Every finding on record at Victoria Post Acute Care

Based on observation, interview and record review, the facility failed to ensure food served to residents was plated with an appetizing presentation.This failure had the potential to lead to a negative dining experience, resulting in reduced appetite, weight loss and feelings of disappointment.Findings:On 1/26/26 at 8:29 A.M., an interview was conducted with Resident 100 in her room. Resident 100 stated the food could have a better presentation, sometimes the look on the plates don't look good, could be nicer.On 1/26/26 at 8:45 A.M., an interview was conducted with Resident 21 in her room. Resident 21 stated the food sometimes would be cold and presentation could be better. A review of the facility's menu dated 1/28/26 indicated the regular diet meal for lunch was, Fish Italiano, Creamy Risotto style Rice, Broccoli with Garlic, Cucumber Onion Salad and Cherry Tart, alternative for the fish was chicken with gravy. The Pureed Diet was served as a pureed version of regular diet.On 1/28/26 at 11:15 A.M., a concurrent observation and interview was conducted with Dietary Manager (DM) and Consultant Dietary Manager (CDM) of the tray line. The food was plated in a hapzardly fashion. Several plates lack intentional design and appeared unbalanced and messy, with sauce spilling off the edges of the plates. The CDM stated plating should have been more presentable in appearance.On 1/29/26 at 10:33 A.M., an interview was conducted with the Director of Nursing (DON). The DON stated plating of the resident food should have been presentable and made with care for the residents. The DON stated this could have caused residents to not to want to eat. The DON stated residents look forward to the food and the food should always be presentable and appealing to the residents.A review of the facility's policy titled, Food Preparation, dated 2023, indicated Policy: Food shall be prepared by methods that conserve nutritive value, flavor, and appearance.

Based on interview and record review, the facility failed to ensure the interdisciplinary team (IDT - a group of healthcare professionals collaborating residents nursing home care, services, and plan) completed documentation in the medical record to indicate it was clinically appropriate for the resident to self-administer medications for one of 10 sampled medication pass observation residents (Resident 89).This failure had the potential for the resident to experience preventable medication errors, preventable infections from accidental cross-contamination of microbes (germs), and inappropriate self-administration of drugs.Findings:During a review of Resident 89's medical record, the History and Physical (H&P - comprehensive resident assessment) note dated 1/8/26, the H&P indicated the resident was admitted to the facility on [DATE], following a fall that resulted in a fracture (partial or complete broken bone). The H&P indicated a fall occurred when the resident caught their toe on the carpeting, causing the resident to hit their face on a door jamb. The H&P indicated the resident lived alone and had to maneuver (position) themself to reach a phone to call for help.During a review of Resident 89's medical record, the physician's orders dated 1/7/26, indicated medication orders for three (3) ophthalmic solutions (eye drops) for glaucoma (eye condition that can lead to permanent vision loss or blindness): brimonidine (drug to lower pressure inside the eye) scheduled twice a day, dorzolamide hydrocholoride - timolol (brand name Cosopt - combination of two drugs to lower eye pressure) scheduled twice a day, and latanoprost (drug to treat high eye pressure) scheduled for bedtime.During a medication pass observation on 1/27/26 at 8:25 A.M., inside Resident 89's room, Licensed Nurse 4 (LN 4) was observed administering medications. No eye drops were observed administered to Resident 89 at this time.During an interview on 1/27/26 at 8:43 A.M., with LN 4, LN 4 stated no more morning medications were due for Patient 89.During a concurrent interview and record review on 1/27/26 at 10:44 A.M., with LN 4, Patient 89's medical record was reviewed with LN 4. LN 4 stated they did not administer the eye drops to Resident 89. Instead, Resident 89 self-administered their eye drops scheduled for the morning.During an interview on 1/27/26 at 10:55 A.M., with Patient 89, Patient 89 stated they self-administered their eye drops.During an interview on 1/28/26 at 3:20 P.M., with the Director of Nursing (DON), the DON stated there was no IDT documentation or physician orders in the medical record regarding Resident 89's self-administration of their eye drops.During a telephone interview on 1/29/26 at 9:17 A.M , with Resident 89's daughter (RD), the RD stated Resident 89's eye drop medications were kept at the bedside during the resident's stay at the facility.During an interview on 1/29/26 at 2:56 P.M., with the DON, the DON stated the importance of IDT is to evaluate if the resident can self-administer medications is to assess for the appropriateness for the residents.During a review of the facility's policy and procedure (P&P) titled, Self Administration of Medications, dated 5/25, the P&P indicated, PROCEDURES.1. If a resident desire to participate in self-administration, an order will be obtained by the nurse from the Attending physician 2. If the resident is a candidate for self-administration, this will be indicated in the chart.5. Appropriate notation [documentation] of these determinations will be placed in the resident's care plan.

Based on observation, interview, and record review, the facility failed to ensure two of eight residents (79 and 138), who were unable to carry out activities of daily living (ADL-self-care activities such as grooming, bathing, and toileting), received assistance with nail care (cleaning, trimming and/or filing of nails). This deficient practice had the potential for Resident 79 and Resident 138 for injury and infection.Findings: Resident 79 was admitted to the facility on [DATE] with diagnoses including fracture of the right pubis (front, lower portion of the hip bone) and need for assistance with personal care according to the facility's admission Record.During an observation and interview on 1/26/26 at 8:13 A.M., Resident 79 was in bed with a breakfast tray on the overbed table. Resident 79 was observed with long fingernails with black debris under the nails. Resident stated she needed assistance with trimming her nails.During a review of Resident 79's Minimum Data Set (MDS- a clinical assessment tool) dated 1/8/26, the MDS section GG0130I indicated Resident 79 required moderate assistance with personal hygiene.An interview and concurrent observation was conducted with the Director of Staff Development (DSD- a licensed nurse certified for staff training) on 1/28/26 at 8:11 A.M. The DSD stated nail care for residents were completed on Sundays. During a concurrent observation in Resident 79's room, Resident 79 showed the DSD her fingernails and told the DSD that she (Resident 79) needed assistance with cutting her long fingernails. The DSD then went to the nursing station to check Resident 79's admission date. The DSD stated Resident 79 was admitted on [DATE] and nail care should have been provided.During an interview on 1/28/26 at 8:50 A.M. with Certified Nurse Assistant (CNA) 23, CNA 23 stated nail care for residents were completed on Sundays and as needed to prevent scratching self and for infection control.Resident 138 was re-admitted to the facility on [DATE] with diagnoses including dementia (an impairment of brain function, such as memory loss and judgment) and need for assistance with personal care.During a review of Resident 138's Activities of Daily Living (ADL- bathing or showering, dressing, getting in and out of bed or a chair, walking, toileting and eating)) care plan dated 1/16/26, the care plan indicated Resident 138 was dependent with personal hygiene. During observations on 1/27/26 at 8:25 A.M. and on 1/28/26 at 8:05 A.M., Resident 138 was in bed and observed with long fingernails. During an interview on 1/28/26 at 8:05 A.M. with Resident 138, Resident 138 stated she would like her fingernails trimmed. An interview was conducted with the DSD on 1/28/26 at 8:11 A.M. The DSD stated nail care for residents were completed on Sundays. During a joint observation on 1/28/26 at 8:23 A.M. with the DSD, Resident 138 was in bed. The DSD looked at Resident 138's fingernails and stated Resident 138's fingernails were long and should have been trimmed for infection control. An interview was conducted with the Director of Nursing (DON) on 1/29/26 at 10:45 A.M. The DON stated she expected staff to trim and clean residents' fingernails every shower day if needed. The DON stated it was important to trim and clean residents' fingernails to prevent illness from dirty fingernails and prevent injury from scratching. A review of the facility's policy and procedure (P&P) titled, Activities of Daily Living, Care and Hygiene, dated 2/2025 was conducted. The P&P indicated, It is the policy of this facility to promote cleanliness, sanitation, hygiene and assist in necessary Activities of Daily Living as appropriate and necessary to promote well-being and independence.Personal hygiene, personal habits, and ADL will include but not limited to.Nail Care, Grooming and Dressing.

Based on observation, interview, and record review, the facility failed to ensure safe and effective pharmaceutical services when:1. In one of two medication rooms refrigerators (North Medication Room), one opened and undated multiple-dose Aplisol (tuberculin purified protein derivative - aid to diagnose the tuberculosis infection) vial was observed stored in the medication refrigerator and available for use.This failure had the potential for the resident(s) to be exposed to ineffective Aplisol due to possible oxidation (chemical process) and degradation (reduced quality) which may affect potency (effectiveness) if the opened and undated vials were not discarded according to the drug manufacturer's instructions. 2. In one of one medication carts (Southwest Medication Cart), one discontinued medication for Resident 76 was not removed from the medication cart and available for use.This failure had the potential to expose the resident to medication errors.Findings:1. During a concurrent observation and interview on 1/26/26, at 7:59 A.M., an inspection of a medication room was conducted with the Assistant Director of Nursing (ADON). Inside the North Medication Room refrigerator, one opened and undated multiple-dose Aplisol vial was observed stored in the refrigerator. The ADON acknowledged the opened and undated Aplisol vial was stored in the North Medication Room refrigerator.During an interview on 1/29/26 at 9:40 A.M., with the Director of Nursing (DON), the DON acknowledged an Aplisol vial was stored opened and undated in the North Medication Room on the morning of 1/26/26. The DON stated when the Aplisol vial is opened, the staff should label the vial.During an interview on 1/29/26 at 1:14 P.M., with Licensed Nurse 5 (LN 5), LN 5 stated when the Aplisol vial is opened and the vial cap is discarded, the vial is dated for thirty (30 days).During a review of the Aplisol package insert (PI - document on how to safely use medications) dated 5/24, provided by the facility, the PI indicated, Vials in use more than 30 days should be discarded due to possible oxidation and degradation which may affect potency.During a review of the facility's policy and procedure (P&P) titled, Medication Labels, dated 5/25, the P&P indicated, POLICY: It is the policy of this facility that medications are labeled in accordance with facility requirements and state and federal laws. 2. During a review of Resident 76's medical record, a physician's order dated 11/28/25 at 11:21 A.M., indicated a discontinue medication order for Advair Diskus (combination of two medications) inhaler.During a concurrent observation and interview on 1/26/26, at 10:12 A.M., an inspection of a medication cart was conducted with Licensed Nurse 1 (LN 1). When the Southwest Medication Cart was opened, an Advair Diskus inhaler for Resident 76 was stored inside the medication cart (approximately 59 days after the discontinue date of 11/28/25). Resident 76's Advair medication carton and inhaler mouthpiece were both labeled with an opened date of 11/1/25. LN 1 acknowledged Resident 76's Advair Diskus medication carton and mouthpiece inhaler were dated with an opened date of 11/1/25.During an interview on 1/29/26 at 9:40 A.M., with the DON, the DON stated the facility did not have a policy for discontinued medications but stated the staff should have pulled the medication when the medication order was discontinued.During an interview on 1/29/26 at 1:32 P.M., with Licensed Nurse 7 (LN 7), LN 7 stated the staff should confirm the discontinue order for medications before disposing it.

Based on observation, interview, and record review, the facility failed to ensure safe and effective medication labeling when: 1. Two of two opened inhaler mouthpieces were not dated in accordance with the drug manufacturer's specifications (requirements).This failure had the potential to expose the residents to ineffective medications. 2. Three of three opened inhaler mouthpieces were not properly labeled with sufficient information to clearly identify the specific resident.This failure had to potential to cause medication errors and preventable infections from cross-contamination from other residents if accidently mixed up with other residents' similar or same drugs.1. During a review of the Advair Diskus (combination of two medications) inhaler package insert (PI - document on how to safely and effectively use medications) dated 2023, provided by the facility, the PI indicated, ADVAIR DISKUS should be stored inside the unopened moisture-protective foil pouch and only removed from the pouch immediately before initial use. Discard ADVAIR DISKUS 1 [one] month after opening the foil pouch or when the [inhaler] counter reads 0 (after all the blisters [doses] have been used), whichever comes first.During a review of the Trelegy Ellipta (combination of three medications) inhaler patient information guide dated 12/22, the patient information guide indicated Safely throw away TRELEGY ELLIPTA in the trash 6 weeks after you open the tray or when the counter reads 0, whichever comes first. Write the date you open the tray on the inhaler.During a concurrent observation and interview on 1/26/26, at 10:12 A.M., an inspection of a medication cart was conducted with Licensed Nurse 1 (LN 1). Inside the Southwest Medication Cart, an opened and undated Advair Diskus inhaler mouthpiece for Resident 109 and opened and undated Trelegy Ellipta inhaler tray for Resident 29 were observed stored in the medication cart. LN 1 stated the two inhaler devices for Resident 109 and Resident 29 were opened and undated.During an interview on 1/29/26 at 2:46 P.M., with the Director of Nursing (DON), the DON stated the expectation was for staff to label the inhaler devices with the open date so they know when to discard the medications.During a review of the facility's policy and procedure (P&P) titled, Medication Labels, dated 5/25, the P&P indicated, POLICY: It is the policy of this facility that medications are labeled in accordance with facility requirements and state and federal laws. 2. During a concurrent observation and interview on 1/26/26, at 10:12 A.M., an inspection of a medication cart was conducted with LN 1. Inside the Southwest Medication Cart, an opened and unlabeled Advair Diskus inhaler mouthpiece for Resident 76, an opened and unlabeled Advair Diskus inhaler mouthpiece for Resident 109, and an opened and unlabeled Trelegy Ellipta inhaler tray for Resident 29 were observed stored in the medication cart. LN 1 stated the three inhaler medication cartons were labeled with the residents' information but the three inhaler devices for Resident 29, Resident 76, and Resident 109 were opened and not labeled with resident-specific information. LN 1 stated the potential outcome of the unlabeled inhaler devices could get confused.During an interview on 1/29/26 at 1:25 P.M., with LN 6, LN 6 stated both the inhaler box and the inhaler mouthpiece had to be labeled with resident-specific information due to the potential for the medication errors and the risk of infection if the drugs get mixed up.During an interview on 1/29/26 at 1:43 P.M., with LN 22, LN 22 stated to label both the inhaler box and inhaler device with resident-specific information. LN 22 stated the staff labels the inhaler mouthpiece device if the dispensing pharmacy forgets.During an interview on 1/29/26 at 2:46 P.M., with the DON, the DON stated the importance of labeling the inhaler devices with resident-specific information was due to infection control risk and potential for medication errors.During a review of the facility's P&P titled, Medication Labels, dated 5/25, the P&P indicated, POLICY: It is the policy of this facility that medications are labeled in accordance with facility requirements and state and federal laws.

Based on observation, interview, and record review, the facility failed to follow appropriate infection prevention and control practices when expired food was left in a dedicated refrigerator for the residents.This failure had the potential to result in foodborne illness to an already vulnerable population.Findings:On 1/26/26 at 10:15 A.M., a concurrent observation and interview was conducted with Licensed Nurse (LN) 11 in the staff lounge. LN 11 observed the residents refrigerator. LN 11 stated a food item dated 1/17/26 should have been discarded. LN 11 stated food items with no names and date should have been discarded. LN 11 stated there should not be any expired foods in the residents refrigerator. LN 11 stated eating expired foods could cause food borne illnesses or create stomach upset like nausea and/or vomiting. LN stated the food items should have been discarded after 48 hours of being stored in the refrigerator.1/29/26 at 10:33 A.M., an interview was conducted with the Director of Nursing (DON). The DON stated her expectations were for all Staff to follow the Food Brought by Family or Visitor policy. The DON stated the residents eating expired foods could have caused resident to have GI upset, and/or foodborne illness. A review of facility's policy titled, Food Brought by Family or Visitor, revised 7/21/21, indicated .4. All foods shall be labeled with the resident name, location and date.discarded after 72 hours of storage.

Based on observation, interview, and record review, the facility failed to ensure to a complete medication order for one of 10 sampled medication pass observation residents (Resident 115).This failure had the potential for the resident to experience preventable medication errors and adverse clinical outcomes.Findings:During a review of Resident 115's medical record, the History and Physical (H&P - comprehensive resident assessment) note dated 12/3/25, the H&P indicated the resident was admitted to the facility on [DATE] with a medical history of alcohol abuse (risk factor for thiamine deficiency, also known as Vitamin B1 deficiency, a medical condition where the body doesn't have enough thiamine/Vitamin B1 to function properly).During a review of Resident 115's medical record, a physician's order dated 12/01/25 at 8:58 P.M., indicated a medication order for Vitamin B1 Oral Tablet (Thiamine HCl [hydrochloride salt form]) Give 1 [one] tablet by mouth one time a day. During a medication pass observation on 1/27/26 at 7:51 A.M., inside Resident 115's room, Licensed Nurse 2 (LN 2) was observed administering thiamine (Vitamin B1) to Patient 115.During an interview on 1/28/26 at 3:39 P.M., with LN 3, LN 3 stated if a medication order for thiamine is received, the dose of the medication is needed to make sure the correct dose is given and the physician order is followed.During a concurrent interview and record review on 1/29/26 at 8:13 A.M., with LN 2, Resident 115's medical record was reviewed with LN 2. LN 2 stated for Resident 115 on 1/27/26 around 8 A.M., there was no dose in the medication order for thiamine. LN 2 stated there was no milligrams [mg - unit of measurement for dose].During an interview on 1/29/26 at 2:46 P.M., with the Director of Nursing (DON), the DON stated the importance of a complete medication order was to prevent overdosing or underdosing residents.During a review of the facility's policy and procedure (P&P) titled, Physician Orders - Administration of Medications/Treatments, dated 5/25, the P&P indicated, PROCEDURES.5. Orders must include.D. Dosage.

Based on observation, interview, and record review, the facility failed to implement infection control standards of practice for two of eight residents reviewed for infection control when: 1.Resident 104's nebulizer (a treatment with liquid medication delivered as a fine mist inhaled into the lungs through a mouthpiece or mask) mask was placed on top of the bedside table uncovered, 2. Resident 137's nasal mask for continuous positive airway pressure (CPAP- a machine that delivers mild air pressure through the nose to keep breathing airways open while asleep) was on the floor. This deficient practice had the potential to expose residents to bacteria which could lead to infections. Findings: Resident 104 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD) according to the facility's admission Record.During an observation and interview on 1/26/26 at 8:38 A.M. with Resident 104, Resident 104 was in bed with breakfast tray on the overbed table. Resident 104 stated he received breathing treatments sometimes. A nebulizer machine was observed on the bedside table with tubing and mask connected to the machine. The mask was next to the machine, on top of the bedside table uncovered.A review of the physician's orders in the electronic health record (EHR) for Resident 104 was conducted. The physician's orders indicated, Ipratropium-Albuterol Solution [medication to open air passages in the lungs].3 ml [milliliter] inhale orally every 6 hours as needed for SOB [shortness of breath] or Wheezing via nebulizer.ordered 1/15/26.An interview and joint observation on 1/27/26 at 3:04 P.M. was conducted with licensed nurse (LN) 21. LN 21 checked Resident 104's nebulizer machine with tubing and mask connected. LN 21 stated the tubing, and mask should be changed weekly and as needed. LN 21 further stated the tubing, and mask should be stored in a plastic bag to prevent contamination. 1.Resident 137 was admitted to the facility on [DATE] with diagnoses including obstructive sleep apnea (OSA- a problem in which breathing pauses during sleep due to blocked airways) according to the facility's admission Record.During an interview and observation on 1/26/26 at 8:54 A.M., Resident 137 was sitting up in bed drinking coffee. Resident stated the machine on her bedside table was a CPAP machine. A tubing and nasal mask was observed connected to the CPAP machine. The tubing was hanging down with the nasal mask on the floor. Resident 137 stated she used the CPAP machine for sleep apnea and applied the nasal mask herself.A review of the physician's orders in the EHR for Resident 137 was conducted. The physician's orders indicated, CPAP.Apply at Bed Time [sic] and Remove in AM [morning].for OSA.An interview and joint observation on 1/27/26 at 3:07 P.M. was conducted with LN 21. Upon entering Resident 137's room, a visitor was observed sitting at Resident 137's bedside. Resident 137's CPAP nasal mask was on the floor and was picked up by the visitor. LN 21 stated the CPAP's nasal mask should be stored in a plastic bag. LN 21 stated it was important to store the nasal mask properly to prevent contamination and prevent bacteria from entering the resident's mouth.An interview on 1/29/26 at 10:45 A.M. was conducted with the Director of Nursing (DON). The DON stated respiratory equipment such as oxygen tubing, mask and CPAP mask should be stored in a plastic bag when not in use for infection control.During a review of the facility's policy and procedure (P&P) titled, CPAP/BIPAP Monitoring / Management / Storage, dated 2/2025, the P&P indicated, Store tubing and mask appropriately when not in use.A review of the facility's P&P titled, Infection Prevention and Control Program, dated February 2025 was conducted. The P&P indicated, Goals.Decrease the risk of infection to residents and personnel.Recognize infection control practices while providing care.The facility personnel will conduct themselves and provide care in a way that minimizes the spread of infection.

Based on interview and record review, the facility failed to check a resident's blood sugar for a resident with diabetes (high blood sugar) for one of two sampled residents reviewed for diabetes management (Resident 1). This failure had the potential to place Resident 1 at risk for poor diabetes management.Findings: On 8/21/25, the Department received a complaint related to Resident 1's untimely and missed blood sugar check at the facility. Resident 1 was admitted to the facility on [DATE], with diagnoses which included diabetes and on long term use of insulin (injectable medication for diabetes), per the facility's admission Record. Resident 1's history and physical, dated 7/29/25 indicated Resident 1 had the capacity to understand and competent to make complex medical decisions. On 9/4/25 at 1:13 P.M., a joint interview with the Director of Nursing (DON) and a review of Resident 1's clinical record was conducted. The DON stated Resident 1 was alert and oriented and knew what was going on. The DON stated Resident 1's blood sugar was checked four times a day (before meals and at bedtime). The DON stated on 7/30/25, Resident 1's blood sugar was documented as checked at 9:52 A.M. The DON stated the facility usually served breakfast around 8 A.M. The DON also stated on 7/30/25, there was no blood sugar check documented for Resident 1 before lunch. The DON stated Licensed Nurse (LN) 2 was the LN who worked that day. The DON stated there was no blood sugar check and no insulin coverage at lunch time for Resident 1. The DON stated there was no documentation Resident 1 refused blood sugar check. The DON stated the expectation was for the LNs to follow the physician's order and document in the resident's clinical record. The DON stated blood sugar monitoring was important so the facility could implement appropriate interventions if high or low. On 9/4/25 at 1:39 P.M., a telephone call was made to interview LN 2, but unable to talk to LN 2. A policy for diabetes management was requested but per DON, the facility had a policy for Physician Orders. A review of the facility's undated policy titled, Physician Orders - Administration of Medications/Treatments, indicated, It is the policy of this Facility, medication and treatment shall be administered by Licensed Nurse as prescribed by the resident's physician .4. Medication and treatment administration will be recorded on the resident's administration record (i.e. MAR/TAR/DAR).

Based on interview and record review, the facility failed to ensure a safe and orderly discharge and continuum of care, for one of three residents (Resident 1), when Resident 1 was discharged to a homeless shelter that was closed and not accepting any admissions for the evening, when reviewed for discharges.This failure resulted in Resident 1 not having a place to sleep or have supervision for the evening of his discharge. Findings:An unannounced visit was made to the facility on 7/31/25, in regard to a complaint regarding an unsafe discharge. Per the complainant, when Resident 1 arrived at the homeless shelter, they were closed for the evening. The resident had no place to go and later presented himself to the emergency room department.Resident 1 was admitted to the facility on [DATE], with diagnoses which included need for assistance with personal care and abnormal gait and mobility, per the facility's admission Record.Resident 1's medical record was reviewed on 7/31/25:According to the care plan, titled Discharge, dated 7/9/25, Resident 1 wished to return/be discharged to the community. Interventions included establishing a pre-discharge plan with the resident, home health or outpatient rehabilitation to be arranged for continuity of care, make arrangements with required community resources to support resident, and needs written instructions. According to the physician's History & Physical, dated 7/10/25, Resident 1 had the capacity to understand and make decisions.According to the Physician's order, dated 7/10/25, discharge to shelter vs Independent Living Facility. According to the Case Manager notes, dated 7/15/25, Met with resident to inform of new MD (medical doctor) order and last covered day 7/15/25, related to health plan provided. Resident declined to appeal and will proceed with discharge to community resource vs independent living facility placement on 7/16/25. Resident offered placement resources and homeless shelters and declined. Resident declined transportation.According to the Case Manager notes, dated 7/16/25, Resident 1 and brother refusing to choose a homeless shelter and transportation. Resident requested name of homeless shelters in El Cajon, stating he wanted to discharge today.According to the nurse's note, dated 7/16/25 at 2:55 P.M., Resident discharged to community of choice, declined transportation. All medications and belongings were given to resident. An interview and record review was conducted with Case Manager Assistant (CM-A) on 7/31/25 at 12:41 P.M. The CM-A stated she tried to work with Resident 1 and his brother, regarding placement multiple times. The CM-A stated they had a plan for a shelter discharge, but the day before discharge, the resident declined and said he would find something on his own. The CM-A stated on the day of discharge, she provided the name and address of a local shelter, that the resident could walk to, because he refused transportation. The CM-A stated the resident left their facility around 5 P.M., and was instructed bed assignments at the shelter closed at 6:P.M.On 7/31/25 at 12:49 P.M. the CM-A called the homeless shelter she referred Resident 1 to. The call was placed on speaker phone. The Shelter (name) stated they only accept clients from 8 A.M. to 4 P.M. The representative stated after 4 P.M., the doors are locked and no admittance was allowed.The CM-A stated she was unaware the shelter closed at 4 P.M. and she should have called the shelter first to the confirm there was a bed, and what time they closed before she sent Resident 1 there. The CM-A stated since the resident was not agreeable to the previous arrangements, she should have signed the resident out AMA (against medical advice), since the discharge was not safe and organized. The lead Case Manager was unavailable for an interview.An interview and record review was conducted with the Social Service Director (SSD) on 7/31/25 at 12:56 P.M. The SSD stated the Interdisciplinary Team (IDT-when department heads meet to discuss resident issues), met on 7/15/25, and had Resident 1's discharged planned to a specific shelter, with follow up care of home health, physical therapy, and occupations therapy. After all the arrangements were made, Resident 1 announced he wanted to select his own homeless shelter and he refused transportation. The SSD stated she had no further more involvement in the discharge plan, because he was considered a short-term resident and the Case Managers were doing all the discharge planning for short term residents. The SSD stated if Resident 1 refused the discharge recommendations, it was his right, but staff should have signed him out as AMA and not a planned discharge.An interview was conducted with Licensed Nurse 1 (LN 1) on 7/31/25 at 1:06 P.M. LN 1 stated it was important for resident's being discharged to have a place to go for continuity of care. LN 1 stated all residents should have a discharge summary, MD orders, home health services such as physical therapy, medications and follow up care, along with transportation. LN 1 stated if the discharge cannot be conducted safely, and orderly, and the resident was not agreeable to the recommendations, then the discharge should be considered AMA.An interview was conducted with the Director of Nursing (DON) on 7/31/25 at 1:18 P.M. The DON stated she expected all discharges to be safe and organized for a continuum of care. The DON stated if Resident 1 changed his mind to the organized discharge at the last minute, then he should have been considered a AMA discharge. According to the facility's policy, titled Discharge Planning Process, undated, .1. The Facility's discharge planning process shall: 1. Provide and document sufficient preparation and orientation to resident 5. When discharge is anticipated.a. Facility staff shall provide preparation and orientation to the resident to help ensure the transition is as anxiety free as possible .i. This may include trial visits by the resident to the new location.

Based on observation, interview, and record review, the facility failed to ensure food safety and sanitation practices in dietary services were maintained for food storage according to standards of practice when: 1. One ice machine, and two three-compartment sinks did not have a proper air gap system to adequately prevent backflow of contaminated foods. 2. One facility prep sink was covered with white stained deposits, rust, and discolored raised pebble sized rock-like substance permanently embedded on the surface was being used. 3. The facility mixer for preparing food did not have a splash guard to prevent contaminating floor and kitchen equipment surfaces during use. 4. The facility did not safely prepare a meat recipe by using unpasteurized eggs. Cross Reference (F804) These failures had the potential to cause widespread food borne illness among all 110 residents who received food from the kitchen. Findings: 1. On 9/10/24 at 8:00 A.M., an observation and interview was conducted with the Dietary Supervisor (DS), in the kitchen. The ice machine was piped directly through a food production sink pipe underneath the food prep sink station with an air gap system that was connected to a black PVC (polyvinyl chloride: synthetic plastic material) drain and two narrow white PVC pipes that was pushed down into the sink floor drain. The DS stated that there was no air gap in between the ice machine drain and the sink floor drain. The DS stated the importance of an air gap was to prevent backflow contamination. On 9/10/24 at 9:10 A.M., an observation and interview was conducted with the DS and the Director of Maintenance (DOM) in the kitchen. The three-component dishwashing station #1 (by the low-temp dishwashing machine) was connected to a black PVC pipe that was pushed down towards the floor drain with no air gap. The DOM measured the pipe drain for the three-component dishwashing station #1 at four inches inside the floor drain. The DOM stated it's important for the water to drain and the backflow [sic] and it can go up to the sink and you don't want it to back up to contaminate the kitchen. Per the 2022 Federal FDA food code, section 5-202.13 titled BACKFLOW PREVENTION, AIR, .An air gap between the water supply inlet and the flood level rim of the PLUMBING FIXTURE, EQUIPMENT, Or nonfood EQUIPMENT shall be at least twice the diameter of the water supply inlet and may not be less than 25 mm (1 inch). 2. On 9/10/24 at 8:00 A.M., an observation and interview was conducted with the Dietary Supervisor (DS), in the kitchen. The prep sink posted a sign that stated NO THAWING MEATS IN THIS SINK. SLOW DRAIN, WILL FLOOD. An interview was conducted with the Dietary Supervisor (DS) and stated that the sink was used to prep (prepare) vegetables. The prep sink was observed with discoloration throughout the prep area to the right, with white-stained deposits, with pencil eraser-sized scattered rust surrounding the circular middle surface, along with a burnt-like, raised pebble-sized, rock-like substance that had with a dark grayish bubble discoloration, permanently embedded on the surface. On 9/11/24 at 8:30 A.M., an interview was conducted with the dietary cook (DC), in the kitchen. The DC stated that they [dietary staff] currently used the prep sink to prepare vegetables and other non-meat products. On 9/13/24 at 8:57 A.M., an observation and interview was conducted with the DS and Dietary Aide (DA) 1. The prep sink had a silver serving container with individual packets of sugar, along with a red bucket placed on top of the prep sink. The prep sink was still observed with the same discoloration, white calcium deposits, rust and raised burnt-like, pebble-sized discoloration on the prep surface area. DA 1 stated he left the red sanitation bucket on top of the prep sink with a wet rag hanging off the edge of the bucket to clean the surface. DA 1 tested the sanitation bucket's disinfectant concentration with his bare hands, with a reading of 100 PPM (parts per million). DA 1 stated it should be between 200-400 PPM. The DS stated that DA 1 should have used/wore gloves prior to testing, to protect DA 1's hands from the chemicals in the disinfectant before testing. The DS stated the prep sink did not look clean and sanitary to be used for prepping foods, and that the red sanitation bucket and sugar container should not be placed on top of the prep sink. On 9/13/24 at 10:59 A.M., an interview was conducted with the DS, in the conference room. The DS stated the prep sink was not cleaned from the previous observation and that using the prep sink could have caused food-borne illnesses and chemical contamination with foods being served to the residents. The DS stated that the PPM reading decreased within two hours to validate a possible reason for the 100 PPM reading, and acknowledged if the red sanitation bucket was on the prep sink area for two hours, that this was a safety concern for all residents and staff, for food and chemical contamination. The facility policy and procedure titled FOOD PREPARATION dated 2023 indicated, .10. Do not use cleaning products or sanitizer in the food preparation or food storage areas in any way that could result in contamination of exposed food items. This includes spraying or pouring cleaning products near food items during preparation or cooking . 3. On 9/11/24 at 9:12 A.M., an interview and observation was conducted with the dietary cook (DC), in the kitchen. The DC was preparing a recipe for turkey meatballs and placed the ground turkey in a large capacity industrial mixer. The DC stated the mixer was known to splash food all over the floor and kitchen equipment during food preparation and that staff needed to stay away from the mixer to avoid being splashed with food. The DC stated there was no splash guard for the mixer and the only way to avoid being splashed was to stay away from the mixer. During the mixing process, the ground turkey components splashed on the kitchen floor, and the food preparation area across the stove at about an arm to two arms width apart within the circumference (the approximate circular surrounding of an area) of the mixer. On 9/13/24 at 10:59 A.M., an interview was conducted with the Registered Dietician (RD) and the Dietary Supervisor (DS), in the conference room. The DS stated using a splash guard for the mixer should be used to prevent food from splashing and contaminating the kitchen floor, and surfaces from food contaminants. The DS stated problems with the mixer could result in cross contamination from contaminated surfaces. The RD stated she did not think it was a problem for the mixer to splash on the kitchen surfaces and stated, as long as they clean the mess. The facility policy and procedure titled FOOD PREPARATION dated 2023 indicated, .8. Consider all raw product as contaminated. Handle it with methods designed to reduce existing contamination or to prevent cross-contamination to other products . 4. On 9/11/24 at 8:30 A.M., an observation and interview was conducted with the dietary cook (DC), in the kitchen. The DC was preparing the recipe titled Apple Glazed Meatballs. The DC stated she was preparing the ground turkey according to the serving size of 120 to serve to the 110 residents in the facility. The cook stated that the temperature from when she removed the ground turkey from the refrigerator was at 40 F (Fahrenheit), and moved the ground meat from the holding container to the large capacity industrial mixer. The DC added black pepper, salt, and breadcrumbs to the ground turkey, then mixed the ingredients together in the large capacity industrial mixer. The DC stated she was going to the kitchen refrigerator for eggs that she needed for the recipe. The DC returned to the food preparation table with 29 unpasteurized (not heat-treated to kill harmful bacteria) eggs. The DC stated she needed 12 eggs to add to the turkey meatball recipe and cracked the unpasteurized eggs into a measuring cup. The DC re-read the recipe which stated, Large Pasteurized (heat-treated to kill harmful bacteria) eggs. The DC stated she needed 15 large, pasteurized eggs and stated, these eggs are not pasteurized. On 9/11/24 at 8:54 A.M., an observation and interview was conducted with the Registered Dietician (RD) and the DC. The RD stated that they [the facility] only purchased pasteurized eggs. The RD inspected the eggs and stated the eggs are blank and did not have a stamped P. The DC shook her head and stated no she grabbed the wrong eggs (unpasteurized eggs) and stated pasteurized eggs have a stamped letter P. The DC stated it was important to use the pasteurized eggs because the recipe stated to use pasteurized eggs for the meat recipe and that she was serving food for all the residents and not just for one resident. The RD stated it was important to use pasteurized eggs because the bacteria was treated. The RD then told the DC it was ok to use the unpasteurized eggs and moved/positioned the egg crate closer to the DC and stated, continue with the meatball recipe. On 9/11/24 at 8:58 A.M., an observation and interview was conducted with the DC. The DC proceeded to retrieve pasteurized eggs from the kitchen refrigerator. The DC stated that complications of using unpasteurized eggs with the meat recipe included food-borne illnesses, since the facility residents can easily become sick due to their health status. Per the 2022 Federal FDA (Food Drug Administration) Food Code, section 3-801.11 (B) titled SPECIAL REQUIREMENTS FOR HIGHLY SUSCEPTIBLE POPULATIONS: Pasteurized Foods, Prohibited Re-service, and Prohibited food, Pasteurized eggs or egg products shall be substituted for raw eggs in the preparation of . (2) ., recipes in which more than one egg is broken and the eggs are combined . (F) Subparagraph (B) (2) of this section does not apply if: (1) the raw eggs are combined immediately before cooking for one CONSUMER's serving at a single meal . and served immediately, such as an omelet, souffle, or scrambled eggs; (2) the raw EGGS are combined as an ingredient immediately before baking and the EGGS are thoroughly cooked to a READY-TO-EAT form, such as a cake, muffin, or bread . The facility policy and procedure titled FOOD PREPARATION dated 2023 indicated, .4. Poorly prepared food will not be served-such food is to . either be improved, prepared again, or replaced with an appropriate substitution .

Based on observation, interview and record review, the facility failed to ensure food served was in a palatable, flavorful manner that maintained the nutritional value of the menu items served when: 1. Food complaints were not being addressed appropriately. 2. The recipe was not followed during the preparation for a meat recipe. Cross-reference (F812) This failure had the potential to decrease residents' meal intake and contribute to weight loss. The facility census was 110. Findings: 1. A document review was conducted on 9/10/24 at 9:57 A.M., of the facilities policy titled Meal Service indicated 1. Meal times . Lunch at 11:00-12:30 P.M . An interview was conducted on 9/10/24 at 11:28 A.M., with the licensed nurse (LN) 1. LN 1 stated Due to coronavirus (COVID: a highly contagious respiratory virus caused by the SARS-COV-2 virus) outbreak only the front dining room was being used but mainly for residents that were on restorative nursing assistant (RNA) dining. A dining observation was conducted on 9/10/24 at 11:47 A.M., in the dining room. The lunch trays arrived in the dining room. An interview was conducted on 9/10/24 at 11:50 A.M., in the dining room, with the registered dietician (RD). The RD stated tray line was getting it (resident trays) [sic] ready as to why the meal trays were late. During dining observations and interviews on 9/10/24 and 9/11/24, confidential interviews and observations were conducted with facility residents. Resident food concerns addressed included: - 9/10/24 confidential Resident stated, I don't eat the meals because I want Mexican food and the food taste terrible, so I don't eat it. The staff don't ask me if I want something else and if I call the kitchen they hang up on me. - 9/10/24 confidential Resident stated, The food is cold, I don't like the taste and it looks bad . - 9/10/24 confidential Resident stated, The food is tasteless. - 9/10/24 confidential Resident stated Pizza was like play dough and the burger looked like a poop emoji. Cheese potato made him sick. - 9/10/24 confidential Resident stated .portions were too small . turkey burger was not something I would ever eat again. -9/10/24 confidential Resident stated . food can be dry. And not aware that they can get an alternative meal. - 9/10/24 confidential Resident stated Not appetizing, not seasoned, not identifiable. - 9/10/24 confidential Resident stated .food portions especially lunch were too large . preferred sandwiches. -9/10/24 confidential Resident stated chicken is dry . - 9/10/24 confidential Resident stated, Chicken is dry, and was unsure it was cooked at thickest part. Unsure of what yellow orange puree was, not going to eat it, broccoli was mushy. - 9/11/24 confidential Resident stated, the meat was awful. I put it in a napkin and threw it away. - 9/11/24 confidential Resident stated, food did not taste good. - 9/11/24 confidential Resident stated, food was institutionalized. - 9/11/24 confidential Resident stated, eggs daily, no variety. - 9/11/24 confidential Resident stated, no variety of food and drinks. Review of the facility's Resident Council meeting minutes dated July 11, 2024, and August 8, 2024, the following dietary concerns were identified: - July 11, 2024 Resident Council meeting minutes indicated, .Went over staffing concerns [Administrator Name] acknowledged and assured them they will get staffing in order . - August 8, 2024 Resident Council meeting minutes indicated, . Resident expressed food preference concerns [Administrator Name] acknowledged and assured the residents he is working with dietary . During an interview on 9/12/24 at 8:32 A.M., with the resident council president (Resident 77). Resident 77 stated there was always concerns about food and often menus were not given. Resident 77 stated people [facility residents] don't like it [food trays] there's no flavor. Resident 77 stated that they always get chicken and fish, it's often cooked the same way without variety and that alternative meals were available but need to order two hours ahead and lacked cultural food alternatives. A review of Resident 77's admission Minimum Data Set (MDS, a standardized care screening and assessment tool), dated 9/4/24, indicated that Resident 77 understood or understood others, and had no cognitive (mental process involved in knowing, learning, and understanding things) deficits. Review of the facility's menu dated 9/11/24 lunch menu indicated the regular diet was served apple glazed meatballs, brown rice Florentine, carrots with parsley, wheat roll and mousse dessert. On 9/11/24 at 12:45 PM, a test tray observation and interview with the Dietary Supervisor (DS) was conducted, at the end of the hall outside of room [ROOM NUMBER] after the last tray was provided. The pureed and the regular texture diet with apple glazed meatball tasted very sour, and the meat was a little undercooked and red in the center. The brown rice was sticky and lacked flavor. The DS stated the pureed was mixed with sauce according to the recipe to bring to a pureed consistency to taste according to the menu served. On 9/13/24 at 10:30 A.M., an interview with the Registered Dietitian (RD) and the DS was conducted. The RD stated she addressed food complaints with four questions (to address food concerns) but did not use a tracking system to identify issues. The RD stated she documented in the facility's medical record, titled, Nutrition and Evaluation RDN [registered dietician nutritional] review-V2 under preference to indicate dislikes on admission and quarterly. The RD stated complications from food complaints included weight loss and malnutrition. Further, the DS stated that if residents disliked their meals, then they won't enjoy their food and behaviors can change. The facility was not able to provide a policy and procedure that addressed test trays. A review of the facility policy titled MENU PLANNING, dated 2023, the policy indicated .8. Menus are planned to consider A. The religious, cultural, and ethnic needs of the resident population, as well as input received from residents and resident groups. 2. On 9/11/24 a recipe review was conducted with the facility menu titled Apple Glazed Meatballs. The recipe included the following ingredients: - Large Pasteurized (heat treated to kill harmful bacteria) eggs - Milk - Bread crumbs - Ground Turkey - Garlic, chopped (*May substitute with 1/8 tsp garlic powder per 1 clove garlic) On 9/11/24 at 8:30 AM, an observation and interview was conducted with the dietary cook (DC), in the kitchen. The DC was preparing the recipe titled Apple Glazed Meatballs. The DC stated she was preparing the ground turkey according to the serving size of 120 to serve to the 110 residents in the facility. The cook stated that the temperature from when she removed the ground turkey from the refrigerator was at 40 F (Fahrenheit), and moved the ground meat from the holding container to the large capacity industrial mixer. The DC added black pepper, salt, garlic powder, milk, and breadcrumbs to the ground turkey, then mixed the ingredients together in the large capacity industrial mixer. The DC stated she was going to the kitchen refrigerator for the eggs that she needed for the recipe. The DC returned to the food preparation table with 29 unpasteurized (not heat treated to kill harmful bacteria) eggs. The DC stated she needed 12 eggs to add to the turkey meatball recipe, and cracked the unpasteurized eggs into a measuring cup. The DC re-read the recipe which stated, Large Pasteurized eggs. The DC stated she needed 15 large, pasteurized eggs and stated, these eggs are not pasteurized. On 9/11/24 at 8:54 A.M., an observation and interview was conducted with the Registered Dietician (RD) and the DC. The RD stated that the facility only purchased pasteurized eggs. The RD inspected the eggs and stated the eggs are blank and did not have a stamped P. The DC shook her head and stated no she grabbed the wrong eggs (unpasteurized eggs) and stated pasteurized eggs have a stamped letter P. The DC stated it was important to use the pasteurized eggs because the recipe stated to use pasteurized eggs for the meat recipe and that she was serving food for all the residents, and not just for one resident. The RD stated it was important to use pasteurized eggs because the bacteria was treated. The RD then told the DC it was ok to use the unpasteurized eggs, and moved/positioned the egg crate closer to the DC and stated, continue with the meatball recipe. On 9/11/24 at 12:35 P.M., an observation and interview during test tray was conducted with the Dietary Supervisor (DS), outside of room [ROOM NUMBER]. The DS stated it was important for recipes to be followed according to the menu so that all the residents were aware of what was being served and to preserve the nutritive value and taste. The facility policy and procedure titled FOOD PREPARATION dated 2023 indicated, 2. Recipes are specific as to the portion yield, method of preparation, quantities of ingredients, and time and temperature guidelines .

Based on observations, interviews, record reviews the facility failed to provide a safe, sanitary (clean), and comfortable environment to help prevent highly contagious infections when: 1. Facility did not store respiratory equipment properly for Resident 261. 2. Licensed Nurses (LN) did not have interventions in place to clean Resident 33's continuous positive airway pressure (CPAP) mask according to professional standards of practice. 3. Three certified nursing assistants (CNA) did not practice infection control protocols with hand hygiene and/or the use of protective personal equipment (PPE: clothing or equipment that protects people from injury or infection in the workplace) for residents (Resident 45, Resident 95, and Resident 108) on transmission-based precautions. a) Resident 45 with droplet precautions for corona virus (COVID-19: A highly contagious respiratory infection caused by the SARS-2 virus). b) Resident 95 with droplet precautions for corona virus (COVID-19: A highly contagious respiratory infection caused by the SARS-2 virus). c) Resident 108 with contact precautions for clostridioides difficile (CDiff: a germ [bacterium] that causes diarrhea and colitis [an inflammation of the colon] and can be life-threatening) 4. No hand hygiene was observed during a dining observation in the dining room. This deficient practice had the potential to cause a wide-spread infection outbreak to all residents, staff, and visitors in the facility. Findings: 1. Resident 261 was readmitted to the facility on [DATE] with diagnoses including obstructive sleep apnea (a problem in which breathing pauses during sleep due to blocked airways) according to the facility's Admission Record. The MDS (a clinical assessment tool) dated 8/20/24 for Resident 261 listed a cognitive (thinking, reasoning, or remembering) score of 15, indicating cognition was intact. During an observation and interview on 9/10/24 at 9:58 A.M., Resident 261 was lying in bed. A bilevel positive airway pressure (BIPAP-machine as breathing support and administered through a face mask or nasal mask) machine was observed on top of Resident 261's bedside drawer. The BIPAP machine was observed without water inside the machine and the tubing was touching the floor. The tubing did not have a mask. Resident 261 stated that she used the BIPAP occasionally. During another observation on 9/11/24 at 8:06 A.M., Resident 261 was lying in bed with her eyes closed. Resident 261 did not have the BIPAP mask on her. The BIPAP tubing was hanging on the bedside table with no mask and the tubing was touching the floor. A joint observation and interview was conducted with licensed nurse (LN) 11 on 9/11/24 at 8:10 A.M. LN 11 entered Resident 261's room and stated Resident 261 had a continuous positive airway pressure (CPAP- a machine that delivers mild air pressure through the nose to keep breathing airways open while asleep) machine. LN 11 observed the machine's tubing hung over the bedside table and touching the floor. Upon further observation of the machine's tubing, LN 11 was not able to find the mask for the tubing. LN 11 stated the CPAP tubing and mask should always be stored in a plastic bag for infection control. A review of physician's orders for Resident 261 titled, Order Summary Report .Active Orders As of: 9/13/24 . indicated, .BIPAP .Apply at Bed Time and Remove in AM upon Awakening . The physician's order did not indicate proper storage of the BIPAP mask. During an interview on 9/13/24 at 2:04 P.M. with the Director of Nurses (DON), the DON stated Resident 261's BIPAP tubing was an infection control issue, and the mask should be stored in a plastic bag. A review of the facility's undated policy and procedure (P&P) titled, CPAP/BiPAP Monitoring and Management, was reviewed. The P&P did not provide guidance to staff regarding proper storage of BIPAP mask for infection control. 48263 2. A review of Resident 33's Admission Record indicated Resident 33 was admitted to the facility on [DATE] with diagnoses which included a history of obstructive sleep apnea (OSA: a disorder in which a person frequently stops breathing during sleep). A review of Resident 33's admission Minimum Data Set (MDS, a standardized care screening and assessment tool), dated 8/2/24, indicated that Resident 33 understood or understood others, and had no cognitive (mental process involved in knowing, learning, and understanding things) deficits. On 9/10/24 at 10:08 A.M., an observation and interview was conducted with Resident 33, in Resident 33's room. Resident 33's CPAP machine and CPAP accessories (masks, headgear, and tubing) was placed on top of his right nightstand. The CPAP accessories were not bagged (stored in a bag) or secured. Resident 33 stated the nursing staff would leave his CPAP machine and CPAP accessories on top of the nightstand table for easy access. On 9/11/24 at 12:38 P.M., an observation and interview was conducted with Resident 33, in Resident 33's room. Resident 33's CPAP machine and CPAP accessories were still placed on top of his right nightstand table. Resident 33 stated he did not remember the last time that LNs performed any cleaning for his CPAP machine and CPAP accessories. Lastly, Resident 33 stated they did not clean it [CPAP machine and CPAP accessories] yesterday or today. On 9/11/24 a review of Resident 33's electronic health record (EHR) was conducted. There were no physician's orders for CPAP cleaning. There were no care plans for CPAP maintenance. On 9/13/24 at 9:37 A.M., a concurrent interview and record review was conducted with LN 2, at the Northside nursing station. LN 2 stated he did not know when Resident 33's CPAP machine and CPAP accessories needed to be cleaned. LN 2 stated Resident 33 only had one CPAP order since he was admitted to the facility on [DATE] that indicated, Apply Oxygen 2LPM [liters per minute] with CPAP at bedtime for OSA. LN 2 stated they (LNs) just initiated new physician's orders for cleaning and CPAP settings for Resident 33's CPAP maintenance as of 9/12/24. LN 2 stated he was unable to find records in Resident 33's EHR since his admitted [DATE], regarding CPAP cleaning and use. LN 2 stated it was important to clean Resident 33's CPAP machine and CPAP accessories daily to prevent respiratory infections. On 9/13/24 at 12:47 P.M., an interview was conducted with the Infection Prevention Nurse (IPN). The IPN stated she did not know CPAP machines needed to be cleaned. The IPN stated it was important to clean Resident 33's CPAP because there's air that goes in their lungs with the use of a CPAP, and complications that included breathing and respiratory infections, if not cleaned. On 9/13/24 at 1:37 P.M., the DON stated she was aware that there were no orders to maintain and clean Resident 33's CPAP device as of 9/12/24. The DON stated her expectation was for the LNs to make sure that orders were in place for Resident 33's CPAP use, so that LNs know they have to clean the CPAP device. The DON stated complications including harmful microbes (bacteria, virus, and fungi that can cause illness and death) can grow in CPAP machines and CPAP accessories if not maintained in a sanitary way. [Brand Name] Auto set CPAP Elite Manual dated 2021 .Clean the device and its components according to the schedules shown in this guide, to maintain the quality of the device and to prevent the growth of germs that can adversely affect your health . [Brand Name] Full Face Mask User Guide dated 7/2020 .Regularly clean your mask and its components to maintain the quality of your mask and to prevent the growth of germs that can adversely affect your health . 3a. A review of Resident 45's Admission Record indicated Resident 45 was admitted to the facility on [DATE] with diagnoses which included a history of chronic obstructive pulmonary disease (COPD-prevents airflow to the lungs, causing breathing problems). A record review of Resident 45's Minimum Data Set (MDS- a nursing assessment tool that is used to develop a plan of care) dated 9/3/24, indicated a Brief Interview for Mental Status (BIMS- developed by reviewing the resident's status during the prior seven-day period) score of 10 points out of 15 possible points which indicated Resident 45 had moderate cognitive (pertaining to memory, judgement and reasoning ability) deficits. On 9/10/24 at 10:52 A.M., an observation and interview was conducted with Certified Nursing Assistant (CNA) 3, outside of Resident 45's room. Posted outside of Resident 45's room was a red and white sign in all capital letters which indicated, Droplet and contact precaution hand hygiene, gown, N95 (a mask that filters airborne particles to prevent and guard against respiratory infections such as COVID), eye protection, and gloves before entering the room and a PPE drawer outside of Resident 45's room. CNA 3 was seen walking into Resident 45's room without performing hand hygiene and putting on PPE up until Resident 45's bathroom by the back sliding door of the room, then exited the room. CNA 3 stated he went into Resident 45's room because he did not know where she was, and to help assist Resident 45's roommate (Resident 95) who was in the bathroom calling out to him. CNA 3 stated he did not perform hand hygiene before entering Resident 45's room or put on PPE. CNA 3 stated I know it's a droplet precaution because they have COVID. CNA 3 stated regardless of the time spent in the room, if it was a droplet precaution room, he had to perform hand hygiene and wear PPE's before entering, to prevent any COVID outbreak. On 9/10/24 at 10:56 A.M., an observation and interview was conducted with LN 1, outside of Resident 45's room. LN 1 stated she saw CNA 3 and CNA 4 enter Resident 45's room without performing hand hygiene and wearing PPE prior to entry. LN 1 stated it was important for all staff to read the signage prior to entering Resident 45's room and abide by the droplet precautions to prevent the spread of COVID infections. On 9/13/24 at 12:54 P.M., an interview and record review was conducted with the Infection Prevention Nurse (IPN). The IPN stated Resident 45's COVID status was confirmed on 9/2/24 and tested positive for the virus. The IPN stated that CNA 4 should have performed hand hygiene and wore PPE prior to entering (Resident 45's room) because Resident 45's room was a droplet precaution room, and regardless of performing direct or indirect care, anyone who entered a droplet or contact precautions room needed to gown up (put a gown on). On 9/13/24 at 1:21 P.M., an interview was conducted with the DON. The DON stated her expectations was for all staff to perform hand hygiene before and after, wear PPEs before entry of any resident room identified as contact or droplet precautions, regardless if they were performing resident care or not. The DON stated the potential for not adhering to infection control protocols could lead to the spread of infection to other residents, staff, and visitors in the facility. A review of the facility's policy and procedure titled IPCP [infection prevention and control program] and Transmission-Based Precautions undated, indicated . 4. Droplet Precautions .c. Use personal protective equipment (PPE) appropriately . A review of Centers for Disease Control and prevention (CDC, a federal agency) Transmission-Based Precautions: Droplet Precautions Everyone must: Clean their hands before entering, and when leaving the room. Make sure their eyes, nose and mouth are fully covered before room entry . chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://www.cdc.gov/infection-control/media/pdfs/droplet-precautions-sign-P.pdf 3b. A review of Resident 95's Admission Record indicated Resident 95 was admitted to the facility on [DATE] with diagnoses which included a history of cerebral infarction (blood flow to the brain is blocked, leading to symptoms such as speech difficulty, headache, motor weakness, and in severe cases, death). A record review of Resident 95's Minimum Data Set (MDS- a nursing assessment tool that is used to develop a plan of care) dated 8/12/24, indicated a Brief Interview for Mental Status (BIMS- developed by reviewing the resident's status during the prior seven day period) score of 15 points out of 15 possible points which indicated Resident 95 had an no cognitive (pertaining to memory, judgement and reasoning ability) deficits. On 9/10/24 at 10:55 A.M., an observation and interview was conducted with Certified Nursing Assistant (CNA) 4, outside of Resident 95's room. Posted outside of Resident 95's room was a red and white sign in all capital letters which indicated, Droplet and contact precaution hand hygiene, gown, N95 (a mask that filters airborne particles that guard against respiratory infections such as COVID), eye protection, and gloves before entering the room and a PPE drawer outside of Resident 95's room. CNA 4 was walking down the hallway pushing a snack cart towards Resident 95's room. Resident 95 was unmasked sitting on her wheelchair in her room when CNA 4 entered the room. CNA 4 did not perform hand hygiene and wear PPE prior to entering Resident 95's room. CNA 4 stated he went inside Resident 95's room to ask if Resident 95 wanted a snack. CNA 4 stated he did not perform hand hygiene or wore PPEs because he was not doing resident care. CNA 4 stated the droplet sign outside of Resident 95's door meant that Resident 95 or her roommate (Resident 45) had COVID. CNA 4 stated the purpose for performing hand hygiene and wearing PPEs was to prevent the spread of infection for himself, and other people in the facility. On 9/10/24 at 10:56 A.M., an observation and interview was conducted with LN 1, outside of Resident 95's room. LN 1 stated she saw CNA 3 and CNA 4 enter Resident 95's room without performing hand hygiene and wearing PPE prior to entry. LN 1 stated it was important for all staff to read the signage prior to entering Resident 95's room and abide by the droplet precautions to prevent the spread of COVID infections. On 9/13/24 at 12:54 P.M., an interview and record review was conducted with the Infection Prevention Nurse (IPN). The IPN stated that CNA 4 should have performed hand hygiene and wore PPE prior to entering (Resident 95 and 45's room) because the room was identified as a droplet precaution room. The IPN furter stated that even if the CNA did not touch anything or provide direct resident care, anyone who entered a droplet or contact precautions room needed to gown up. On 9/13/24 at 1:21 P.M., an interview was conducted with the Director of Nursing (DON). The DON stated her expectations was for all staff to perform hand hygiene before and after, wear PPEs before entry of any resident room identified as contact or droplet precautions, regardless if they were performing resident care or not. The DON stated the potential for not adhering to infection control protocols could lead to the spread of infection to other residents, staff, and visitors in the facility. A review of the facility's policy and procedure titled IPCP [infection prevention and control program] and Transmission-Based Precautions undated, indicated . 4. Droplet Precautions .c. Use personal protective equipment (PPE) appropriately . A review of Centers for Disease Control and prevention (CDC, a federal agency) Transmission-Based Precautions: Droplet Precautions Everyone must: Clean their hands before entering, and when leaving the room. Make sure their eyes, nose and mouth are fully covered before room entry . chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://www.cdc.gov/infection-control/media/pdfs/droplet-precautions-sign-P.pdf 3c. A review of Resident 168's Admission Record indicated Resident 168 was admitted to the facility on [DATE] with diagnoses which included a history of sepsis (a serious condition in which the body responds improperly to an infection). A record review of Resident 168's Minimum Data Set (MDS- a nursing assessment tool that is used to develop a plan of care) dated 9/4/24, indicated a Brief Interview for Mental Status (BIMS- developed by reviewing the resident's status during the prior seven day period) score of 8 points out of 15 possible points which indicated Resident 168 had an no cognitive (pertaining to memory, judgement and reasoning ability) deficits. On 9/12/24 at 8:18 A.M., an observation and interview was conducted with LN 2, outside of Resident 168'2 room. Posted outside of Resident 168's room was a yellow sign that indicated, CONTACT PRECAUTIONS EVERYONE MUST: Clean their hands . put on gloves . put on gown . and a PPE drawer outside of Resident 45's room. LN2 stated Resident 168 had clostridioides difficile (CDiff: a very contagious bacterial infection that causes symptoms such as frequent watery diarrhea, abdominal cramping, and nausea that can be life-threatening). On 9/12/24 a record review was conducted on Resident 168's electronic health record (EHR). Resident 168 had a care plan dated, 9/11/24 that indicated, Has Clostridium Difficile r/t [related to] chronic diarrhea, hx [history] of antibiotic Cefpodoxime for UTI last dose 9/6/24 . CONTACT ISOLATION: Wear gowns and masks [PPE] when changing contaminated linens. Place soiled linens in bags marked biohazard . On 9/12/24 at 8:21 A.M., an observation and interview was conducted with CNA 7, outside of Resident 168's room. CNA 7 was in Resident 168's room, and was not wearing PPE while changing Resident 168's linens. Afterwards, CNA 7 walked outside of Resident 168's room and placed the dirty linens in an unmarked clear plastic bag. CNA 7 stated I went in the room thinking it was an orange sign for enhanced barrier precautions [EBP: PPE's used only during direct resident care] but it wasn't. CNA 7 stated he should have PPE prior to entry regardless if he was doing direct patient care or not because Resident 168 had CDiff. CNA 7 stated it was important to gown up to prevent the spread of infection because CDiff was contagious. On 9/12/24 at 8:23 A.M., an interview was conducted with LN 2, outside of Resident 168's room. LN 2 stated CNA 7 was supposed to perform hand hygiene before entering Resident 168's room and washed hands with soap and water upon exit, because alcohol-based hand rubs (ABHR) does not kill the CDiff bacteria. LN 2 stated CNA 7 was supposed to wear a gown and mask before entry regardless of performing resident care or not, to prevent the spread of infection. On 9/13/24 at 12:57 P.M., an interview was conducted with the Infection Prevention Nurse (IPN). The IPN stated whenever I give my in-services, the second you see a contact or droplet sign you have to have PPEs. The IPN stated that all staff should be washing their hands before and after entering a contact precautions room, especially for Resident 168 because he had CDiff. The IPN stated her expectations were for the nursing staff to also bleach objects (clean objects with bleach) if they used them and to remove their PPEs prior to exiting Resident 168's room or anyone with contact precautions. The IPN stated not following infection control protocols can cause infection outbreaks in the facility. On 9/13/24 at 1:21 P.M., an interview was conducted with the Director of Nursing (DON). The DON stated her expectations was for all staff to perform hand hygiene before and after, wear PPEs before entry of any resident room identified as contact or droplet precautions, regardless if they were performing resident care or not. The DON stated the potential for not adhering to infection control protocols could lead to the spread of infection to other residents, staff, and visitors in the facility. A review of the facility's policy and procedure titled IPCP [infection prevention and control program] and Transmission-Based Precautions undated, indicated . 2. Contact Precautions .b. Wear a gown and gloves for all interactions that may involve contact with the patient or the patient's environment . 4. On 9/10/24 at 11:28 A.M., a dining observation and interview was conducted with LN 1, in the front dining room. There were a total of eight residents and three staff members. LN 1 stated they had two dining rooms, but only one dining room was being used because of the corona virus (COVID-19: a highly contagious respiratory illness that is caused by the Sars-2 virus) outbreak in the facility. On 9/10/24 at 11:50 A.M., an observation and interview was conducted with the Registered Dietician (RD), in the front dining room. The RD stated meal tray delivery was late and the usual schedule was 11 A.M., for food trays to arrive. The dining room reached eight residents waiting for their meal tray, which finally arrived. The nursing staff distributed the meal trays to the residents, but did not perform hand hygiene for the residents. On 9/10/24 at 12:50 P.M., an observation was conducted in the front dining room. The last resident left the dining room without hand hygiene performed on any residents, prior to leaving the dining room. On 9/11/24 at 12:14 P.M., an observation and interview was conducted with LN 1, in the front dining room. LN 1 stated they did not perform hand hygiene (on 9/10 and 9/11) prior to residents receiving their meal trays. LN 1 stated that residents in the dining room should have had antibacterial hand wipes once trays were delivered, and after residents were finished with their meals before leaving the dining room. LN 1 stated it was important that hand hygiene was performed when trays were delivered to make sure resident's hands were clean, because she was unsure if hand hygiene was performed prior to entering the dining room. LN 1 stated it was important that hand hygiene was performed right after resident's were finished with their meal trays, before leaving the dining room, to make sure the residents were clean and comfortable and to prevent the spread of germs. On 9/13/24 at 1:21 P.M., an interview was conducted with the Director of Nursing (DON). The DON stated it was important for residents eating in the dining room to perform hand hygiene before and after residents received their meal trays. The DON stated she expected staff to provide hand hygiene wipes prior to the resident's meals and after they finished their meals, to prevent the spread of infection. A review of the facility's policy and procedure titled IPCP [infection prevention and control program] and Transmission-Based Precautions undated, indicated . 1. Standard Precautions are infection prevention practices that apply to the care of all residents, regardless of suspected or confirmed infection or colonization status .b. Hand hygiene .

Based on observation, interview, and record review, the facility failed to ensure three of seven residents reviewed for activities of daily living (ADL- self- care activities such as grooming, bathing, and toileting), who were unable to carry out their ADLs, received assistance with nail care (cleaning, trimming and/or filing of nails) and grooming. (Resident 7, 63 and 67) This deficient practice had the potential for the residents' personal well-being to be affected. Findings: 1. Resident 7 was readmitted to the facility on [DATE] with diagnoses including hemiplegia (total or partial paralysis of one side of the body) and hemiparesis (muscle weakness on one side of the body) following cerebral infarction (disrupted blood flow to the brain, stroke) affecting right side of the body according to the facility's Admission Record. During an observation on 9/11/24 at 8:38 A.M., Resident 7 was observed sitting up in bed, eating, using a fork with Resident 7's left hand. Resident 7's right hand was contracted (shortening of muscles and tendons, often leading to permanent deformity, and stiffening of joints) holding a hand roll (cushion to keep the hand open). Resident 7's fingernails on both hands were observed to be long, jagged and with faded nail polish. Resident 7 made grunting sounds to communicate and nodded when asked if she wanted her fingernails trimmed. An interview was conducted on 9/11/24 at 11:03 A.M. with certified nurse assistant (CNA) 13. CNA 13 stated only the licensed nurse or treatment nurse can trim residents' fingernails. During an interview on 9/11/24 at 3:34 P.M. with CNA 12, CNA 12 stated CNAs were allowed to trim fingernails which was scheduled during grooming days on Sundays. A joint observation and interview on 9/11/24 at 11:35 A.M. was conducted with licensed nurse (LN) 12. LN 12 observed Resident 7's fingernails and stated the fingernails were long and jagged. LN 12 stated it was the CNA's responsibility to trim fingernails. During an interview on 9/13/24 at 9:52 A.M. with the Director of Staff Development (DSD-person responsible for training staff), the DSD stated she expected CNAs to provide nail care and grooming for residents on shower days for the resident's personal well-being. The DSD stated if fingernails were not trimmed, the resident may be at risk for infection and scratching of skin. During an interview on 9/13/24 at 2:04 P.M. with the Director of Nurses (DON), the DON stated she expected residents to be clean and well groomed. A review of the facility's policy and procedure (P&P) titled, Activities of Daily Living, Care and Hygiene, dated 2/2024 was conducted. The P&P indicated, .It is the policy of this facility to promote cleanliness, sanitation, hygiene, and assist in necessary Activities of Daily Living as appropriate and necessary to promote well-being and independence . 2. Resident 63 was readmitted to the facility on [DATE] with diagnoses including unspecified Alzheimer's disease (a brain disorder that slowly destroys memory, thinking skills and eventually the ability to carry out simple tasks) and dementia (a condition characterized by loss of memory, language, problem solving and other thinking abilities) according to the facility's Admission Record. During a joint observation and interview on 9/13/24 at 9:17 A.M., Resident 63 was sitting up in bed with an opened milk carton at bedside. Resident was observed to be unshaven. Resident 63 was asked if he would like to be shaved and stated yes, but nobody has helped him with shaving. CNA 14 was in the hallway across Resident 63's room and entered the room. CNA 14 stated Resident 63 needed to be shaved. CNA 14 stated residents were supposed to be shaved on shower days. CNA 14 further stated it was important to make residents feel good about their appearance. During an interview on 9/13/24 at 9:52 A.M. with the Director of Staff Development (DSD-person responsible for training staff), the DSD stated she expected CNAs to provide nail care and grooming for residents on shower days for the resident's personal well-being. The DSD stated if fingernails were not trimmed, the resident may be at risk for infection and scratching of skin. During an interview on 9/13/24 at 2:04 P.M. with the Director of Nurses (DON), the DON stated she expected residents to be clean and well groomed. A review of the facility's policy and procedure (P&P) titled, Activities of Daily Living, Care and Hygiene, dated 2/2024 was conducted. The P&P indicated, .It is the policy of this facility to promote cleanliness, sanitation, hygiene, and assist in necessary Activities of Daily Living as appropriate and necessary to promote well-being and independence . 3. Resident 67 was admitted to the facility on [DATE] with diagnoses including unspecified dementia (a condition characterized by loss of memory, language, problem solving and other thinking abilities) according to the facility's Admission Record. During an observation on 9/11/24 at 7:57 A.M., Resident 67 was sitting up in bed having breakfast. Resident 67's fingernails were long and when asked if she wanted them trimmed, Resident 67 nodded. A joint observation and interview on 9/11/24 at 11:20 A.M. was conducted with licensed nurse (LN) 12. LN 12 observed Resident 67's fingernails and stated the fingernails were long. LN 12 stated it was the CNA's responsibility to trim fingernails. During an interview on 9/13/24 at 9:52 A.M. with the Director of Staff Development (DSD-person responsible for training staff), the DSD stated she expected CNAs to provide nail care and grooming for residents on shower days for the resident's personal well-being. The DSD stated if fingernails were not trimmed, the resident may be at risk for infection and scratching of skin. During an interview on 9/13/24 at 2:04 P.M. with the Director of Nurses (DON), the DON stated she expected residents to be clean and well groomed. A review of the facility's policy and procedure (P&P) titled, Activities of Daily Living, Care and Hygiene, dated 2/2024 was conducted. The P&P indicated, .It is the policy of this facility to promote cleanliness, sanitation, hygiene, and assist in necessary Activities of Daily Living as appropriate and necessary to promote well-being and independence .

Based on interviews, and record review, the facility failed to complete a comprehensive assessment within 14 calendar days after admission for one of three residents (Resident 94) reviewed for dialysis. This deficient practice had the potential to delay the care planning process that would have been identified by Resident 94's care area assessments (CAA) to meet Resident 94's individualized care needs. Findings: A review of Resident 94's Admission Record indicated Resident 94 was admitted to the facility on [DATE] with diagnoses which included a history of end stage renal disease (the last stage of long-term (chronic) kidney disease when the kidneys are no longer able to carry out their daily functions). A record review of Resident 94's Minimum Data Set (MDS- a nursing assessment tool that is used to develop a plan of care) dated 8/28/24, indicated a Brief Interview for Mental Status (BIMS- developed by reviewing the resident's status during the prior seven-day period) score of 14 points out of 15 possible points which indicated Resident 94 had an intact cognition. A record review of Resident 94's MDS dated [DATE], indicated Resident 94 was coded for dialysis (Section O0100 J1) while a resident at the facility within the last 14 days. On 9/13/24 at 8:44 A.M., a concurrent interview and record review was conducted with the MDS Coordinator (MDSC), in the MDS office. The MDSC stated Resident 94 was admitted on [DATE] with an assessment reference date (ARD) of 8/28/24. The MDSC stated that she completed the MDS and the CAA on 9/5/24 and stated it was completed late. The MDSC stated both the MDS and CAA needed to be completed within 14 days of admission. The MDSC stated it was important that the MDS was completed timely because this triggers the CAA to develop a comprehensive person-centered plan of care for Resident 94's current health status such as dialysis and may cause financial penalties for reimbursement. On 9/13/24 at 1:32 P.M., an interview with the Director of Nursing (DON) was conducted. The DON stated it was important that the MDSC complete the MDS and the CAA in a timely manner for Resident 94 to develop a comprehensive care plan that reflects Resident 94's health status and to prevent health care delays needed to appropriately care for Resident 94. A review of Centers for Medicare and Medicaid Services (CMS, a federal agency) RAI Manual 3.0 October 2023, (Page 4-3) 4.3 What Are the Care Area Assessments (CAAs)? .By statute, the RAI must be completed within 14 days of admission . (Page 5-2) 5.2 Timeliness Criteria .For the Admission assessment, the MDS Completion Date must be no later than 13 days after the Entry [admission] Date .For the Admission assessment, the Care Area Assessment (CAA) Completion Date must be no later more than 13 days after the Entry Date .

Based on interview and record review the facility's Quality Assessment and Assurance Committee (QAA-facility group that monitors concerning trends in a facility) failed to identify and include in the facility's Quality Assurance Performance Improvement plan (QAPI-plan developed by QAA to help improve conditions in the facility), trends identified by surveyors during the recertification survey concerning grooming/hygiene and the cleaning of bi-level positive airway pressure/continuous positive airway pressure machines (BIPAP/CPAP- a type of noninvasive ventilation that helps you breathe). This failure had the potential for the facility to overlook trends in resident care that might have affected residents' dignity and/or health. Cross Reference: F677, F880 Findings: On 9/13/24 at 2:15 P.M., a concurrent interview with the Administrator (ADM) and the Director of Nursing (DON) and a review of QAPI program was conducted. The ADM stated that the main areas that the QAPI team monitored were Falls, Abuse, Staffing and Retention, and Infection Control. In addition, the ADM stated some new areas that QAPI were addressing were Food Preferences and Room Renovations. During the recertification survey, deficient trends in basic grooming (nail care and beard care) and cleaning of CPAP and BIPAP machines were identified by surveyors. The ADM stated that neither of these trends had been identified by the QAA Committee and/or included in the QAPI plan. On 9/13/24 at 3 P.M., an interview with the ADM was conducted. The ADM stated that the expectation was for the QAA Committee to have identified the trends that were identified by the surveyors. In addition, the ADM stated the deficient trends should have been included in the QAPI plan. The ADM stated the importance of the QAA Committee identifying deficient trends and including them in the QAPI plan was to promote the highest standard of care for their residents. On 9/13/24 at 3:05 P.M., an interview with the DON was conducted. The DON stated that the expectation was that the QAA Committee should have identified the trends identified by the surveyors. In addition, the DON stated the deficient trends should have been included in the QAPI plan. The DON stated the importance of QAA Committee identifying trends was to maintain resident dignity (for grooming) and to minimize the risk of infection (CPAP and BIPAP cleaning), and to promote the highest standard of care for their residents. A review of the undated facility policy titled Quality Assurance and Performance Improvement indicated 1. Quality Assessment and Assurance Committee (QAA) .d. Committee functions include .identifying and prioritizing PIP's [Performance Improvement Plan (PIP) is a document that helps employees improve their job performance], implementing actions to correct quality issues, and monitoring to ensure the corrective action implemented being sustained .3. Identification of, and prioritizing of, PIPs through .f. Prioritizing through identification of high-risk, high volume, or problem prone issues .

Based on observations, interviews, and record review, the facility left medications unattended at the bedside for one of eight residents (Resident 80) reviewed for medication storage. These failures had the potential for medication misuse, divergence (another person taking medications or medications used wrongfully), and/or severe allergic complications. Findings: A review of Resident 80's Admission Record indicated Resident 80 was admitted to the facility on [DATE] with diagnoses which included a history of hemiplegia (one sided muscle weakness) and hemiparesis (inability to move one side of the body) following cerebral infarction affecting left dominant side (a brain attack known as a stroke that stops blood flow to the brain causing left sided weakness and movement to the body). A review of Resident 80's admission Minimum Data Set (MDS, a standardized care screening and assessment tool), dated 7/7/24, indicated that Resident 80 understood or understood others, and had no cognitive (mental process involved in knowing, learning, and understanding things) deficits. On 9/10/24 at 10:22 A.M., an observation and interview was conducted with Resident 80, in Resident 80's room. Two eye medications were left unsecured and unattended on top of Resident 80's bedside table. An antifungal powder was also left unsecured and unattended on top of Resident 80's left nightstand table. Resident 80 stated she was unaware that her antifungal (medication to treat fungal and yeast infection on skin) powder was near the top of her left nightstand table. On 9/11/24 at 3:51 P.M., and observation and interview was conducted with Resident 80, in Resident 80's room. Resident 80's eye drops (two) were left unattended and unsecured on top of Resident 80's bedside table. Resident 80 stated the nurses leave her eye drop medications so that she could self-administer the medications. On 9/12/24 at 4:45 P.M., a record review was conducted on Resident 80's medication orders for the medications left at Resident 80's room. Resident 80's medication record indicated an order that included: miconazole nitrate powder Apply to peri area twice a day every day and evening shift for rash Ocusoft Lid Scrub Plus External Pad (Eyelid Cleanser) apply to both eyelids topically one time a day for Blepharitis (inflammation of the eyelids) Ok to self-administer if able Rephresh Tears Opthalmic [eye] Solution 0.5% (Carboxymethylcellulose Sodium (Opth)) [sic] instill 1 drop in both eyes two times a day for dry eyes May leave at bedside for self administration On 9/13/24 at 9:15 A.M., an interview and record review was conducted with LN 2, at the Northside Nursing station. LN 2 stated to leave medications at the bedside an medical doctor (MD) order would need to be obtained. LN 2 stated that prior to getting an MD order to leave medications at the bedside that safety evaluations should be conducted with any residents to self-administer medications to include a return demonstration. LN 2 stated he was unable to find any nursing assessments and/or evaluations for Resident 80 that demonstrates her ability to safely administer her own medications. LN 2 stated it should also be care planned and was unable to find a care plan that indicated a list of self-administration for the two eyedrops. LN 2 stated it was important that Resident 80 was evaluated for safety with self-administration of medications because she could injure herself if not done correctly. LN 2 stated that all medications should be stored in a secure container that is locked such as in a medication cart and if ok to leave at bedside in a Ziploc (plastic bags with a seal) and stored in a secure locked container such as Resident 80's nightstand table that is locked. LN 2 stated it is unsafe to leave any medications unattended because of the potential for the medication to be used on somebody else like Resident 80's roommate that can cause severe allergic reactions from misuse. On 9/13/24 at 1:46 P.M., an interview was conducted with the DON. The DON stated Resident 80's medications should be stored appropriately in a safe and secured container that is locked and not left unattended regardless if an order stated ok to leave at bedside. The DON stated safety evaluations to include return demonstration is needed to determine if medications are still appropriate for self-administration. The DON stated self-medication evaluations should be continuous on a quarterly basis because resident status can change overtime. The DON stated her expectations were for the nursing staff to do medication safety evaluations prior to obtaining orders to keep medications at the bedside and should be stored securely that in a locked container and not left out in the open to avoid medication misuse. The DON further stated her expectations were for the nurses to be at the resident's bedside and watch the residents self-administer their own medications to monitor for any medication side effects and allergic reactions. A review of the facility's policy and procedure titled MEDICATION ADMINISTRATION AND STORAGE undated, indicated .4. Drugs and/or biologicals should not be left unsecured/unattended. Drug deliveries should be stored immediately after delivery and should not be left unattended .

Based on observation, interview, and record review, the facility failed to provide a safe, clean, comfortable, and homelike environments for five of 22 sampled residents (Resident 33, Resident 80, Resident 9, Resident 14 and Resident 54) when: 1. Resident 33's sliding door was stuck in a position that was unable to open and close fully causing safety concerns along with a damaged closet door and an ineffective overhead bed lighting to cause safety and emotional distress for Resident 33. 2. Resident 80's telephone wall jack was detached and hanging from the wall causing the telephone line to dangle with concerns for pests and safety concerns to cause accidents. 3. Resident 9, Resident 14 and Resident 54's rooms were not comfortable. These failures have caused and/or had the potential to place residents, staff, and visitors at risk for harm due to safety concerns and emotional distress. Findings: 1. A review of Resident 33's Admission Record indicated Resident 33 was admitted to the facility on [DATE] with diagnoses which included a history of spastic paraplegia (group of rare inherited disorders that cause weakness and stiffness in the leg muscles). A review of Resident 33's admission Minimum Data Set (MDS, a standardized care screening and assessment tool), dated 8/2/24, indicated that Resident 33 understood or understood others, and had no cognitive (mental process involved in knowing, learning, and understanding things) deficits. On 9/10/24 at 10:04 A.M., an interview was conducted with Resident 33, in Resident 33's room. Resident 33 stated he had notified the maintenance director directly over a month ago that his sliding door was busted since his current admission to the facility. Resident 33 stated he was frustrated and upset because there were times that it was hot outside, and the heat comes in making the temperature uncomfortable for him. Resident 33 also stated that he wanted a lock on his nightstand table to store some belongings and that he notified the maintenance director about this as well. Resident 33 stated because of the lack of storage space and the convenience for staff some items were stored on top of his overhead bed light (baseball cap, urinal, soft case, and sunglasses). Resident 33 also stated that his closet door by the entry had a doorknob sized hole and that his overhead bed light had a broken secondary light that was not working and stated it was important for him that it worked to be comfortable to adjust if he needed more light for reading or relaxing. Resident 33 stated he felt anxious about his safety with the sliding door not opening or closing all the way and stated in an emergency with his built (over 150 lbs) and him relying on his wheelchair that he would not be able to fit through the sliding door opening and exit from the facility. A review of Resident 33's MDS Prior functioning: Everyday Activities (Section GG 0100B) indicated, Resident 33 was not independent with ambulation (walking) and required partial assistance from another person to complete any activities. On 9/12/24 at 10:22 A.M., an observation and interview was conducted with the Director of Maintenance (DOM), in Resident 33's room. Resident 33's room closet door had a doorknob sized hole, the sliding door opening was the size of a standard printer paper (8x11) landscape width and the overhead bed light turned off. The DOM stated that he found out about the door yesterday and that he was going to fix it and stated he knew about the sliding door about a month ago. The DOM stated that he had already contacted an outside contractor to fix it and would bring the receipt or contact document to show as proof that he had contacted an outside contractor. The DOM stated he did not have a date for when the outside contractor would come out to get the sliding door fixed and stated he will get a lock for Resident 33's nightstand table. The DOM tested the sliding door and was unsuccessful with trying to shut the sliding door to fully close or open. The DOM tested Resident 33's overhead bed light with the secondary light not working. On 9/12/24 at 10:26 A.M. an interview was conducted with the DOM and Resident 33, in Resident 33's room. Resident 33 expressed his frustration with the DOM and stated I've told you more than once about that sliding door and the closet. You come in and you say nothing to me. Resident 33 also stated to the DOM I was not notified of what you would do about it (pointing at sliding door). The DOM stated Resident 33's secondary light should be in working condition due to visibility and safety and stated that the sliding door needed to be fixed right away because Resident 33 cannot escape and it's a health and fire hazard along with possible pests that can get inside the room. The DOM stated he conducts monthly room inspections and documents them on his computer in his office. On 9/12/24 at 10:30 P.M., a concurrent interview and record review was conducted with the DOM, in the DOM office. The DOM stated that residents at the facility can call him directly for any maintenance problems or submit work tickets electronically. The DOM showed a computer screen of work tickets and stated room inspections would be documented here. The DOM was unable to pull a record within the last 3 months of room inspections. On 9/12/24 at 2:54 P.M., an interview was conducted with CNA 6. CNA 6 stated she does not document maintenance concerns and instead personally reaches out to maintenance department to let them know of any broken furniture, fixtures or equipment that needed to be fixed. On 9/12/24 at 3:00 P.M., an interview was conducted with the Activities Director (AD). The AD stated if there were maintenance concerns with anything that needed to be repaired or was broken that she would notify the maintenance department and let them know. The AD also stated that both stations have maintenance logs that staff can also use to let the maintenance department know. On 9/12/24 at 3:12 P.M., an interview was conducted with LN 4, at the Northside nursing station. LN 4 stated she reports to the maintenance department via a group chat line and if she was unable to report it through the group chat, she would notify the administrator directly. LN 4 stated she does not document maintenance concerns in the maintenance log. On 9/12/24 at 3:50 P.M., an interview was conducted with the DOM, in the conference room. The DOM brought a copy of an email he sent to a contractor company to fix Resident 33's sliding door. The email was sent on Thursday, September 12, 2024 [sic] 3:40 P.M. to the contractor company. The email stated Hello, Please [sic] see below for your payment for today's transaction. The appointment for your sliding glass door inspection is scheduled for Tuesday 09/17/24 . The DOM admitted that he did not contact an outside contractor for the sliding door as from previous interview and stated I just contacted them today. On 9/13/24 at 1:37 P.M., an interview was conducted with the Director of Nursing (DON). The DON stated it was unacceptable that Resident 33's sliding doors were unable to completely open and shut. The DON stated that it was a fire hazard and a safety concern and stated we don't want things from the outside (animals, people, debris, heat, rain) coming in that can enter Resident 33's room. The DON's expectations was for the maintenance team to also fix Resident 33's broken items such as the closet door, overhead bed light to prevent safety hazards and a lock on Resident 33's nightstand tables as requested and to be as homelike as possible that is comfortable for the Resident 33. A review of the facility's policy and procedure titled SAFE AND HOMELIKE ENVIORNMENT undated, indicated .3. Housekeeping and maintenance service will be provided as necessary to maintain a sanitary, orderly, and comfortable environment .5. The Facility will provide sufficient individual closet space in each resident room .7. The facility will maintain comfortable and safe temperature levels .9. The facility will ensure the equipment's are maintained per manufacture's guideline and as needed . The policy did not indicate the frequency for routine room inspections to promote safe and homelike environments. 2. A review of Resident 80's Admission Record indicated Resident 80 was admitted to the facility on [DATE] with diagnoses which included a history of anxiety (feelings of fear, dread, and uneasiness that may occur as a reaction to stress). A review of Resident 80's admission Minimum Data Set (MDS, a standardized care screening and assessment tool), dated 7/7/24, indicated that Resident 80 understood or understood others, and had no cognitive (mental process involved in knowing, learning, and understanding things) deficits. On 9/10/24 at 10:22 A.M., an observation and interview was conducted with Resident 80, in Resident 80's room. The wall behind Resident 80's headboard centered to left side of the room above the floor had a landline telephone socket with exposed wires dangling off the wall with a hand fist sized opening on the top of the telephone socket. Resident 80 stated she felt uncomfortable and stated I think there's bugs that come out of there. It's not a good site at all. Resident 80 stated the phone outlet had been dangling off the wall for about a week and a half and stated she felt uneasy that it would cause accidents such as falls from someone tripping over the phone cords with her visitors or staff. On 9/11/24 at 3:51 P.M., an observation and interview was conducted with Resident 80, in Resident 80's room. Resident 80 stated that the phone outlet was still not fixed and that it had been broken 3 times since her admission to the facility. Resident 80 stated she had called maintenance to fix the outlet, but they still did not fix it correctly. On 9/12/24 at 10:30 P.M., a concurrent interview and record review was conducted with the Director of Maintenance (DOM), in the DOM office. The DOM stated that residents at the facility can call him directly for any maintenance problems or submit work tickets electronically. The DOM showed a computer screen of work tickets and stated room inspections would be documented here. The DOM was unable to pull a record within the last 3 months of room inspections. On 9/12/24 at 10:37 AM an observation and interview was conducted with the DOM, in Resident 80's room. The DOM stated Resident 80's telephone socket should not be dangling of the wall. The DOM stated the wires exposed was not a fire hazard but stated that it was safety hazard for falls, and insects that can come out from the opening of the telephone socket. The DOM attempted to screw back the telephone socket but was unsuccessful and remained dangling off the wall. The DOM stated the wall may need to be replaced. On 9/12/24 at 10:41 A.M., an interview was conducted with Resident 80, in Resident 80's room. Resident 80 stated I have told Maintenance about it but it's hard to get them to come. Resident 80 stated the telephone socket was still dangling off the wall. On 9/12/24 at 2:54 P.M., an interview was conducted with CNA 6. CNA 6 stated she does not document maintenance concerns and instead personally reaches out to maintenance department to let them know of any broken furniture, fixtures or equipment that needed to be fixed. On 9/12/24 at 3:00 P.M., an interview was conducted with the Activities Director (AD). The AD stated if there were maintenance concerns with anything that needed to be repaired or was broken that she would notify the maintenance department and let them know. The AD also stated that both stations have maintenance logs that staff can also use to let the maintenance department know. On 9/12/24 at 3:12 P.M., an interview was conducted with LN 4, at the North side nursing station. LN 4 stated she reports to the maintenance department via a group chat line and if she was unable to report it through the group chat, she would notify the administrator directly. LN 4 stated she does not document maintenance concerns in the maintenance log. On 09/13/24 at 1:44 P.M., an interview was conducted with the Director of Nursing (DON). The DON stated that Resident 80's room should promote safety and a homelike environment that is comfortable for her. The DON stated her expectations was for the phone outlet to not be dangling off the wall and if the wall needs to be repaired to repair it since attempts to fix the outlet were unsuccessful. The DON stated Resident 80 should be as comfortable with her surroundings to prevent any uneasiness she feels with pests coming out of the socket and to prevent fall hazards. A review of the facility's policy and procedure titled SAFE AND HOMELIKE ENVIORNMENT undated, indicated .3. Housekeeping and maintenance service will be provided as necessary to maintain a sanitary, orderly, and comfortable environment .9. The facility will ensure the equipment's are maintained per manufacture's guideline and as needed . The policy did not indicate the frequency for routine room inspections to promote safe and homelike environments. 47956 3. On 09/10/2024 at 1:25 P.M., an observation was conducted of Resident 9's room. Resident 9's telephone jack located on the wall behind the head of the bed was observed to dangling from the wall. On 9/10/2024 at 1:40 P.M., an observation was conducted of Resident 54's room. Resident 54's wall at the head of the bed was observed to have multiple areas of repaired drywall. On 9/10/2024 at 2:45 P.M., an observation was conducted of Resident 14's room. Resident 14's wall was observed to have a green-grey discoloration approximately twenty-four inches in length and fifteen inches in height at its highest point. On 9/15/2024 at 9:20 A.M., an observation was conducted Resident 14's room. Resident 14's wall was observed to have been covered by a Fiberglass Reinforced Panel (FRP). On 09/15/2024 at 9:25 A.M., an interview was conducted with the Director of Nursing (DON). The DON stated That is a wall protector, it is affixed to the wall. It is common when there are heavy scrapes. It does not really match the wall, but it is only temporary. If it was my house, I would fix the wall instead of putting that up. On 9/15/2024 at 9:30 A.M., an interview was conducted with the Director of Maintenance (DOM). The DOM stated It is an FRP panel, to prevent scratches. It is only temporary until we can clean, paint, and re-protect the area and have the area tested . I wouldn't use an FRP at home. On 9/15/2024 at 9:33 A.M. an interview was conducted with the Administrator (ADM). The ADM stated We are aware, we have an older facility. It is a capital expenditure. We have bids out. Repairs are for walls and handrails. A review of Facility Policy and Procedure, titled Safe and Homelike Environment undated, indicated .the facility will provide a safe, clean, comfortable and homelike environment

Based on observation, interview, and record review, the facility failed to treat two of seven residents reviewed for resident rights, in a dignified manner when staff stood over while feeding the residents (Resident 63 and Resident 67). In addition a resident (Resident 65) was served food in a Styrofoam (foam-like) food container. This deficient practice had the potential for residents' self-esteem and self-worth to be devalued and as a result Resident 65 had a difficult time with self feeding requiring feeding assistance from the nursing staff. Findings: 1. Resident 63 was readmitted to the facility on [DATE] with diagnoses including unspecified Alzheimer's disease (a brain disorder that slowly destroys memory, thinking skills and eventually the ability to carry out simple tasks) and dementia (a condition characterized by loss of memory, language, problem solving and other thinking abilities) according to the facility's Admission Record. During an observation on 9/10/24 at 8:41 A.M., a staff member was observed sitting next to Resident 63's bed assisting Resident 63 with feeding. Resident 63's eyes were closed but Resident 63 was chewing the food and opened his eyes when greeted. A review of Resident 63's care plans were conducted. Resident 63's care plan for activities of daily living (ADL-basic tasks of everyday life) initiated on 12/17/21 indicated, .ADL Self Care Performance Deficit r/t [related to]assistance required in ADLs . Resident 63's nutritional care plan initiated on 12/17/21 indicated, .Interventions .1:1 [one on one] Feeding assistance for all meals .Date initiated: 9/11/24 . During a joint observation and interview on 9/10/24 at 12:29 P.M., Resident 63 was observed sitting up in bed having lunch. A staff member was observed feeding Resident 63 standing next to Resident 63. Licensed nurse (LN) 11 observed the staff member standing and stated he expected certified nurse assistants (CNA) to sit while feeding residents. LN 11 stated if he was the resident, he would feel intimidated if someone was standing to feed him. During an interview on 9/13/24 at 2:04 P.M. with the Director of Nurses (DON), the DON stated staff should assist in the appropriate height based on the resident's need to maintain dignity. A review of the facility's undated policy and procedure (P&P) titled, Resident Rights was conducted. The P&P indicated, .The Resident has the right: 1. To be treated with consideration, respect, and full recognition of his or her dignity and individuality . 2. Resident 67 was admitted to the facility on [DATE] with diagnoses including unspecified dementia (a condition characterized by loss of memory, language, problem solving and other thinking abilities) according to the facility's Admission Record. During an observation on 9/10/24 at 9:41 A.M., Resident 67 was in bed and did not respond when greeted, but with good eye contact. A review of Resident 67's care plans were conducted. Resident 67's undated care plan for ADLs indicated, .has ADL Self Care Performance Deficit r/t [related to] assistance with ADLS .EATING: Requires total assistance to eat . The undated nutritional care plan indicated, .Interventions .1:1[one on one] feed . Resident 67 was observed during mealtime on 9/10/24 at 12:23 P.M. Resident 67 was in bed in a sitting position with a staff member feeding Resident 67. The staff member was standing at bedside while feeding Resident 67. A joint observation on 9/10/23 at 12:29 P.M. was conducted with licensed nurse (LN) 11. LN 11 observed Resident 67 being fed while a staff member was standing. LN 11 stated he expected certified nurse assistants (CNA) to sit while feeding residents. LN 11 stated if he was the resident, he would feel intimidated if someone was standing to feed him. During an interview on 9/13/24 at 2:04 P.M. with the Director of Nurses (DON), the DON stated staff should assist in the appropriate height based on the resident's need to maintain dignity. A review of the facility's undated policy and procedure (P&P) titled, Resident Rights was conducted. The P&P indicated, .The Resident has the right: 1. To be treated with consideration, respect, and full recognition of his or her dignity and individuality . 48263 3. A review of Resident 65's Admission Record indicated Resident 65 was admitted to the facility on [DATE] with diagnoses which included a history of traumatic brain injury (an injury to the brain caused by a trauma to the head) and anxiety (feelings of fear, dread, and uneasiness that may occur as a reaction to stress). A record review of Resident 65's Minimum Data Set (MDS- a nursing assessment tool that is used to develop a plan of care) dated 9/5/24, indicated a Brief Interview for Mental Status (BIM- developed by reviewing the resident's status during the prior seven day period) score of 6 points out of 15 possible points which indicated Resident 65 had severe cognitive (pertaining to memory, judgement and reasoning ability) deficits. On 9/10/24 at 9:08 A.M., an observation and interview was conducted with Resident 65, in Resident 65's room. Resident 65 was in bed in an upright position wearing a hospital gown and stated, I'm hungry for more food. Resident 65 pressed the call light and told CNA 1 that he wanted to get changed and asked for a breakfast tray. CNA 1 returned with a Styrofoam food container that included a fried egg with scattered ketchup on top of the eggs. Resident 65 grabbed his adaptive fork(eating utensil/specialized tool designed to help individuals with physical disabilities, motor impairments, and cognitive issues) with his right hand. His right hand was shaking as he tried to lift his fork high enough to grab on to the eggs, due to the edges of the Styrofoam container that caused a barrier to lift the fork and grab the eggs. Resident 65 stated they [the facility] don't usually serve my meals like this in a container box. Resident 65 stated he preferred to eat the food that was served to him, on a regular food tray in order for him to eat independently. Resident 65 stated he was having a hard time feeding himself, and then used the call light to call CNA 1. On 9/10/24 at 9:17 A.M., an observation and interview was conducted with Resident 65 and CNA 1, in Resident 65's room. Resident 65 told CNA 1 that he needed help to eat because he was having a hard time scooping the food with his fork. CNA 1 stated that Resident 1 goes to the dining room during lunch for restorative nursing assistant (RNA) dining, but usually had no problem feeding himself during breakfast. CNA 1 stated that when they ask the kitchen staff for an extra meal for a resident, they serve the meals in Styrofoam containers. CNA 1 stated that Resident 65 had a breakfast tray prior, as to why the extra meals were in Styrofoam food containers because it was convenient for staff. On 9/11/24 at 12:45 A.M., an observation and interview was conducted with the Dietary Supervisor (DS). The DS stated that they have a list of residents who preferred using plastic utensils or other dishware such as Styrofoam, to honor preferences. On 9/11/24, a document provided by the DS was reviewed. The document titled Residents that Prefer and or Recommended to use Plastic Utensils or Dishware . did not include Resident 65 on the list. On 9/12/24 at 3:22 P.M., an interview was conducted with CNA 5. CNA 5 stated sometimes they'll [kitchen staff] put food in a Styrofoam container and stated, maybe it's easier to give. CNA 5 stated she has not seen a preference list that lists residents for dishware use. On 9/12/24 at 3:27 P.M., an interview was conducted with LN 3. LN 3 stated it was only appropriate to serve a meal in a Styrofoam container if it was a preference for a resident because it was a resident's right to choose an alternate dishware. LN 3 stated there were only a few residents that preferred different dishware and Resident 65 was not one of them. LN 3 stated this would be a dignity concern for Resident 65 because this was not his preference to be served in a Styrofoam container and should be treated with respect to promote his independence and well-being. On 9/12/24 at 8:26 A.M., an interview and record review was conducted with LN 2. LN 2 stated Resident 65 was able to feed himself for breakfast and dinner but goes to RNA dining during lunch only. LN 2 stated Resident 65's meals should not be served in a Styrofoam container because he required adaptive eating utensils (built up fork and scoop dish) to promote self-performance with eating. LN 2 stated Resident 65 should be treated with dignity. On 9/13/24 at 1:13 P.M., an interview with the Director of Nursing (DON) was conducted. The DON stated Resident 65 should be treated according to his choices and preferences should be honored in a dignified manner. The DON stated that the kitchen staff should be preparing meals on dishware that was appropriate for Resident 65 and not served on a Styrofoam container to promote independence and dignity. A review of the facility's policy and procedure titled RESIDENT RIGHTS undated, indicated . 1. To be treated with consideration, respect, and full recognition of his or her dignity and individuality .

Based on interviews, and record review, the facility failed to accurately code the Minimum Data Set (MDS: a nursing assessment tool) for one of two residents (Resident 45) reviewed for dementia care. As a result, the facility sent Resident 45's MDS to the federal database with inaccurate picture of the Resident 45's current health status. Findings: A review of Resident 45's Admission Record indicated Resident 45 was admitted to the facility on [DATE] with diagnoses which included a history of bipolar (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration). A record review of Resident 45's Minimum Data Set (MDS- a nursing assessment tool that is used to develop a plan of care) dated 9/3/24, indicated a Brief Interview for Mental Status (BIMS- developed by reviewing the resident's status during the prior seven-day period) score of 10 points out of 15 possible points which indicated Resident 45 had moderate cognitive (pertaining to memory, judgement and reasoning ability) deficits. On 9/12/24 at 1:33 P.M., an interview and record review was conducted with the Minimum Data Set Coordinator (MDSC). The MDSC stated she was unable to find a diagnosis of dementia (the loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities) written by a physician or anywhere in Resident 45's current and past medical record within the last 14 days of the assessment reference dated (ARD: Date of MDS) 9/3/24. The MDSC stated she was following the previous coding from the previous MDS assessments to code the dementia diagnosis. The MDSC stated only active diagnosis within the last seven days should be coded on the MDS. The MDSC stated she did not code Resident 45's MDS accurately for dementia. The MDSC stated it was important to accurately code the MDS because the MDS had to reflect Resident 45's current health status which drives the plan of care that is triggered to appropriately meet Resident 45's individual needs and would cause misinformation to treat Resident 45 for dementia care. The MDSC further stated that information from the MDS gets sent to State and Federal databases and that she needed to modify Resident 45's MDS. On 9/13/24 at 1:32 P.M., an interview with the Director of Nursing (DON) was conducted. The DON stated it was important that the MDSC accurately codes Resident 45's MDS because the MDS triggers the plan of care for Resident 45. The DON stated if Resident 45 does not have a diagnosis of dementia then this would cause inaccurate care for dementia and cause confusion with reporting giving an inaccurate picture of Resident 45's health status. The DON stated her expectations was for the MDSC to code accurately according to the Resident Assessment Instrument (RAI: MDS manual) and to modify the MDS and re-submit to the Federal databases. A review of Centers for Medicare and Medicaid Services (CMS, a federal agency) RAI Manual 3.0 October 2023, (Page I-5) Section I4800: Non-Alzheimer's Dementia .Active Diagnosis in the last 7 days-check all that apply

Based on observation, interview and record review, the facility failed to immediately follow up on one of 21 residents (Resident 39) who, had a reported abnormally low blood pressure (When the pressure of circulation blood against the walls of blood vessels read below ,d+[DATE] mmHg). As a result, Resident 39 developed an acute change in condition (sudden clinically important deviation from a resident's baseline to prevent complications) which resulted in unresponsiveness and death. Findings: Resident 39 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An initial tour of the facility was conducted on [DATE] at 9:13 AM. Resident 39 was observed on [DATE] at 9:13 during the initial tour, seated in his wheelchair next to his bed. Resident 39's body was positioned slumped over on the bed. In addition, during the initial tour, Resident 39's name was called and there was no response from Resident 39. A concurrent interview and observation with a Licensed Nurse (LN 22) was conducted on [DATE] at 9:14 AM. LN 22 was made aware of Resident 39's unresponsiveness during the interview. LN 22 did not have any comment during the interview and was then observed to have entered Resident 39's room, assessed Resident 39, initiated a Rapid Response (assessment of treatment needed for life sustaining measures), and then instructed staff to call 911. An observation of two Licensed Nurses LN 3, LN 22, one Infection Prevention Nurse (IP) and 1 Certified Nurse Assistant (CNA 23) was conducted on [DATE] at 9:15 AM. The 2 LNs, the IP and CNA 23 carried Resident 39 from his wheelchair to the floor then performed CPR (Cardiopulmonary resuscitation) on Resident 39. An observation of the arrival of EMS (Emergency Medical Services) personnel was conducted on [DATE] at 9:30 AM, and during the arrival, the EMS staff initiated ACLS (Advanced Cardiovascular Life Support) for Resident 39. An interview with LN 22 was conducted on [DATE] at 9:35 AM. LN 22 stated, CNA 23 said the [Resident 39's] blood pressure was low this morning but could not remember what the blood pressure reading was. LN 22 stated, Resident 39 was scheduled for [CONDITION(S)] with a chair time of 8:30 AM. LN 22 further stated, Usually, they pick him [Resident 39] up around 7:20 AM but today he said he did not want to be picked up unless it was a gurney pick up and this was a new request. LN 22 further stated, When [Resident 39] said he did not want to go unless it was a gurney transport, I did not ask why he didn't want to go; he has a history of refusing [CONDITION(S)], I assumed he was too weak to go on a wheelchair transport. An observation of facility staff and EMS personnel, who continued to provide CPR for Resident 39, was conducted on [DATE] at 9:48 AM. An observation of EMS personnel was conducted on [DATE] at 9:58. The EMS personnel stated, The medical doctor has called time of Death at 9:58 AM. A record review was conducted on [DATE]. Resident 39's progress notes indicated; the last set of vital signs (measurement of essential body functions including heartbeat, respiration rate, temperature and blood pressure) were last taken on the NOC (work shift from 11 P.M. to 7 A.M.) shift on [DATE] at 12:40 AM. Resident 39's blood pressure reading at 12:40 AM was ,d+[DATE] and his pulse was 81. On [DATE] at 10 AM Resident 39's roommate (Resident 37) was interviewed. Resident 37 stated, They knew about his [Resident 39] low blood pressure. I heard the CNA [CNA 23] say, Wow, your blood pressure is very low. The CNA [CNA 23] said the blood pressure [Resident 39] was 74 and 80. The CNA [CNA 23] kept taking the blood pressure over to make sure it was right. The CNA [CNA 23] told the nurse about the low blood pressure. The nurse came in an hour later to see [Resident 39]. On the NOC shift he [Resident 39] was very lethargic, he had horrible diarrhea. Resident 37 further stated, They knew about the low blood pressure for 2 hours. An interview with CNA 23 was conducted on [DATE] at 10:45 AM. CNA 23 stated, I took the resident's [Resident 39]'S vital signs at 6:30 AM on [DATE], the first blood pressure reading was ,d+[DATE], the pulse was 45. The second blood pressure reading was ,d+[DATE], the pulse was 39. The third blood pressure reading was ,d+[DATE], the pulse was 50. The Resident [Resident 39] said he wasn't feeling well. I told him I was going to bring his breakfast tray. The resident [Resident 39] said he didn't want to eat. I let the charge nurse know and I told the med nurse (licensed nurse who administers medication) then I went to another resident's room. Normally, in the morning, the Resident's [Resident 39]'s systolic blood pressure (maximum pressure the heart exerts while beating) is in the130's and the diastolic pressure (amount of pressure in the arteries between beats) is in the 70s. An interview with LN 24 was conducted on [DATE] at 11 AM. LN 24 stated, As the resident [Resident 39] was getting ready for his [CONDITION(S)] appointment, he said he was not feeling well, his blood pressure was ,d+[DATE], his pulse was 79. He said his stomach was upset, lots of gas. LN 24 said she held his blood pressure medication and went to check his orders to see if there was medication for his upset stomach. LN 24 said she held the blood pressure meds on [DATE] at 7:58 AM but was not able to get medication for Resident 39's stomach as she was distracted by another resident. An interview with CNA 25 was conducted on [DATE] at 6:25 AM. CNA 25 stated, I worked on the NOC shift on [DATE], at 12:40 AM, I took the resident's [Resident 39]'s vital signs, it was normal. The resident [Resident 39] called for assistance to go to the bathroom two times during my shift. The first time was at 3 am. Normally, the resident [Resident 39] could stand and bear weight on his right leg and was able to bear a little weight on the left leg. On this night, the resident [Resident 39] was not able to stand. A CNA [CNA 31] and I helped the resident [Resident 39] transfer from his wheelchair to the toilet. At this time, the resident [Resident 39] said he wasn't feeling well, and he wanted to cancel [CONDITION(S)] that morning. CNA 25 further stated, I told the licensed nurses [LN 26], [LN 27] immediately that the resident [Resident 39] said he did not want to go to [CONDITION(S)] this morning. CNA 25 stated, The licensed nurse [LN 26] said she would talk with the resident [Resident 39]. CNA 25 further stated, At 6 AM, the resident [Resident 39] said he needed to go to the toilet again. CNA 25 stated, A CNA [CNA 31] and I helped the resident [Resident 39] to the toilet. CNA 25 stated, At around 6:30 AM, I asked a CNA [CNA 23] to help me transfer the resident [Resident 39] on to the wheelchair from the toilet and that he [Resident 39] wanted to cancel his [CONDITION(S)] that morning. CNA 25 stated, When I left, CNA 23 was taking Resident 39's blood pressure. An interview with LN 27 was conducted on [DATE] at 7 AM. LN 27 stated, While I was working at the facility on [DATE], at 7 AM, a CNA [CNA 25] told me the resident [Resident 39] changed his mind [after reporting at 3 AM that he did not want to go to [CONDITION(S)]] and that he did want to go to [CONDITION(S)]. No one told me he had low blood pressure. LN 27 stated, The nurse should have done a thorough assessment to find out why he didn't want to go to [CONDITION(S)]. A change in vital signs, like an abnormally low blood pressure would be considered a change in condition, the nurse should have used a manual blood pressure cuff and stethoscope to retake the blood pressure. An interview with LN 22 was conducted on [DATE] at 3:45 PM. LN 22 stated, I saw the resident (Resident 39) at 7:20 AM on [DATE]. He was fine and appropriate. The resident (Resident 39) has episodes of refusing [CONDITION(S)]. He wanted to be transported on a gurney, I'm guessing he was feeling weak. LN 22 further stated, I did not retake his blood pressure. The CNA took the blood pressure a few times. The CNA must have given it to the med nurse. The blood pressure should have been repeated manually. The med nurse would normally do this. An interview with LN 24 was conducted on [DATE] at 3:55 PM. LN 24 stated, The resident [Resident 39] did not want to go to [CONDITION(S)]. He was complaining about an upset stomach. I notified the supervisor [LN 22]. The resident not wanting to go to [CONDITION(S)] and having an upset stomach was a change but the NOC nurse [LN 26] did not report that the resident [Resident 39] was having any change in condition. A CNA [CNA 23] reported the low blood pressure to me. LN 24 stated, When the CNA [CNA 23] reported the low blood pressures to me, I tried to retake the blood pressure but was only able to get a systolic of 80. We were not getting a diastolic reading. I held the resident's [Resident 39] blood pressure medications, I did not call the doctor. A concurrent review of Resident 39's [CONDITION(S)] care plans and interview with the Director of Nursing (DON) was conducted on [DATE] at 8:30 AM. The DON stated, The resident [Resident 39] has refused [CONDITION(S)] in the past. Review of Resident 39's care plans did not indicate Resident 39's episodes of refusing to go to [CONDITION(S)]. An interview with LN 28 was conducted on [DATE] at 2:10 PM. LN 28 stated, A change of condition should be followed up by physically going to the resident having the change of condition. Any systolic below 100 and diastolic below 60 reported by a CNA must be re-assessed manually by the licensed nurse. If a low blood pressure or low pulse warrants an intervention, the doctor should be called. An interview with LN 29 was conducted on [DATE] at 2:22 PM. LN 29 stated, For all my residents who take blood pressure medications, I take their blood pressure readings manually with a stethoscope. If the blood pressure is low, I let the charge nurse know, then I let the doctor know. An interview with LN 30 was conducted on [DATE] at 3:38 PM. LN 30 stated, When a resident has a change of condition, like a low blood pressure, I verify it myself. I go to the resident and do a full assessment. Then report it to the charge nurse and doctor. An interview with the Director of Staff Development (DSD) was conducted on [DATE] at 3:40 PM. The DSD stated, If a CNA reports that they already checked an abnormal blood pressure two times, at two different sites, and the blood pressure is still low or high, the licensed nurse must recheck it right away. If the blood pressure is not normal, assess the resident head to toe. If the resident is experiencing a change in condition, the doctor must be notified. A concurrent interview and record review was conducted with the DON on [DATE] at 10:28 AM. The DON stated, When the licensed nurse [LN 24] got the systolic of 80 and was unable to get a diastolic reading, it was a big opportunity for the licensed nurse [LN 24] to do a thorough assessment. The licensed nurse [LN 24] did not record the low blood pressure. Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no documentation of a low blood pressure. There was no documentation in the nurse's progress notes to explain the change in the Resident 39's condition. Review of the facility's document titled Job Description Registered Nurse, dated [DATE], indicated, Essential Duties and Responsibilities .Examine the resident and his/her records and charts to distinguish between normal and abnormal findings in order to recognize early stages of serious physical, emotional or mental problems .Determine when to refer the resident to a physician for evaluation, supervision, or directions .Chart all changes in resident condition and the response to those changes . Review of the facility's document titled Job Description License Vocational Nurse/Licensed Practical Nurse, dated [DATE], indicated . Examine the resident and his/her records and charts to distinguish between normal and abnormal findings in order to recognize early stages of serious physical emotional or mental problems .Determine when to refer the resident to a physician for evaluation, supervision, or directions .Cart all changes in resident condition and the response to these changes . An interview with the Medical Director (MD) was conducted on [DATE] at 2:24 PM. The MD stated, One abnormally low blood pressure would have alerted me. If I were a nurse and two low blood pressures were reported to me, I would believe it. MD further stated, If the resident said he is not feeling well, I would expect the nurse to examine the resident. Is he drowsy? Does he have orthostatic blood pressure (Blood pressure changes during position changes of lying, sitting, standing)? After the third blood pressure below 80, I should have been called. Review of the facility's undated policy titled; Change of Condition Reporting indicated It is the policy of this facility that all changes in resident condition will be communicated to the physician .Acute Medical Change .1. Any sudden or serious change in a resident's condition manifested by a marked change in physical or mental behavior will be communicated to the physician with a request for physician visit promptly and/or acute care evaluation. The licensed nurse in charge will notify the physician.