilities Operations Manager (FOM), the FOM confirmed two of three samples tested positive on 5/1/25 but unable to determine which site the positive samples were taken from. The FOM stated the company that did the testing recommended flushing the pipes and removing the water softener. The FOM was not able to provide documentation to confirm if recommendations were followed or corrective actions were taken. The FOM stated she believed that the previous maintenance director communicated the results to management. During an interview on 9/19/25 at 9:45 a.m. with the Administrator (ADM), the ADM stated the facility's Maintenance Director will inform the facility management if there were any positive Legionella results and stated, Anything that affects the SNF water, they need to communicate with me. The ADM confirmed that she was not notified of the positive results from 5/1/25 and stated, IP should be aware also of the positive result.That's something we need to report.Nothing was communicated during QAPI [Quality Assurance and Performance Improvement] meetings.They should report it to me so we can take actions and report to licensing and county. During a review of the facility's P&P titled Legionella/Legionnaires Disease, revised 7/2023, the P&P indicated, .Surveillance activities are part of the water management program established by facility services which includes logging data of each water source tested and results of those tests.When positive test results are discovered by facility services, the Executive Director, Health Care Administrator, the facility Medical Director and Infection Preventionist are to notified [sic].

Based on observation, interview, and record review, the facility failed to ensure one of 17 sampled residents (Resident 40) was treated with dignity and the right to privacy when Resident 40's urinary catheter drainage bag was not completely covered while in the dining room.This failure increased the potential for Resident 40 to experience emotional or psychological distress.A review of the admission Record indicated Resident 40 was admitted [DATE] with diagnosis including Parkinson's disease (a brain disorder causing problems with movement and balance) with dyskinesia (involuntary, uncontrolled, & repetitive muscle movements) and generalized muscle weakness. Further review of Resident 40's clinical records indicated the following information:- An Order Summary Report dated 9/9/25 indicated Urinary Catheter: Cover Urinary Drainage Bag for privacy every day and evening shift;- A care plan dated 9/10/25 indicated, [Resident 40] has Indwelling Suprapubic Catheter [a tube surgically placed in the lower abdomen into the bladder to drain urine continuously] R/T [related to] Obstructive & Reflux Uropathy [blockage in the urinary tract & urine flows backward]; and,- A Brief Interview for Mental Status (BIMS- an assessment tool used by facilities to screen, and identify memory, orientation, and judgement status of the resident) dated 9/10/25 indicated Resident 40 was cognitively intact. During a dining observation conducted on 9/16/25 at 12:40 p.m., Resident 40 was assisted by a staff member in the Dining Room. Resident 40 was in a wheelchair, and his urinary catheter bag had a blue material cover. The bottom portion of the catheter bag was visible. A concurrent observation and interview was conducted on 9/16/25 at 12:46 p.m. with Certified Nursing Assistant 2 (CNA 2). The CNA 2 stated the purpose of the blue material was to cover Resident 40's catheter bag. When CNA 2 checked Resident 40's catheter cover, the snap that kept the cover together was broken. The CNA 2 further stated the cover for Resident 40's catheter bag was broken and the whole drainage bag should be covered. A subsequent observation was conducted on 9/16/25 at 12:50 p.m. inside the dining room. The CNA 2 replaced Resident 40's catheter bag cover in the dining room without providing privacy. During a concurrent interview and record review with the Director of Nursing (DON) on 9/18/25 at 12 p.m. The nurse surveyor showed the photo of Resident 40's drainage bag taken on 9/16/25 and DON stated, It's not acceptable, it's a dignity issue. The DON stated Resident 40's broken drainage bag cover should have been replaced before resident was assisted in the dining room. A review of the facility's policy revised 8/2013 and titled, Privacy of Care indicated, It is the policy of the Company to treat all residents with dignity and respect and assure them of their basic resident's rights by providing adequate privacy . A review of the facility's undated document titled, NOTICE OF RESIDENT RIGHTS UNDER FEDERAL LAW indicated, As a resident at the skilled nursing facility .you have the following rights .The right to be treated with respect and dignity, and to be cared for in a manner and in an environment that promotes maintenance or enhancement of your quality of life .

Based on interview and record review, the facility failed to ensure the electronic record reflected the resident's treatment decisions for one of 17 sampled residents (Resident 2) when Resident 2's code status (a status indicating what should be done if the resident had no pulse and not breathing) was not indicated on the electronic medical record and was not available to staff, and had no physician order.This failure decreased the facility's potential to respond appropriately based on Resident 2's choices in the event of a medical emergency.Findings:During a review of Resident 2's admission records, the records indicated Resident 2 was admitted in [DATE] with diagnoses that included periprosthetic fracture (a fracture that occurs around or near an artificial joint), dementia (a progressive state of decline in mental abilities), anxiety (a condition characterized by excessive worry and fear that can interfere with daily life), Alzheimer's disease (a disease characterized by a progressive decline in mental abilities), and delirium (a serious disturbance in a person's mental abilities that results in a decreased awareness of one's environment and confused thinking). Resident 2's Minimum Data Set (MDS, a federally mandated resident assessment tool) indicated Resident 2 had moderate cognitive impairment.During a review of Resident 2's Physician Orders for Life-Sustaining Treatment (POLST - a form that contains written medical orders for healthcare professionals regarding specific medical treatments that can or cannot be done at the end-of-life care), dated [DATE], the POLST indicated Resident 2 was DNR (Do Not Attempt Resuscitation) and on Comfort-Focused Treatment (primary goal of maximizing comfort).During a review of Resident 2's electronic medical record, the record did not indicate Resident 2's DNR or comfort-focused care status. The record also did not contain a physician order for Resident 2's DNR status.During an interview on [DATE] at 8:10 a.m. with Licensed Nurse 2 (LN 2), LN 2 stated that in case of emergency, staff refer to the code status note on the resident's electronic chart and refer to the physician order. LN 2 further stated if code status was not available on either, staff needed to dig in more on the admission records, which cannot be done during an emergency situation. LN 2 added that the code status and physician order is important to make sure staff are aware of the resident's code status and will not provide CPR (cardiopulmonary resuscitation, an emergency procedure that combines chest compression and rescue breathing to restart a person's breathing and heartbeat) for residents on DNR, and full code (indicates that all life-saving measures, including CPR, should be used) residents received CPR during emergency situations.During a concurrent interview and record review on [DATE] at 8:30 a.m. with the Director of Nursing (DON), the DON stated that in cases of emergency, the code status of residents can be found in the code status note in the electronic medical chart. The DON also stated the record should have a physician order on the code status of the resident and stated, .important so the staff is aware on what to do during emergency, providing CPR to full code residents and not providing CPR for DNR residents. The DON further stated, .if there was no note and no physician order, we usually consider the resident as full code. The DON confirmed Resident 2's electronic medical record did not indicate Resident 2's code status and that there was no physician order for the code status. The DON further confirmed Resident 2's POLST indicated Resident 2 was DNR and stated, .the code status should have been entered upon admission. The DON stated Resident 2 could have received CPR if there was an emergency because the code status was not available for the staff.During a review of the facility's policy and procedure (P&P) titled Advance Directives, revised 5/2025, the P&P indicated, .3. If a resident has completed an updated Advance Directive or POLST, the Social Services Director or designee will document this in the Advance Directive section of the medical record and include a copy of the Advance Directive as well.4. If the resident or legal representative has executed one or more advance directive(s), these documents are obtained, incorporated and consistently maintained in the same section of the resident's health information record readily retrievable by any facility staff, and the facility will communicate the resident's wishes to the resident's direct care staff and physician.6. In the absence of an Advanced Directive or POLST or in the absence of a physician order consistent with the resident's wishes, the facility will proceed with full code measures.9. The Advanced Directive, related documents, and physician orders will be audited quarterly or upon significant change of condition by the Clinical Records Coordinator or designee to ensure the Electronic Health Record reflects the resident most recent wishes regarding resuscitation.

Based on observation, interview and record review, the facility failed to maintain acceptable parameters of nutritional status for one of 36 sampled residents, (Resident 32) when Resident 32's unplanned weight loss was not assessed and managed. This failure had the potential for Resident 32 to experience continued weight loss.Findings:A review of Resident 32's medical record indicated Resident 32 was admitted to the facility in the Spring of 2021 with diagnoses of Protein Calorie Malnutrition (lack of sufficient protein or calories), Chronic Kidney Disease and Acute on Chronic Heart Failure. Resident 32's Minimum Data Set (MDS, a federally mandated resident assessment tool) indicated Resident 32 had no cognitive impairment. During a medical record review, Resident 32's weights were as follows:9/13/25 weight 103.3 lbs9/12/25 weight 103.4 lbs9/11/25 weight 111.2 lbs The medical records indicated that Resident 32 had a 7.8 lb weight loss between 9/11/25 and 9/12/25. During an observation and interview on 9/18/25 at 10:20 a.m. with Resident 32, Resident 32 appeared thin and fragile. Resident 32 stated she had concerns with her weight loss. Resident 32 stated, I normally weigh around 115 pounds, but I started to lose weight. they gave me shakes but I have not had them in 2 weeks or so now.Based on The Center of Disease Control and Prevention (CDC) website (www.cdc.gov) dated 6/2024, a Body Mass Index (BMI) is based on mathematical formula that uses height and weight to estimate body fat and is used to categorize individuals into categories like underweight, healthy weight or overweight. During a review of Resident 32's medical record, Resident 32's weight and height record indicated Resident 32 measured 64 inches tall (5 feet and 3 inches) and on 9/12/25, weighed 103.4 pound(s) (lb/lbs). Per the recorded height and weight, Resident 32's Body Mass Index (BMI) is in the underweight category.During an interview and concurrent record review on 9/18/25 at 10:58 a.m. with Licensed Nurse 3 (LN 3), when asked what the policy and procedure is for managing weight loss for the residents in this facility, LN 3 stated, . I would notify the Dr [doctor], do a COC [change of condition assessment] and then tell the DON and RD [Registered Dietitian].we would offer snacks or shakes that are ordered. it should be in the Care Plan. we have to find the cause of the weight loss LN 3 was unable to find a COC or Care Plan in the electronic health record (EHR) for Resident 32's weight loss on 9/12/25. During an interview and concurrent record review on 9/18/25 at 11:30 a.m. with the Director of Nursing (DON), the DON reviewed the weights documented on 9/11/25 and 9/12/25 and stated, there was a .7.8-pound difference in one day. The DON further stated, That should have triggered a re-weigh and a COC . The DON was unable to find a re-weigh weight and/or a COC for this weight loss. The DON stated her expectation is . the CNA should have re-weighed the resident and the nurse should have completed a COC and notified me [DON]. if there was drastic weight loss, there are things we could have done in the meantime while waiting for that meeting with the RD.During a review of Resident 32's medical record, in a note titled, Weight Change Note on 6/5/25 the RD stated that, . Patient [Resident 32] has shown a 10.2 lb/8.7% weight loss in the past 6 months .Recommend addition of fortified meals for support of weight maintenance. Continue to monitor weight trend. During an interview and concurrent record review on 9/18/25 at 12 p.m. with the Registered Dietitian (RD), the RD stated, . Based on her height of 64 inches, her ideal body weight would be 120 pounds.she is now 104 pounds. based on her BMI, she is underweight. I did make recommendations that she be put on a fortified diet. she did have an order to give her shakes BID [2 times a day] . I am not sure why they stopped giving the shakes. When asked what diet Resident 32 is on, the RD stated that she had recommended a fortified diet due to her weight loss and stated, . She is on a Regular diet, minced and moist. I see that she is not currently on a fortified diet.I am not sure why they changed that either. The RD stated that, . weight loss contributes to an overall decline in health status. A review of the facility Policy and Procedure (P&P), last revised 4/2025, titled Change in Condition, the P&P indicated .the Licensed Nurses will assume the responsibility of making sure that any change in condition is brought to the attention of the Director of Nursing Services. The Licensed Nurses will notify the physician .and will document such notification in the health information record .the residents Care Plan will be reviewed and updated as needed to reflect the change of condition .A review of the facility Policy and Procedure (P&P), last revised 10/2023, titled Weight, the P&P indicated . It is the policy of the Company to weigh residents according to State and Federal guidelines with focus on measures to prevent unintended weight changes, promote good hydration and monitor for change in condition .Any significant weight variance .will require the designated staff member do a reweigh for that resident .If there continues to be a significant weight variance, the physician will be notified by licensed staff, RD or RCM/MDS Coordinator will be contacted to assess, and appropriate interventions instituted.

Based on observation, interview and record review, the facility failed to provide safety and supervision for one of three sampled residents (Resident 1), when the resident was left in the bathroom unattended and unsupervised during toileting. This failure could have contributed to Resident 1 ' s fall that resulted in right hip fracture. Findings: Resident 1 was admitted in the middle of 2021 with diagnoses which included left hip fracture, delirium, intermittent confusion and forgetfulness, dependent for all care, and at risk for falls, and was readmitted in early 2025 with diagnoses which included infection, pneumonia (lung infection) and altered mental status. During a review of Resident 1 ' s Fall Risk Evaluation (FRE), dated 2/5/25, the FRE indicated Resident 1 was disoriented at all times and was high risk for falls and fall prevention protocol should be initiated immediately. During a review of Resident 1 ' s Nursing Care Plan (NCP), dated 2/6/25, the NCP indicated, [Resident 1] is at risk for falls .will be free from avoidable falls, and to anticipate and meet the resident ' s needs. All staff will keep alert to resident ' s need for safety and will be vigilant and intervene as needed in situations that may precipitate a fall. During a review of Resident 1 ' s Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 2/11/25, the MDS indicated Resident 1 had severe memory impairment and needed assistance with activities of daily living (ADLs). During a review of Resident 1 ' s Nursing Progress Notes (NPN), dated 3/5/25, the NPN indicated, Fall evaluation: Date/Time of Fall: 03/04/2025 7:38 PM. Fall was not witnessed. Fall occurred in the bathroom. Activity at the time of fall: Res attempting to get up after toileting to ambulate .Did an injury occur as a result of the fall: Yes. Injury details: Severe pain to Rt [right] hip and leg involving transfer to ED [emergency department] . During a review of Resident 1 ' s Order Summary Report (OSR), dated 3/10/25, the OSR indicated, [Resident 1] does NOT have the capacity to make for decision making and consent. During a review of Resident 1's Hospital Discharge Summary Report (HDS) dated 3/10/25, the HDS indicated, [Resident 1] is a 98yr [year] old female who present to [hospital name] on 3/5/25 for: right femoral neck [hip] fracture after falling at SNF [skilled nursing facility] on 3/4/25. During a concurrent observation and interview on 3/12/25 at 10:33 a.m., Resident 1 sat in a wheelchair, alert and verbally responsive at the bedside with family member present. Resident 1 stated, My leg still trying to get it back together. When asked about the fall, the resident stated, I don ' t remember falling. I ' m getting confused with the time, you know, between our time and your time, and the [NAME] time. I guess the time changed. When asked if the fall was the first time for the resident, the resident stated, All the time. I don't think I have any proof of it. During an interview on 3/12/25 at 10:35 a.m. with Family Member 1 (FM 1), FM 1 stated, [Resident 1] had a fall four years ago at home. She broke her left hip, and this time that she fell on that bathroom, her right hip .She cannot be left alone .she's forgetful and she's a confused. During an interview on 3/12/25 at 10:38 a.m. with Resident 1 and FM 1, when asked what the year was, Resident 1 stated, Right now, yes. This year will be my 100th birthday. Right now, what year? Let me see if I have that right. Resident 1 could not recall the current year. When asked if the resident can go to the bathroom, the resident stated, I don ' t think that's fine. I need help .I go in, but I have to have somebody nearby . FM 1 stated, [Resident 1] cannot be left alone in the bathroom. She needs a lot of supervision. She is not able to stand up in the bathroom. During an interview on 3/12/25 at 10:45 a.m. with FM 1, FM 1 stated, My concern regarding the fall, I would prefer that even when [Resident 1] is in the bathroom that I don't care about privacy. I think it's more important to keep eyes open for her safety. I think there's a way to do that without closing the door .I think it's just to look there and supervise her all the time because of her confusion. She is going to be [AGE] years old in April, and I would prefer as always because we don ' t know if she's not going to necessarily know not to get up or trying to get up on her own. During an interview on 3/12/25 at 11:05 p.m. with Certified Nursing Assistant 2 (CNA 2), CNA 2 stated, [Resident 1] has dementia and she needs to be supervised for safety .If she is on the toilet, you're not supposed to leave or close the door or anything like that .when they are confused . During an interview on 3/12/25 at 11:08 a.m. with Licensed Nurse 1 (LN 1), LN 1 stated, [Resident 1] had a fall on the 4th [March, 2025]. [Resident 1] was unsupervised, and to be left at the bathroom, none of that should have happened. She is forgetful and confused .she has cognitive problems. During an interview on 3/12/25 at 11:18 a.m. with the Occupational Therapist (OT), the OT stated, [Resident 1] needs a lot of supervision in terms of activities of daily living .She is not safe being left alone. During an interview on 3/12/25 at 11:22 a.m. with the Social Services Coordinator (SSC), the SSC stated, [Resident 1] needs a lot of supervision. When asked if the resident was safe to be left alone in the bathroom, the SCC stated, I would say no, absolutely not. During an interview on 3/12/25 at 11:30 a.m. with the Activities Director (AD), the AD stated, Definitely, [Resident 1] has some confusion .I wouldn't say she would be safe going to the bathroom by herself. I think she definitely needed assistance with any activity, all the time. During an interview on 3/12/25 at 11:52 a.m. with the Physical Therapy Rehab Director (PTRD), the PTRD stated, [Resident 1] needed help all the time. She is not safe to be alone in the bathroom to do her activities or take a shower or toileting .She needed supervision every time with her toileting .somebody should be with her because of her mentation, and her aides usually stay with her for safety. During an interview on 3/12/25 at 12:31 p.m. with the MDS Coordinator (MDSC), the MDSC stated, [Resident 1] was confused at times and forgetful. She needed a lot of help and supervision .I don't think that she was safe being alone in the bathroom because of her confusion. During an interview on 3/12/25 at 2:15 p.m. with the Director of Nursing (DON), the DON stated, The CNAs should not leave their residents alone in the bathroom when they are confused. They should always be there when they are assisting the resident . During an interview on 3/12/25 at 1:55 a.m. with the Administrator (ADM), the ADM stated, I know that our staff are big into like respecting the residents ' wishes, but in this case, [Resident 1] is not oriented. She has dementia. [CNA 1] should have taken that into consideration. During a telephone interview on 3/13/25 at 9:28 a.m. with CNA 1, CNA 1 indicated she brought Resident 1 by wheelchair, assisted and transferred her to the toilet, and stated, I left the bathroom to give her privacy. CNA 1 stated, I heard the fall through the cracked door while waiting for her to use the call light. During a review of the facility ' s policy and procedure (P&P) titled Fall Reduction and Management Program Policy and Procedure, dated 10/2023, the P&P indicated, Evaluation should consider supervision that may be needed based on the individual resident ' s needs and risks. Considerations of special needs may include, but not limited to: a. Residents with cognitive impairment. b. Residents with recurrent falls. c. Toileting supervision: Whether resident needs direct supervision in the bathroom or whether resident can use bathroom call light independently and appropriately and staff can remain directly outside the bathroom if resident requests. d. unsafe behaviors. During a review of the facility ' s P&P titled Safe Environment/Accident P&P, the P&P indicated, All reasonable precautions will be taken by the facility to protect a resident from possible injury from dangerous conditions, falling .

Based on observation, interview, and record review, the facility failed to provide a safe environment with adequate supervision for one of three sampled residents (Resident 1), when Resident 1 eloped (left facility unsupervised and without prior authorization) from facility, fell , and then was moved after the fall before being assessed by a licensed nurse (LN). This failure resulted in Resident 1 experiencing a left orbital fracture (fracture of the bones of the eye socket) and contusion (bruise) of right lower leg and had the potential for further injury. Findings: A review of Resident 1's Admission Record indicated Resident 1 was admitted to the facility, initially, in April 2019 with multiple diagnoses including dementia (progressive state of decline in mental abilities), bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), and osteoporosis (weak and brittle bones due to lack of calcium and Vitamin D). A review of Resident 1's Minimum Data Set (MDS-a federally mandated resident assessment tool), Cognitive Patterns, dated 8/31/24, indicated Resident 1 had a Brief Interview for Mental Status (BIMS- an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score of 3 out of 15 which indicated Resident 1 had severe cognitive impairment. A review of Resident 1's MDS, Functional Abilities and Goals, dated 8/31/24, indicated Resident 1 required moderate assistance for bed mobility and supervision or contact guard assistance [hands on assistance to maintain balance] for transfers and walking. A review of Resident 1's order dated 5/25/24, indicated May have wander guard [wander management system using sensors to alert caregivers of elopement] attached to wheelchair to alert staff for attempt of exiting door unassisted . A review of Resident 1's Order Summary Report indicated order dated 10/19/24, Monitor left facial (eye) hematoma for s/sx [signs or symptoms] of worsening . A review of Resident 1's Order Summary Report indicated order dated 10/19/24, Staff to rounds and do visual checks on Resident every 30 minutes . A review of Resident 1's Order Summary Report indicated order dated 10/19/24, Behavior Monitoring: Attempts to exit facility without assistance. Record the # [number] of times behavior exhibited during shift . A review of Resident 1's Order Summary Report indicated order dated 10/21/24, Resident may have Wanderguard at all times. Check placement and functionality. Monitor and records [sic] of refusal to wear the wanderguard . A review of Resident 1's Wandering Risk Assessment, dated 7/11/24, indicated Resident 1 was a high risk for wandering. A review of Resident 1's SBAR [situation, background, assessment, recommendation-a communication tool used by healthcare workers when there is a change of condition in the resident] Communication Form, dated 8/31/24, indicated .change in condition: Elopement attempts .Reoriented . A review of Resident 1's SBAR Communication Form, dated 9/4/24, indicated .Falls .CNA [Certified Nursing Assistant] was passing by resident's room, heard loud noise coming from resident's room. CNA found resident lying on the floor by her dresser .c/o [complained of] L[left] side rib cage pain . A review of Resident 1's SBAR Communication Form, dated 10/18/24, indicated .Falls .CNA reported to this RN [Registered Nurse] resident was found outside down on the ground. Resident was last seen at approx [approximately] 0230 [2:30 a.m.] in her bed. She sat in her wheelchair at RN station .CNA cleaned her and placed her back into her bed . A review of Resident 1's Progress Notes, dated 10/18/24 at 8:17 a.m., indicated .Resident was sent out to [name of acute hospital] after an unwitnessed fall with left eye hematoma found down outside of facility. Resident was last seen approx 0230 [2:30 a.m.] during safety rounds. Unknown how long resident was outside of facility or how she exited . A review of Resident 1's Progress Notes, dated 10/18/24 at 6:31 p.m., indicated .Resident readmitted .following a fall, presenting with an orbital floor fracture on the left, subacute fractures of the left lateral ribs (6-8) . A review of Resident 1's Care Plan, initiated 8/16/23, revised 9/9/24, At risk for elopement as she is independent with ambulation. Refused to wear wanderguard and thinks she is a prisoner .Uses wheelchair at times. Resident can ambulate with FWW [Front Wheeled Walker] with supervision .impulsively ambulate without walker .has a hx [history] of wandering in the hallways .Goal .Resident will not have a serious injury from episodes of elopement until next review date .Target Date: 11/30/2024 .Interventions .Redirect as needed .Staff will offer assistance and redirect .back for safety . Date Initiated : 07/11/2024 .Redirect resident if she is trying to walk out of the unit .Date Initiated: 08/18/2023 . has a wanderguard on the bottom part of w/c [wheelchair]. Agreed to used necklace wanderguard but often takes it off. She also has a wanderguard on the FWW. Monitor episodes of removing .Date Initiated: 10/20/2024 . A review of Resident 1's Emergency Department After Visit Summary, dated 10/18/24, indicated .Reason for Visit Fall Diagnoses .Closed fracture of left orbital floor .Contusion of right lower leg .Unwitnessed fall . CT [computed tomography scan- a type of imaging study] Maxillofacial [relating to the jaws and face] .Impression .There is a fracture involving the left inferior orbital wall, with notable involvement of the infraorbital foramen [small opening in the upper jawbone] .The fracture lines extend along the superior wall of the maxillary sinus [cavities in bones in the cheeks] . During an interview on 10/25/24 at 10:22 a.m. with the Director of Nursing (DON), the DON stated Resident 1 walked out of the building on 10/18/24 at approximately 5:00 a.m. without her walker and CNA found her outside. Resident 1 was found sitting on the ground with bruise to left eye. Resident 1 walked back to the nurse's station with the CNA. The DON stated Resident 1 did not have wanderguard on at the time of the elopement and fall. The wanderguard was on Resident 1's wheelchair. The DON stated the wanderguard was initially ordered on 4/5/23 for the wheelchair then tried wanderguard to the ankle on 5/13/23, but Resident 1 would not tolerate it. The DON stated have tried in the past to have Resident 1 use a wanderguard on her person, including ankle and wrist, but Resident 1 was able to remove it. Resident 1 was sent to the emergency department on 10/18/24 and had left orbital fracture and possible rib fractures. The DON acknowledged that Resident 1 had fallen in the past including on 9/4/24 and frequently wandered in the building. During a concurrent observation and interview on 10/25/24 at 10:49 a.m. with Resident 1, observed Resident 1 in bed with blankets covering her chest up to her neck. Observed large purple discoloration over outer left eye. Observed wanderguard sensors on wheelchair and walker at bedside. Resident 1 stated she did not remember fall and did not want to talk. During a telephone interview on 10/25/24 at 11:19 a.m. with CNA 1, CNA 1 stated CNA 2 saw Resident 1 outside through the window when she was assisting a resident in another room. CNA 2 notified CNA 1 that Resident 1 was outside. CNA 1 stated she panicked and attempted to locate the LN to notify her but was not able to find her. CNA 2 went outside to get Resident 1. CNA 2 brought Resident 1 back into the building prior to the LN assessing Resident 1. CNA 1 stated Resident 1 was cold, bruised, and had blood on her face. CNA 1 stated they were short staffed that night. Usually have 3 CNAs with 12 residents each, but that night only had 2 CNAs with 18 residents each. CNA 1 stated normally do rounds on residents every two hours but since short staffed it was difficult to get to everybody. CNA 1 stated the CNAs were busy doing rounds and did not know when Resident 1 left the building. CNA 1 stated she last saw Resident 1 in bed, sleeping, around 3:00 a.m. CNA 1 stated Resident 1 was not stable on her feet and should use the wheelchair or walker, but would get up on her own without using the call light. CNA 1 stated Resident 1 takes her wanderguard off. During an interview on 10/25/24 at 11:38 a.m. with the DON, the DON stated CNA should not have gotten resident up before nurse assessed. Trained to not pick up resident. Did not wait for the nurse. The DON stated the CNA may have panicked and decided on her own to pick up resident. The DON acknowledged that the LN did not go outside to assess Resident 1. The DON stated, The nurse just started at the facility. The DON acknowledged that usually there are 3 CNAs working the night shift, but that night between 2:00 a.m. and after 5:00 a.m. there were only 2 CNAs working. During a telephone interview on 10/25/24 at 12:27 p.m. with CNA 2, CNA 2 stated she was with a resident in another room and saw through the window Resident 1 outside sitting on the ground. CNA 2 stated she notified CNA 1 who looked for the nurse. CNA 2 went outside to Resident 1. CNA 2 stated she helped Resident 1 to stand up and walked her back into the building. CNA 2 stated she brought Resident 1 to the nurse's station and asked a housekeeper to watch her while she went to get a wheelchair. CNA 2 and a CNA who arrived for day shift assisted Resident 1 to bed. The LN came to Resident 1's room after she was in bed. CNA 2 stated the day shift nurse came, assessed the resident, and called an ambulance. When asked about policy for CNAs getting residents up after falls, CNA 2 stated, Not supposed to get them up until nurse has assessed. Couldn't find her [nurse]. It was really cold that day. She did not have shoes on. Got her up and back into the building. CNA 2 stated Resident 1 takes off the wanderguard. CNA 2 stated Resident 1 gets up on her own, is really quick, and does not use her call light. During an interview on 10/25/24 at 1:15 p.m. with LN 1, LN 1 stated if resident falls, should assess for injuries before moving resident. LN 1 stated if a CNA finds a resident who has fallen, the CNA must notify the nurse before moving resident. During a telephone interview on 10/25/24 at 1:59 p.m. with LN 2, LN 2 stated on 10/18/24 at approximately 5:20 a.m. she was notified by two CNAs that Resident 1 was found outside and one of the CNAs had walked Resident 1 back into the building. LN 2 stated the CNA was concerned that Resident 1 was outside in the cold. LN 2 observed Resident 1 in the wheelchair at the nurse's station. LN 2 stated, CNAs should contact nurse before moving resident. CNAs should have contacted me first, absolutely. LN 2 stated 'Resident 1's left eye was swollen and bruised and when she asked Resident 1 if she had any pain, Resident 1 pointed to her left eye. LN 2 stated Resident 1 had wanderguard on earlier in the night, but not at the time she left the building. When LN 2 was asked how staff know wanderguard was working, LN 2 stated, I don't know. Just make sure it is in place. Never assessed for wanderguard prior to this incident. Now document wanderguard in place and behaviors. LN 2 stated Resident 1 gets up independently. LN 2 stated only had 2 CNAs on that night and that may have contributed to the elopement incident because they had limited frequency to check on residents. During a concurrent interview and policy review on 10/25/24 at 3:22 p.m. with the DON, the DON acknowledged that the facility policy titled Fall Reduction and Management Program-SNF [skilled nursing facility] indicated resident will not be moved until directed by the LN. The DON stated, Have told CNAs not to move residents until nurse assessed. Could have back injury. The DON acknowledged that only 2 CNAs were working at the time of the incident instead of the usual 3 CNAs. The DON stated Resident 1 slipped by the staff that night. When asked if having 3 CNAs that night would have prevented Resident 1's elopement and fall, the DON stated, If extra eyes, maybe would not have occurred. Staff is so busy all the time. The DON stated Resident 1's wanderguard is now being checked since the incident but was not being checked prior to this incident. The DON stated there was no wanderguard charting prior to the new order on 10/21/24 and was not being monitored prior. During a telephone interview on 10/25/24 at 5:14 p.m. with LN 3, LN 3 stated she arrived at facility after Resident 1's elopement and fall at approximately 6:00 a.m. LN 3 stated Resident 1 was in bed, and she assisted LN 2 who was new to the facility. LN 3 stated she assessed Resident 1 and observed Resident 1's left eye was bruised. LN 3 stated she saw Resident 1's wanderguard necklace on the dresser when she arrived in the room and was told Resident 1 had removed the wanderguard and was not wearing it when she left the building. LN 3 stated if a resident has fallen the CNA needs to contact the nurse before the resident is moved. LN 3 stated, CNAs are not supposed to move residents before the nurse assesses the resident. A review of the facility's Policy and Procedure (P&P) titled Elopement and Hazardous Wandering, revised 6/22, indicated .Hazardous or unsafe wandering .by a resident who may be oblivious to his or her physical or safety needs and the wandering places the resident at significant risk of getting to a dangerous place (e.g. wandering outside .) or encountering a dangerous situation .Elopement is a situation in which a resident with impaired cognition an/or demonstrated lack of safety awareness or judgment successfully leaves the organization or a secured area, .undetected or unsupervised by staff .It is the policy of the Company to be responsible for maintaining a system that provides protection for those residents who are at risk for elopement The facility will put measures in place to minimize the risk of elopement Individualized interventions may include .Accounting for residents at risk for elopement every 30 minutes .Use of resident safety alarms .In the event of a resident elopement from the facility: .If the individual is found, nurse to assess for any injuries and necessary treatment . A review of the facility's P&P titled Safe Environment/Accident Prevention, revised 11/16, indicated .All reasonable precautions will be taken by the facility to protect a resident from possible injury from dangerous conditions, falling, wandering .Monitoring of all accidents and incidents will be completed with follow up recommendations to prevent further occurrence by the Director of Nursing or designee . A review of the facility's P&P titled Fall Reduction and Management Program- SNF, revised 10/23, indicated .It is the policy of the Facility that every effort be made to reduce and/or prevent falls from occurring and/or minimize serious injury if fall should happen .The Licensed Nurse will: .Evaluate each resident's need for supervision, the resident environment, and assistive devices to avoid a fall .Considerations of special needs may include .Residents with cognitive impairment .Residents with recurrent falls .unsafe behaviors .Response to a fall .When a fall occurs, the fall will be immediately reported to the Licensed Nurse .The resident who fell will not be left alone, if possible, and will not be moved unless directed to do so by the Licensed Nurse .Licensed Nurse will complete a full body check to assess for injury and proceed accordingly to treat and/or protect, and keep the resident safe . A review of the facility's P&P titled Wandering Resident Management : Wanderguard, revised 3/15, indicated .Facilities will provide devices to assist in monitoring the whereabouts of wandering residents and prevention of elopement from the facility .If it is determined he/she is at risk for unsafe wandering/elopement, a Wanderguard Bracelet will be placed on the resident .If the resident will not keep the bracelet on wrist/ankle, place it either on the resident's walker, wheelchair or personal clothing .Staff will monitor the Wanderguard for proper placement and function every shift and will be documented on the MAR [Medication Administration Record] or TAR [Treatment Administration Record] .At each change of shift, the whereabouts of all residents shall be determined. During rounds, CNA will verify the location of each of their residents .

Based on observation, interview, and record review, the facility failed to ensure there was safe and accurate provision of pharmaceutical services, for four of 13 sampled residents (Resident 89, Resident 5, Resident 23 and Resident 31) when: 1. Resident 89's medication was not available for administration as scheduled; 2. Resident 5's order for bladder treatment was not followed as ordered; and 3. There was no accurate accountability of controlled medications (high potential for abuse or addiction) for two of four residents (Resident 23 and Resident 31). These failures increased the potential for Resident 89 and Resident 5 to have unresolved symptoms and the potential for abuse, misuse, and diversion of controlled medications. Findings: 1. A review of the ADMISSION RECORD indicated Resident 89 was admitted with diagnoses including urinary tract infection (bladder infection) and Benign Prostatic Hyperplasia (enlarged prostate gland [located below the bladder in men, surrounds the tube that empties the bladder]) with lower urinary tract symptoms. A review of the Order Summary Report indicated an order dated 6/5/24 for Oxybutynin (medication to treat problem with bladder function) ER (extended release) 5 mg (milligram, unit of measurement) 1 tablet two times a day related to Benign Prostatic Hyperplasia with lower urinary tract symptoms. During a medication pass observation conducted on 6/12/24 starting at 8:07 a.m., with the Licensed Nurse 1 (LN 1). The LN 1 stated Resident 89 had no supply of oxybutynin in the medication cart. The LN 1 further stated she ordered the medication from the pharmacy yesterday (6/11/24). In an interview on 6/12/24 starting at 3:58 p.m., the Director of Nursing (DON) stated her expectation was for the licensed staff to reorder the medications 9 days before the medication runs out and not to wait for the last day to reorder medications. A review of the facility policy revised 01/2020 and titled Medication and Treatment Administration indicated, .Medications and treatments shall be administered as prescribed. 2. A review of the ADMISSION RECORD indicated Resident 5 was admitted with diagnoses that included a history of urinary tract infection (bladder infection) and neuromuscular dysfunction of the bladder (lacks bladder control due to brain, spinal cord or nerve problems). A review of the Order Summary Report as of 6/1/24 indicated a physician order dated 6/27/23 for Gentamicin sulfate injection solution 40 mg (milligram, unit of measurement)/ml (millimeter). The instruction indicated Use 60 ml via irrigation one time a day for bladder treatment Inject 4 ml (120 mg) into 250 ml of Normal Saline. Then using a catheter tip syringe, inject 60 ml into bladder. Clamp tube for 1 hour, then connect back to bag for drainage. A concurrent observation and interview were conducted on 6/12/24 starting at 11:11 a.m., with the Resident Care Manager (RCM) in the medication room. Inside the refrigerator, there was an opened bottle of 500 ml of sterile water (not normal saline as ordered). The sterile water bottle was labeled 6/9/24 mixed with Gentamicin (antibiotic used to treat bladder infection). The RCM stated this bottle was used for Resident 5. The LN further stated she was informed the pharmacy sent the 500 ml of sterile water and the night shift doubled the dose since the Gentamicin was mixed with 500 ml of sterile water. Further review was conducted with the RCM on 6/12/24 at 11:30 a.m. The RCM confirmed Resident 5's Gentamicin order indicated 250 ml of normal saline and the facility stock was 500 ml of sterile water. The RCM further confirmed the opened bottle of sterile water mixed with Gentamicin did not have Resident 5's name and the amount of Gentamicin mixed in the solution was not indicated. In an interview on 6/12/24 at 3:58 p.m., the DON stated the opened bottle of sterile water with Gentamicin was used for Resident 5's suprapubic catheter (a urinary catheter inserted through a hole in the abdomen then directly into the bladder) flush. The DON further stated I don't think so when she was asked if the solution was properly labeled and if [they] were following the physician's order. A review of the facility policy revised 01/2020 and titled Medication and Treatment Administration indicated, .Medications and treatments shall be administered as prescribed. 3. A review of Resident 23's physician order dated 2/21/24 indicated the following orders: - Oxycodone HCl [hydrochloride] (medication used to treat moderate to severe pain) 5 milligrams (mg, unit of measurement), give 0.5 (2.5 mg) tablet every 6 hours as needed for moderate pain; and - Oxycodone HCl 5 mg, 1 tablet every 6 hours as needed for severe pain. Resident 23's Controlled Drug Record (CDR) indicated the Oxycodone 5 mg (0.5 or 2.5 mg) was signed out for Resident 23 on 2/28/24 at 2240 [10:40 p.m.]. The Medication Administration Record (MAR) did not indicate the Oxycodone was administered to Resident 23 on this date and time. In a concurrent interview and record review on 6/13/24 at 3:13 p.m., the DON confirmed the finding. The DON stated the licensed nurse probably forgot to document the Tramadol in the MAR for Resident 23 on 2/28/24. A review of Resident 31's physician order dated 5/6/24 indicated Tramadol HCl 50 mg, give 1 tablet every 4 hours as needed for moderate to severe pain. Resident 31's CDR indicated the Tramadol was signed out on 5/16/24 at 2345 [11:45 p.m.]. The MAR did not indicate the Tramadol was administered to Resident 31 on this time and date. A review of Resident 31's progress notes dated 5/17/24 indicated, At midnight resident c/o [complained of] back/legs pain, Tramadol ofered, [sic] refused . resident wants more pain medication but refused Tramadol . There was no documented evidence the Tramadol signed out for Resident 31 on 5/16/24 was discarded. In an interview on 6/13/24 at 3:57 p.m., LN 4 stated when a controlled medication was taken out for administration, the LN 4 should have signed out on both the CDR and the MAR. In a concurrent interview and record review on 6/13/24 at 5:01 p.m., the DON confirmed the finding for Resident 31. The DON stated there was a progress note dated 5/17/24 regarding Resident 31's refusal to take Tramadol. The DON further stated if Resident 31 refused the Tramadol, the medication should be wasted with another nurse. The DON stated her expectation was for licensed nurses to document controlled medication administration both in the CDR and the MAR. A review of the facility policy revised 02/2024 and titled Medication Administration: Controlled Drugs Record Keeping - SNF indicated, It is the policy of the Company to maintain controlled drug audit forms for all controlled drugs according to state regulations .When a controlled medication is administered to a resident, the person administering the medication must record on the narcotic record form or narcotic record book: the date, the time, the amount administered, the amount remaining, and sign the sheet. A review of the facility policy revised 06/2024 and titled, Medication Administration: Disposition of Discontinued Medications indicated, . In instances when a controlled medication/narcotic is refused . It must be wasted and destroyed by two (2) licensed nurses as allowed by state.

Based on observation, interview, and record review, the facility failed to ensure drugs and supplies were stored and labeled in accordance with current acceptable professional standards, for a census of 36, when: 1. A medication container labeled Gabapentin (medication used to treat seizures and pain) was in the medication room on the countertop; 2. An opened bottle of sterile water with Gentamicin (antibiotic used to treat bladder infection) was stored in the refrigerator without a resident's name; 3. There was incomplete documentation of room temperature in the medication room; 4. The discontinued non controlled medications were stored in usable form; 5. There were expired supplies in the medication room; and, 6. An opened bottle of mineral oil was in the medication cart unlabeled with resident name or date. These failures increased the risk for unsafe administration and storage of medications, and potentially increase loss or diversion of medications. Findings: 1. A concurrent observation and interview was conducted with the Resident Care Manager (RCM) on [DATE] at approximately 11 a.m. inside the medication room. There was a plastic bag on the countertop and inside the bag was a medication container labeled Gabapentin. The RCM confirmed the finding and stated the container was taken out from the automated medication dispensing machine (ADM, a computer-controlled machine that functions to store, dispense, and track medications). The RCM stated they leave the medication inside the medication room until it was picked up by pharmacy. In a telephone interview on [DATE] at 11:11 a.m., LN 5 explained the process of restocking medication in the ADM. LN 5 stated when a new medication container was delivered and was scanned in the ADM, the drawer will open. Once the drawer was opened, the LN 5 will remove the old container and replace it with the new container delivered by the pharmacy. The LN 5 further stated her practice was to put the old container inside the non-resealable bag used by the pharmacy to deliver the new container and the LN 5 will put a note outside the bag to please return. There was no designated area in the medication room to store the old container taken out from the ADM. In an interview on [DATE] at 11:24 a.m., the DON agreed there should be a separate area to store the old medication container taken out from the ADM until the container was picked up by the pharmacy. A review of the facility policy revised ,d+[DATE] and titled, CUBIX - SNF Facility Process indicated, It is the policy of the company to utilize the CUBEX station as needed for medication dispensing . Remove cubies (a container of medication in Cubex, double locked) that have popped out during restock and place in tote for return to the pharmacy. Seal the tote once all cubies are restocked for return to pharmacy. 2. In a concurrent observation and interview on [DATE] starting at 11:11 a.m., there was an opened bottle of 500 ml (milliliter, unit of measurement) of sterile water inside the refrigerator. The sterile water bottle was labeled [DATE] mixed with Gentamicin (antibiotic used to treat bladder infection). The RCM stated this bottle was used for Resident 5. In an interview on [DATE] at 3:58 p.m., the DON stated the opened bottle of sterile water with Gentamicin was used for Resident 5's suprapubic catheter (a urinary catheter inserted through a hole in the abdomen then directly into the bladder) flush. The DON further stated I don't think so when she was asked if the solution was properly labeled. A review of a policy revised [DATE] and titled, Medication Storage in the Facility, indicated, .Refrigerated medications are kept in . labeled containers . 3. In a concurrent record review and interview on [DATE] at approximately 11:20 a.m., the room temperature log had missing documentation. The room temperature for today ([DATE]) was not documented, there were 18 days of undocumented room temperatures for [DATE] and 5 days of undocumented room temperatures for [DATE]. The RCMP confirmed the findings and stated the room temperature log was completed by morning shift. In an interview on [DATE] at 3:58 p.m., the DON stated her expectation was for the room temperature to be checked and logged daily. A review of the facility policy revised ,d+[DATE] and titled, CUBIX - SNF Facility Process indicated, It is the policy of the company to utilize the CUBEX station as needed for medication dispensing . Room temperature shall be maintained between 68 degrees to 77 degrees Fahrenheit to maintain the integrity of the medications . A temperature log should be maintained in the vicinity of the CUBEX machine. A review of a policy revised [DATE] and titled, Medication Storage in the Facility, indicated, .The facility should maintain a temperature log in the storage area to record temperatures at least once a day. 4. In a concurrent observation and interview on [DATE] at 11:35 a.m., the RCM confirmed there were loose pills, cream, ointments inside a large blue top container and the medications were retrievable. The contents of the ointments and creams were not pushed out of their containers. The RCM stated these were discontinued noncontrolled medications. In a follow up interview on [DATE] at approximately 11:47 a.m., the RCM stated this was not an effective way of ensuring medications were not retrievable. The RCM further stated the 'drug buster' (neutralize the active ingredients in pills preventing misuse, abuse and contamination) should be poured when there were loose pills. In an interview on [DATE] at 3:58 p.m., the DON stated there was a potential for the loose pills to be taken out from the container and can be potentially diverted. The DON further stated a drug buster should be used to solidify the medications for destruction. The DON confirmed they used the wrong container, and it cannot be locked. A review of the facility policy revised ,d+[DATE] and titled, Medication Administration: Disposition of Discontinued Medications indicated, .Discontinued medications . Destroyed in the facility . The person in charge of destroying the medications is to dispose of them as follows: . Pills, tablets, liquids, creams .etc., are to be pushed out of their unit dose package or container and poured/emptied directly into a sharp container identified for this purpose OR medication wastes container. 5. In a concurrent observation and interview on [DATE] at 11:47 a.m., there were 8 pieces of expired needleless connectors (designed to provide safe, needle-free connection at the end of vascular catheter [inserted into a vein to provide access to the bloodstream] mixed with other supplies. The RCM confirmed the finding and stated everybody was responsible in making sure there was no expired supplies in the medication room. The RCM further stated there was risk for infection if the connector was expired and it potentially will not work properly. In an interview on [DATE] at 3:58 p.m., the DON stated expired supplies should be taken out from the medication room and should be replaced. 6. In a concurrent observation and interview on [DATE] at 3:44 p.m., there was an opened bottle of mineral oil, approximately ,d+[DATE] full, on the bottom drawer of medication cart B with no resident name on the label. The LN 2 confirmed the bottle was unlabeled and the LN 2 had no idea which resident it belonged to. In an interview on [DATE] at 7:56 a.m., the DON stated LN 2 told her about the unlabeled mineral oil on the bottom drawer of the medication cart. The DON confirmed the bottle was unlabeled. The DON stated she had no idea who used the mineral oil. The DON further stated the bottle can be stored in the medication cart provided it was labeled. A review of the facility policy revised ,d+[DATE] and titled, CUBIX - SNF Facility Process indicated, It is the policy of the company to utilize the CUBEX station as needed for medication dispensing . Room temperature shall be maintained between 68 degrees to 77 degrees Fahrenheit to maintain the integrity of the medications . A temperature log should be maintained in the vicinity of the CUBEX machine . Remove cubies (a container of medication in Cubex, double locked) that have popped out during restock and place in tote for return to the pharmacy. Seal the tote once all cubies are restocked for return to pharmacy.

Based on observation, interview and record review, the facility failed to ensure recipes were used and followed during meal preparation when: 1. The Beef Fajitas were prepared without following the recipe with measured ingredients, and 2. The Beef Fajitas were not served according to portion sizes. This failure had the potential to alter the nutritional value of the meals and to affect the health status of the 36 residents receiving food from the kitchen. Findings: 1. During an observation and interviews on a return visit to the kitchen on 6/12/24 at 9:35 a.m., the Lead [NAME] (LC) was preparing the lunch meal. The lunch meal included: Beef Fajitas, Chicken Salad on Croissant, Grilled Chayote Squash, Jicama Mango Slaw, Sweet Pepper Black beans, Quinoa Pilaf, and Sugar Cookie. The LC stated she was cooking the Beef Fajitas. She stated she was cooking for about 50 servings- 36 for Skilled Nursing and 11 for memory care unit. The LC was asked for the Beef Fajitas recipe as recipes where not seen in the food preparation area. The LC then pulled a folder with recipes and showed the recipe for the Beef Fajitas. Cut beef slices and cut vegetables (onions, red and green peppers) were observed in separate stainless food containers. When asked, the LC was not able to say how many pounds of beef and vegetables were in the stainless food container. The LC then started sauteing half portion of the sliced beef with unmeasured amount of oil on the griddle then she added 5 finger pinches of mixed red, white, and brown powder. The LC stated it's a mixture of cumin, chili powder, salt, and pepper. When asked about how much seasoning powder she added on the beef, she stated, not too much because you don't want too much. The LC then added 3 handfuls of mixed vegetables (onions, red and green peppers). She then stirred and cooked the beef with vegetables for about 15 minutes and transferred to the metal serving bin. She stated, she will cook the remaining beef and vegetables later and that she is cooking by batch. She then stated she has enough beef for both memory care and skilled nursing. A review of facility provided Beef Fajitas recipe (Meal Tracker Recipe- Number: 301531) indicated the following ingredients for 50 servings: Beef, Roast, inside round, raw - 9 1/2 lbs. (lbs., pounds, unit of measurement) Green Bell Peppers- 6 1/4 lbs. Onions, Raw- 1 2/3 lbs. Cheese, Cheddar, Shredded- 3 lbs. Tomatoes, Fresh - 7 lbs. Lettuce, Fresh, Head - 5 lbs. Tortillas, Flour, 8 - 50 ea. (each) The recipe did not indicate seasonings in the list of ingredients. During a follow up interview on 6/12/24 at 10:15 a.m., the LC verified the recipe did not indicate that seasoning should be added to the Beef Fajitas. The LC stated, if we don't put the seasoning then the residents will complain that it does not taste good. During a telephone interview on 6/12/24 at 4:10 p.m., the Corporate Registered Dietitian (CRD) stated, he expected the staff to follow the recipe for the number of portions they are cooking. He stated, he also expected the staff to follow the recipe when seasoning the food. A review of facility policy titled, Dietary Services: Dining, revised 1/2020, indicated, It is the policy of the Company that residents will receive well-balanced, nourishing, and palatable meals .that meet their nutritional and special dietary needs . A review of facility policy titled, Cycle Menu Production, revised, 10/2022, indicated, Foods will be prepared to meet the nutritional and therapeutic needs of the residents .3. Food is prepared to conserve nutritional value . 2. During a dining observation on 6/12/24 at 12:15 p.m., the Lead Nutritional Aide (LNA) was observed serving Beef Fajitas on tortillas with chopped tomatoes and lettuce without cheese. The LNA used a gray scoop for the beef, blue scoop for the chopped tomatoes and a metal tong for the lettuce. She stated, the gray scoop was number 4 which means half a cup of beef, the blue scoop was a quarter cup for tomatoes and just a sprinkle of lettuce using the tongs. The LNA verified, they did not put cheese on the Beef Fajitas served. She stated, if the recipe doesn't call for cheese, then we don't put but if recipes call for it then there should be cheese. The chef would have prepared the cheese if those were needed. There was no guide for scoop sizes and disher (used to measure portions) sizes observed in the dining room. A review of facility provided Beef Fajitas recipe (MealTracker Recipe- Number: 301531) indicated, Procedures: .Fill each tortilla with #16 scoop of meat mixture, #30 scoop of cheese, #8 scoop of lettuce and #16 scoop of tomatoes. A review of facility provided Disher Sizes indicated, #16 scoop (for meat mixture and tomatoes) was royal blue colored scoop and was approx. 1/4 cup, the #30 scoop (for cheese) was black colored scoop and was approx.2 1/4 tablespoons, #8 scoop (for lettuce) was gray colored scoop and was approx. 1/2 cup. During a telephone interview on 6/12/24 at 4:10 p.m., the CRD stated, the kitchen staff should be using the tools and servings size guide to communicate the serving sizes and it should be posted to somewhere to guide them. He stated, he expected the staff to use the correct utensils for each item being served. The CRD stated, it is important to follow the serving sizes in the recipe because it ensures that we are providing the residents with the nutrition they need. During a concurrent observation and interview on 6/13/24 at 3:20 p.m., in the kitchen food preparation area, with the Executive Chef (EC), he stated they don't' have the disher sizes guide posted anywhere in the kitchen and he does not know if they have it posted in the skilled nursing dining room. A review of facility policy titled, Cycle Menu Production, revised, 10/2022, indicated, 2. Standard size portions are established by the Executive Chef, Food Service Manager .This information is to be posted in the food preparation area and followed by staff members plating meals .

Based on observation, interview, and record review, the facility failed to store and prepare foods according to professional standards for food safety when: 1. opened food products were not labeled/ dated; 2. food products past the best by dates were not discarded; 3. white and grayish powder accumulation and an unknown liquid was found on the lid of food bins; 4. floor in dry storage room found with onion peels; 5. steak knife was found in the dry storage room; 6. a small potato was found in the pasta bin; 7. cutting boards were badly scraped; 8. beard net was not worn as required, and 9. a pitcher of cranberry juice was served past the labeled consumed by date. These failures had the potential to increase the risk of foodborne illnesses for a total of 36 residents who received food from the kitchen. Findings: 1. During the initial kitchen tour on [DATE] starting at 8:46 a.m., accompanied by the Lead [NAME] (LC). The LC verified, a half-gallon of opened milk and opened heavy whipping cream was unlabeled in the refrigerator and an opened garlic naan bread and a cake was unlabeled in the walk-in freezer. In the dry storage room, a gallon of opened champagne vinegar, a jar of opened pepperoncini, a bottle of opened hot sauce and a container of sushi ginger was found unlabeled. The LC verified the food products were not labeled. She stated, opened food items should be labeled to know when it should be discarded. During a telephone interview on [DATE] at 4:10 p.m., the Corporate Registered Dietitian (CRD) stated, he expected all food products to be labeled once opened prior to putting them away. A review of facility policy titled, Data Code Genie (DCG) [an automated food labeling system] Food Labeling Standard, revised ,d+[DATE], indicated, 1. All .labels should be used for food item date marking must include the following: a. Item Name b. Preparation Date c. Must Use By Date .2. All prepackaged food and beverage items that have been opened, unsealed, and or exposed to outside environmental air must be date marked using a DCG label . 2. During the initial kitchen tour on [DATE] starting at 8:46 a.m., the LC, verified a box of liquid egg yolks in the refrigerator with use by date of [DATE] was past the best by date and a container of red chili pepper sauce with use by date of [DATE] was past the best by date. In a continued observation in the walk- in freezer with the LC, two strawberry shortcakes with use by date of [DATE], two vanilla flan cakes with use by date of [DATE], a chocolate peppermint cake with use by date of [DATE] and a chocolate peanut cake with a use by date of [DATE] were past the use by date. The LC stated, the cakes should have been discarded. The LC stated she does not know why they were not discarded. During a telephone interview on [DATE] at 4:10 p.m., the CRD stated, he expected anything expired from the manufacturing date or label should be thrown away. A review of facility policy titled, Dry Storage Standards, revised ,d+[DATE], indicated, 9. No outdated items should be in stock or stored . 3. During the initial kitchen tour on [DATE] starting at 8:46 a.m., the LC verified there were white powder on the lids of the polenta storage bin and pure sugar cane bag as well as the cornstarch bin. The LC also verified there were grayish and white powder accumulation on the lid of the thickener storage bin and there was an unknown liquid on the lid of the couscous bin. She stated, the night staff should wipe the bins, but they never wipe them. She further stated the staff were supposed to clean the storage bins and they should be free from spilled powders. During a telephone interview on [DATE] at 4:10 p.m., the CRD stated, he expected the staff to follow their cleaning protocol. He further stated containers should have been cleaned according to their cleaning protocol. A review of facility policy titled, Dry Storage Standards, revised ,d+[DATE], indicated, 2. Storage areas need to be clean .7. Regular schedules for cleaning .should be established and enforced . A review of the 2022 US FDA [United States Food and Drug Administration] Food Code Section ,d+[DATE].11 indicated, (A) Equipment food-contact surfaces and utensils shall be cleaned: (5) At any time during the operation when contamination may have occurred . 4. During the initial kitchen tour on [DATE] starting at 8:46 a.m., the LC verified there were onion peels (5 pcs of red onion and 2 pieces of yellow onion) on the floor of the dry storage room. During a telephone interview on [DATE] at 4:10 p.m., the CRD stated, he expected the staff to follow their cleaning protocol and spills should be swept. A review of facility policy titled, Dry Storage Standards, revised ,d+[DATE], indicated, 2. Storage areas need to be clean .7. Regular schedules for cleaning .should be established and enforced . A review of the 2022 US FDA [United States Food and Drug Administration] Food Code Section ,d+[DATE].11 indicated, (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. 5. During the initial kitchen tour on [DATE] starting at 8:46 a.m. the LC verified there was a steak knife on top of the quinoa box. She stated the knife was not supposed to be there. During a telephone interview on [DATE] at 4:10 p.m., the CRD stated, the knife should not be in the dry storage room. A review of the 2022 US FDA [United States Food and Drug Administration] Food Code Section ,d+[DATE].11 Equipment, Utensils, Linens, and Single-Service and Single-Use Articles: indicated, Cleaned equipment and utensils .shall be stored: in a clean, dry location. 6. During the initial kitchen tour on [DATE] starting at 8:46 a.m., the LC verified there was a small potato in the pasta bin. During a telephone interview on [DATE] at 4:10 p.m., the CRD stated, cleaning protocols should be followed by kitchen staff. A review of facility policy titled, Dry Storage Standards, revised ,d+[DATE], indicated, 2. Storage areas need to be .organized . 7. During the initial kitchen tour on [DATE] starting at 8:46 a.m., the Lead Nutritional Aide (LNA) verified there were twenty-two (11 green, 7 red, 2 brown, 2 blue) badly scraped cutting boards still in use in the kitchen. She stated, the cutting boards should have been changed and should not have been used. During a telephone interview on [DATE] at 4:10 p.m., the CRD stated, he expected the staff to replace the cutting boards when they were badly scraped. A review of the 2022 US FDA [United States Food and Drug Administration] Food Code Section ,d+[DATE].12 indicated, surfaces such as cutting blocks and boards that are subject to scratching and scoring shall be resurfaced if they can no longer be effectively cleaned and sanitized, or discarded if they are not capable of being resurfaced. A review of the 2022 US FDA [United States Food and Drug Administration] Food Code Annex, indicated, Cutting surfaces such as cutting boards and blocks that become scratched and scored may be difficult to clean and sanitize. As a result, pathogenic microorganisms transmissible through food may build up or accumulate. These microorganisms may be transferred to foods that are prepared on such surfaces. 8. During a return visit to the kitchen on [DATE] at 11:55 a.m., a dietary aide chopping vegetables in the kitchen preparation area was not wearing a beard net. The Executive Chef (EC) verified the dietary aide was not wearing a beard net. He stated, if his beard is longer than half an inch then he should wear a beard net. During a telephone interview on [DATE] at 4:10 p.m., the CRD stated, he expected staff with beards should wear a beard net to prevent hair from falling on the food. A review of facility policy titled, Uniform Dining Services, revised ,d+[DATE], indicated, .Beards are subject to hair nets . A review of the 2022 US FDA [United States Food and Drug Administration] Food Code section ,d+[DATE].11 indicated, food employees shall wear .beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food; clean equipment, utensils, and Linens; and unwrapped single-service and single-use articles. 48445 9. During a dining observation on [DATE] at 12:28 p.m. at the Magnolia Dining Hall, a pitcher of cranberry juice was observed being used to serve residents during lunch. The label on the pitcher indicated Must use by [DATE] EOD [end of day]. Four residents were observed having cranberry juice. During a concurrent observation and interview on [DATE] at 12:36 p.m. with the LNA, the LNA confirmed the observation and stated, I think it's the wrong one, they made it yesterday, we keep it for three days .we have a system, we know it's made on the 10th, we'll just change the label, this is still good, it can cause confusion if people don't pay attention. When asked about the possible effect if juices past their consume-by-date were served to residents, the LNA stated, The taste will be different, the juice might be sour. During an interview on [DATE] at 12:51 p.m. with the EC, the EC stated, Juices are good for a day, they throw it out at the end of the day when not consumed .the consume-by-date of cranberry juice is only good for a day. The EC further stated, There's no way on making an error on printing the labels or stickers .technically, you should stick to the sticker, they are supposed to discard it at the end of the date, no matter if it's correct or not. Better safe than sorry .they should always serve a new one. During an interview on [DATE] at 1:06 p.m. with the Director of Dining Services (DDS), when showed a photo of the pitcher of cranberry juice, the DDS stated, That should have not been served or stored .not supposed to just change the label and still serve it .it is past the date, it would affect the taste and the flavor but mostly the safety. During a review of the facility's policy and procedure (P&P) titled, Data Code Genie (DCG) Food Labeling Standard, revised ,d+[DATE], the P&P indicated, Food date marking should incorporate identified standards and criteria to ensure all food items are kept safe for consumption within a specific amount of time to minimize bacteria growth and spoilage .1. All DCG labels used for food item date marking must include the following: .c. Must Use By Date (Expiration date pre-loaded into the DCG labeling platform).

Based on observation, interview, and record review, the facility failed to ensure a comprehensive care plan was developed and implemented for two of 13 sampled residents (Resident 9 and Resident 18) when: 1. Resident 9 had no care plan for the use of an anticoagulant (blood thinner, medication to prevent blood clots); and 2. Resident 18 had no care plan for the incidence of a fall. Theses failures increased the potential for Resident 9 and Resident 18 to have unmet needs due to a lack of monitoring. Findings: 1. A review of the 'ADMISSION RECORD' indicated Resident 9 had diagnoses that included unspecified dementia (impaired ability to remember, think, or make decisions that interferes with doing daily activities), and atherosclerotic heart disease of native coronary artery (caused by buildup of fats and other substances blocking the blood flow from the heart to the body). A review of Resident 9's Order Summary Report indicated the following orders: -Monitor for signs/symptoms bleeding every shift such as increased bruising every shift for anticoagulation usage dated 3/21/24; and -Xarelto (blood thinner) 2.5 mg (milligram, unit of measurement) 1 tablet two times as day for Atherosclerotic Heart Disease dated 5/2/24. A review of Resident 9's Monitoring order for signs/symptoms of bleeding which included increased bruising indicated 0 from 6/1/24 to 6/11/24. In a concurrent observation and interview on 6/11/24 at 4:45 p.m., Resident 9 was sitting in a regular wheelchair assisted by Certified Nursing Assistant 1 (CNA 1). Resident 9 had bruises on his left forearm, left elbow, and right forearm. Resident 9 was unable to state how he obtained the bruises. The CNA 1 did not know why Resident 9 had bruises and CNA 1 stated to ask Resident 9's nurse. In an interview on 6/11/24 at 4:49 p.m., the Licensed Nurse 3 (LN 3) stated she did not get a report regarding Resident 9's bruises. The LN 3 further stated she worked yesterday, and she had not noticed the bruises on Resident 9. The LN 3 confirmed Resident 9 was taking Xarelto. In a concurrent interview and record review on 6/14/24 at 10:18 a.m., the Minimum Data Set Coordinator (MDSC) stated Resident 9 was on anticoagulant from the two MDS assessments conducted for Resident 9 on 2/19/24 and 5/20/24. The MDSC confirmed Resident 9 had no care plan for the use of an anticoagulant. The MDSC stated if a resident was on an anticoagulant it should be care planned due to the side effect, risk of bleeding. In an interview on 6/14/24 at 10:53 a.m., the Nurse Consultant (NC) stated if a CNA observed any skin conditions, the CNA would report any skin condition to the nurse and the nurse would assess the resident and document the assessment in the progress note. There was no documented evidence in Resident 9's clinical records of the bruises identified prior to 6/11/24. In a concurrent interview and record review on 6/14/24 at 11:27 a.m., the Director of Nursing (DON) confirmed Resident 9 had no care plan for the use of an anticoagulant and the monitoring for bruising was not documented on 6/11/24. The DON stated her expectation was for the care plan to be completed within 72 hours. 2. A review of the ADMISSION RECORD indicated Resident 18 had diagnoses that included unspecified atrial fibrillation (irregular, rapid heart rate that causes poor blood flow). A review of Resident 18's Incident Note dated 5/27/24 indicated, Resident found by CNA [Certified Nursing Assistant] on floor of bathroom. States trying to pull up pants after toileting and fell .States hit arms on walker beside her in bathroom .Skin tears to right lower arm and left elbow noted. Mentation at baseline, A/O [alert/oriented x 3. Further review of Resident 19's clinical record indicated a care plan dated 1/29/24 for high risk for falls related to gait/balance problems, poor safety awareness and progression of disease process. There was no care plan initiated for the actual fall on 5/27/24 and there was no monitoring for the skin tears from the fall. In a concurrent observation and interview on 6/11/24 at 9:43 a.m., Resident 18 was inside her room and noted with steri-strips (strips of tape to keep the edges of wound together) on her left side of the elbow and a dry dressing on her right forearm. Resident 18 stated she had a fall 2 weeks ago and obtained a skin tear on her left elbow and right forearm. Resident 18 further stated she was using her four wheeled walker and she was not sure how it [fall] happened. In an interview on 6/14/24 at 1:28 p.m., the DON confirmed Resident 18 had no care plan for the fall on 5/27/24 and the skin tear obtained from the fall. The DON stated the licensed nurse who documented the fall should have completed the care plan and obtained treatment orders. The DON further stated if the physician did not order any treatments, monitoring should be done for the skin tears. A review of the facility policy revised 10/2023 and titled, Fall Reduction and Management Program - SNF indicated, .When a fall occurs .The Licensed Nurse will review/revise the care plan as needed and communicate any care plan changes to the unit staff and interdisciplinary team. A review of the facility's policy revised 10/2023 and titled, Care Planning indicated, .The care planning process serves as a means to identify the resident's individual needs, goals of care and provide staff direction on resident's care .Within 21 days of admission and/or within 7 days after the completion of the comprehensive assessment, the interdisciplinary team including the resident and/pr responsible party will develop a comprehensive care plan . The comprehensive care plan will . Describe the care/services that are furnished and the type of staff or discipline to furnish the care/services.

Based on interview and record review, the facility failed to ensure professional standards of quality was maintained for one of 13 sampled residents (Resident 25) when the attending physician was not notified of Resident 25's episodes of hypoglycemia (low blood sugar) as ordered. This failure had the potential to cause a delay in the management of Resident 25's change in condition. Findings: During a review of Resident 25's admission records, the records indicated Resident 25 was admitted in March 2023 with diagnoses that included Type 2 Diabetes Mellitus (high levels of blood sugar in the blood). During a review of Resident 25's care plan, revised on 3/13/24, the care plan indicated, The resident has hypoglycemia episodes r/t [related to] Disease process Low Blood sugar .Monitor/document/report PRN [as needed] s/sx [signs and symptoms] of hypoglycemia . During a review of Resident 25's physician order, dated 5/24/24, the order indicated, HumaLOG KwikPen [medication used to help blood sugar get into cells so the body can use it for energy] Subcutaneous [under the skin] Solution Pen-injector 100unit/mL [milliliters, a unit of measurement] (Insulin Lispro) Inject as per sliding scale [varied dose based on blood sugar level] .Notify MD [medical doctor] for Hypoglycemia (If blood sugar below 80 [mg/dl]). During a review of Resident 25's Medication Administration Record (MAR), dated 6/2024, the MAR indicated Resident 25 had episodes of hypoglycemia with blood sugar of 74 [mg/dl] on 6/10/24 at 4:30 p.m. and blood sugar of 74 [mg/dl] on 6/10/24 at 8 p.m. The MAR also indicated the episodes were coded as Vitals Outside of Parameters for Administration. The MAR did not indicate there were interventions or documentation done for the episodes of hypoglycemia. During an interview on 6/13/24 at 3:13 p.m. with Licensed Nurse 2 (LN 2), LN 2 stated, If there's an order to notify the doctor, you would have to notify, and document in the chart. If not reported to the doctor, the doctor will not be able to order the proper interventions for the situation. During a concurrent interview and record review on 6/14/24 at 10:33 a.m. with the Director of Nursing (DON), the DON verified the order for Humalog indicated to notify the doctor for blood sugar below 80 [mg/dl]. The DON verified there were two episodes of blood sugar of 74 [mg/dl] on 6/10/24 at 4:30p.m. and at 8 p.m. The DON indicated she cannot find any documentation on physician notification and stated, I don't see any notification on the progress notes .problem is they did not follow doctor's order .resident can have more hypoglycemia, the doctor can't order any treatment because he's not aware .expectation is to follow the doctor's order and notify the doctor in case of low blood sugar. During a review of the facility's P&P titled, Medication and Treatment Administration, revised 1/2020, the P&P indicated, 2. Medications and treatments shall be administered as prescribed. During a review of the undated document titled, Nursing Practice Act Rules and Regulations, the document indicated, Article 2. Scope of Regulation 2725 (b). The practice of nursing within the meaning of this chapter means those functions, including basic health care, that help people cope with difficulties in daily living that are associated with their actual or potential health or illness problems or the treatment thereof, and that require substantial amount of specific knowledge of the following: (4) Observation of signs and symptoms of illness, reactions to treatment, general behavior, or general physical condition .and (B) implementation, based on observed abnormalities, of appropriate reporting, or referral, or standardized procedures, or changes in treatment regimen in accordance with standardized procedures, or the initiation of emergency procedures. (Nursing Practice Act Rules and Regulations Issued by Board of Registered Nursing - State of California Department of Consumer Affairs).

Based on observation, interview, and record review, the facility failed to identify and prevent hazards at specific points of food handling for total of 25 residents when: 1. Staff did not wear a beard net while handling food; and 2. A can opener was found with rust and in use. These failures had the potential to place residents at risk for foodborne illnesses. Findings: During an observation of meal preparation on 12/6/22, at 9:40 a.m., Food Server (FS) 1 was observed to be wearing a face mask and to have a beard without wearing a beard cover. The face mask failed to restrain all of the beard. In a concurrent interview, FS1 confirmed and stated, I have never worn a beard net, they never asked me to wear it. During an observation of meal preparation on 12/6/22, at 9:45 a.m., Cook 2 was observed to be wearing a face mask and to have a beard without wearing a beard cover. The face mask failed to restrain all of the beard. In a concurrent interview, Cook 2 confirmed and stated, I have never worn a beard net, they have never asked me to wear it. During an observation of meal preparation on 12/7/22, at 10:30 a.m., FS2 was observed pouring soup in the soup cup and he was wearing a face mask and he had a beard without wearing a beard cover. The face mask failed to restrain all of the beard. FS2 confirmed and stated that I have never worn a beard net before. A review of the FDA Food Code, 2017, indicated, Food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food; clean equipment, utensils, and Linens; and unwrapped single-service and single-use articles. 2. During the initial tour of the kitchen on 12/6/22, at 9:40 a.m., a rusted can opener was in use. In a concurrent interview on 12/7/22 at 10:55 a.m., Cook 1 confirmed and stated, .the can opener needs to be replaced. I should have changed it . According to the 2017 Federal Food and Drug Administration Food Code, Section 4-202.15 Can Openers: Once can openers become pitted or the surface in any way becomes uncleanable, they must be replaced because they can no longer be adequately cleaned and sanitized. Can openers must be designed to facilitate replacement. (FDA Food Code Annex, 2013). According to the 2017 Federal Food and Drug Administration Food Code, Section 3-305.14 Food Preparation. Food preparation activities may expose food to an environment that may lead to the food's contamination. Just as food must be protected during storage, it must also be protected during preparation. (FDA Food Code Annex, 2013).

Based on observation, interview, and record review, the facility failed to ensure proper infection control practices were followed when the oxygen tubing for one resident (Resident 15) was left uncovered after use and was not changed as scheduled, for a census of 25. This failure increased the potential to cause respiratory infection for Resident 15. Findings: A review of the medical records indicated Resident 15 was admitted with diagnoses including acute respiratory failure with hypoxia (there is not enough oxygen in the blood). A Minimum Data Set (MDS, an assessment tool) dated 9/30/22 indicated Resident 15 was cognitively intact with a score of 14/15 in the Brief Interview for Mental Status (BIMS, a test of cognition). Further review of Resident 15's medical records indicated a physician order dated 9/5/22 to, Start supplemental Oxygen 2-4 LPM [liters per minute] as needed for SOB [shortness of breath] . A concurrent observation and interview was conducted on 12/6/22 starting at 1:34 p.m. in Resident 15's room. The oxygen tubing was hanging by Resident 15's siderail with no cover and the tubing was dated 9/12/22. Resident 15 stated she had been using her oxygen at night. A concurrent interview and record review with the Director of Nursing (DON) was conducted on 12/6/22 starting at 2:43 p.m. The DON stated the oxygen tubing should be changed every Sunday by the night shift nurse. The DON further stated there should be a bag to store the oxygen tubing after use. The DON confirmed the label in the oxygen tubing was 9/12/22 as photographed by the the Department. The DON further confirmed she cannot find an order to change the oxygen tubing every week in Resident 15's medical record. In an interview with the Licensed Nurse 1 (LN 1) on 12/9/22 at 7:47 a.m., LN 1 stated she worked night shift and she was responsible in changing the oxygen tubing weekly. An interview with the Infection Preventionist (IP) was conducted on 12/9/22 at 2:26 p.m. The IP stated it had been a practice for the facility to change oxygen tubing weekly and to use a mesh bag to store the oxygen tubing when not in use to prevent infection. A review of the facility's policy and procedure revised 7/2019 and titled, Oxygen/Respiratory Therapy & Safety indicated, .Oxygen/respiratory equipment will be operated, cleaned and maintained to optimize functions, safety and prevent infection .Oxygen/respiratory equipment tubing .will be changed at least weekly and anytime as needed .will be dated and initialed each time it is changed .When oxygen/respiratory equipment is not in use, place the tubing .into the cloth bag to keep clean and prevent contamination.

Based on observation, interview, and record review, the facility failed to ensure adequate pressure ulcer management was provided for one resident (Resident 9), for a census of 25 when: 1. The low air loss mattress (LAL, designed to distribute the body weight and help prevent skin breakdown) was not provided as ordered; and 2. There was missing and incomplete wound assessments. These failures increased the risk for wound deterioration. Findings: A review of the medical records indicated Resident 9 was admitted with diagnoses including heart failure (the heart cannot pump enough blood and oxygen to support other organs in the body). A Minimum Data Set (MDS, an assessment tool) dated 10/11/22 indicated Resident 9 was cognitively intact with a score of 13/15 in the Brief Interview of Mental Status (BIMS, test of cognition). Resident 9's Braden Scale for Predicting Pressure Sore Risk indicated he was at risk. Resident 9's physician order dated 10/6/22 indicated, May have LAL mattress for pressure ulcer and skin management every shift. Resident 9's progress note dated 10/21/22 indicated a new pressure ulcer/injury on the left heel. Resident 9's Wound evaluation dated 10/21/22 indicated an unstageable (the stage is not clear, wound bed covered by slough or dead tissue) pressure ulcer on left heel measuring 1.47 cm (centimeters, unit of measure) for the length and 1.26 cm for the width. The wound bed with 60% slough. A progress note dated 10/28/22 indicated, IDT [Interdisciplinary] Review for Skin dated 10/21/22 [Resident 9] reported to have an open are [sic] to left heel .[Resident 9] is alert and independent with transfer and ambulation. Root cause: [Resident 9] is self transfer and ambulation and is wearing improper footwear that put pressure to the heel .medical condition related. A concurrent observation and interview was conducted on 12/7/22 starting at 2:08 p.m. inside Resident 9's room with the Director of Nursing (DON), Licensed Nurse 2 (LN 2) and a Certified Nursing Assistant. Resident 9 was lying in bed with his left foot elevated with a pillow and a regular mattress. Resident stated he had no pain when his left foot was examined by the LN 2. The LN 2 stated Resident 9's wound was unstageable, identified on 10/21/22 due to his footwear and his preference to lay on his left side. In a concurrent interview and record review with the DON on 12/7/22 at 3:14 p.m., the DON confirmed Resident 9 had a regular mattress and an order for LAL mattress. The DON stated Resident 9 refused to have the LAL mattress. Requested for DON to provide documented evidence of Resident 9's refusal of the LAL mattress. A follow-up interview was conducted on 12/8/22 at 3:17 p.m. Resident 9 stated he does not remember when and how he developed the ulcer on his left heel. Resident 9 further stated he does not remember the facility offering him a special mattress when he developed the ulcer on the left heel. Further review of Resident 9's medical records indicated the following: - Wound evaluation dated 10/27/22, no description of the wound bed; - Wound evaluation for the first week of November was not available; - Wound evaluation dated 11/15/22, wound bed with 100% slough; - Wound evaluation dated 11/18/22, no description of the wound bed; - Wound evaluation dated 11/25/22, no description of the wound bed; - Wound evaluation dated 12/1/22, no description of the wound bed; and - Wound evaluation dated 12/7/22, no description of the wound bed. A concurrent interview and record review was conducted on 12/9/22 starting at 10:11 a.m. The DON stated she cannot find any documentation of Resident 9's refusal to use the LAL mattress when it was offered to him. The DON confirmed the wound assessments for Resident 9 was incomplete on 10/27, 11/18, 11/25, 12/1, and 12/7/22. The DON further confirmed there was no wound assessment conducted on the first week of November, scheduled on 11/4/22. The DON stated her expectation was for licensed nurses to conduct a complete weekly skin assessment every Tuesday including the measurements, characteristics and progress of the wound. A review of the facility's policy and procedure revised 2/2022 and titled, Pressure Injury Prevention and Care indicated, .The aim is PREVENTION, .interventions to prevent breakdown if determined at risk .to promote healing .For all wounds: Document the assessment and picture in the .Wound evaluation .Weekly assessment of the affected area and document on the .Wound Evaluation .Record the size of the pressure injury in centimeters, and other characteristics at least once weekly.

Based on observation, interview, and record review, the facility failed to ensure Resident 1's fall care plan interventions were implemented when Resident 1's call buttons and reacher were not within reach. This failure increased Resident 1's risk for fall and injury. Findings: A review of Resident 1's clinical record indicated she was admitted with diagnoses which included anemia (body does not get enough oxygen-rich blood, the lack of oxygen can make one feel tired or weak) and orthostatic hypotension (low blood pressure which could cause dizziness or lightheadedness and possibly fainting). A review of the minimum data set, (MDS, an assessment tool) dated 3/29/22 indicated Resident 1 had no memory problem, required one person assist for transfer and was frequently incontinent with bowel, and always incontinent with bladder function. A review of Resident 1's risk for fall care plan titled, high risk for fall related to decreased safety awareness revised on 1/4/22 indicated, Be sure the Resident's call light in within reach and revised on 7/6/22 indicated, Keep reacher attached Velcro to the 1/8 siderail at all times when in bed. During an observation and concurrent interview on 7/5/22 at 2:10 p.m., Resident 1 was in bed, her body was slightly turned to the right side facing the window. Resident 1 verbalized she could not reach her call button buried under the pillow and tied to the other siderail behind her. Resident 1 stated twisting her body to reach the call button would caused her pain. Resident 1 stated the call button should have been clipped in front of her siderail when she was turned to her right side, but it was not. Resident 1 also stated her reacher was not placed where she wanted it to be. During an observation and concurrent interview on 7/5/22 at 2:43 p.m., the Director of Nursing (DON) confirmed the call button and the reacher were beyond the reach of the resident. The DON stated it was the expectation that call button and the reacher should be within reach of the resident but were not. A review of the facility's policy and procedure titled, Care Planning, revised 1/18 indicated, Resident care and services will be provided or arranged by the facility as outlined on the care plan.

Based on interview and record review the facility failed to develop, update, and keep accurate nursing care plans for one resident (Resident 1) of four sampled residents when: 1. Staff did not develop a nursing care plan for the indication and monitoring of Resident 1's use of oxygen; 2. Staff did not update the comprehensive care plan after Resident 1 had a change in condition; and 3. Staff commingled Resident 4's care plan with Resident 1's care plan. These failures decreased the facility's potential to provide person-centered care for Resident 1. Findings: 1. A review of an admission record indicated Resident 1 was admitted to the facility in April 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of a Minimum Data Set (MDS, an assessment tool), dated 4/20/21, indicated Resident 1 had mild memory problems. A review of a clinical admission evaluation dated 4/13/21 at 5:22 p.m. indicated, .Lungs clear throughout bilaterally. No difficulty breathing. No cough noted .Met [indicated] .Oxygen .No [indicated] .Lung sounds clear. Breathing is even and unlabored . A review of an order summary report printed on 8/9/21 indicated, Start Oxygen at 2L/min [Liters per minute, an amount of oxygen flow] for SOB [Shortness of Breath], chest pain, O2 sat [Oxygen saturation, a measurement of the amount of oxygen in the bloodstream] <90%; notify MD. Pulse Oximetry [to be measured every] shift .Start Date .4/13/21 . A review of Resident 1's care plans showed no documented evidence a care plan for the indication and monitoring for the use of oxygen. In an interview on 5/7/22 at 5:10 p.m., the Director of Nursing (DON) confirmed there was no care plan developed for the indicate and monitoring of Resident 1's use of oxygen. The DON further confirmed the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the facility's untitled policy and procedure, undated, indicated, .oxygen is a medication and is not to be adjusted without a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] A review of the facility's policy titled Medication Management: General approved 2/21, indicated, .Resident-centered medication administration will be implemented .to promote resident-centered care .Medication-related goals and monitoring for effectiveness .will be incorporated in the care plan .Non-pharmacological interventions as adjunct to medications will be incorporated in the care plan . A review of the facility's policy titled Care Planning, revised 1/2018, indicated, Within 21 days of admission and/or within 7 days after the completion of the comprehensive assessment .the interdisciplinary team .will develop a comprehensive care plan .The comprehensive care plan will be person-centered and will incorporate resident's .medical .problems .and will .Describe the care/ services that are to be furnished and the type of staff or discipline to furnish the care/services . 2. A review of a progress note dated 5/3/21 at 2:12 p.m. indicated, Change of Condition .Resident's cough has worsened over the past couple of days. Today Resident has [complained of] 'feeling overly tired, weak and just not myself' .MD recommends to send Resident out to [the hospital] for further assessment and treatment as indicated . A review of care plans dated 4/13/21 to 5/3/21 showed no documented evidence a care plan was created for Resident 1's change of condition. A review of the facility's policy titled Change in Condition, approved 6/2021, indicated, .The resident's Care Plan will be reviewed and updated as needed to reflect the change in condition. 3. A review of Resident 1's care plans indicated, [Resident 4] is at risk for increasing difficulty eating and drinking leading to weight loss [related to] [CONDITION(S)] and mental decline. Hospice patient .[Resident 4] will eat a diet with texture modification as needed for safe consumption. Support will be provided as needed. [Resident 4] will be encouraged to eat and drink to her satisfaction . A review of Resident 1's clinical record showed no documented evidence of a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] In a concurrent record review and interview on 8/9/21 at 4:30 p.m., the DON was shown a copy of Resident 1's care plans. The DON confirmed the care plan regarding a risk for difficulty eating related to [CONDITION(S)] and hospice was inaccurate. The DON also stated it was written in error and should have been corrected or deleted. A review of the facility's policy titled Documentation, revised 1/2020, indicated, .All documentation is expected to be .accurate .pertinent and held in confidence. Documentation should .ensure the needs of the residents are met through proper representation of their condition in the health record.