Every finding on record at Villa Maria Post Acute

Based on interview and record review, the facility failed to ensure one of one sampled residents (Resident 83) had a qualified licensed nurse perform their initial comprehensive nursing assessment.This failure had the potential for Resident 83 to not have a complete initial comprehensive nursing assessment and not have all their needs met.During a review of Resident 83's admission Record (AR), dated 7/25/25, the AR indicated, Resident 83 was a [AGE] year old, admitted [DATE] with diagnoses including, heart failure (the heart not able to pump enough blood to meet the body's needs), atrial flutter (uncoordinated beating of the heart), diabetes (the body is not able to turn food into energy), and cognitive communication deficit (problems with communication).During a review of Resident 83's Initial admission Record ([IAR] a comprehensive assessment,) dated 4/25/25, the IAR indicated, Neuro/Mental [brain function assessment].EENT [eye, ear, nose, mouth assessment]. Oral Assessment. Cardiovascular System [heart assessment]. Pulmonary System [breathing assessment]. Bowel and Bladder. Gastrointestinal System [digestive system]. Musculoskeletal System [muscle and bone system]. Current Infections. Behavior, were all signed by a LPN [licensed vocational nurse (LVN)]. Review of the California Association of Long-Term Care Medicine (CALTCM) website indicated, The RN is to perform the nursing process, which includes a clinical assessment. Similarly, the LVN has the authority to conduct basic patient assessments. The limitation is that, in California, the LVN is not allowed to conduct comprehensive health assessments.During a review of the facility's policy and procedure (P&P) titled, Admission, dated 2/2023, the P&P indicated, Licensed Nurse Procedure. Do a complete assessment of body systems and complete admission assessment form and nursing notes.During an interview on 7/24/25 at 4:42 p.m. with the Assistant Director of Nursing (ADON), the ADON stated there wasn't any evidence of the RN oversight during the admission assessment and there should have been.During a review of Barclays Official California Code of Regulations website indicated, The licensed vocational nurse performs services requiring technical and manual skills which include. Uses and practices basic assessment (data collection) . Performs basic nursing services.

Based on interview and record review, the facility failed to ensure one of one sample residents (Resident 83), had a nursing note recorded in their medical record following the completion of the comprehensive assessment on admission to the facility.This failure resulted in an incomplete record of Resident 83's nursing home stay and had the potential to hinder communication among Resident 83's interdisciplinary team ([IDT], a group of healthcare professionals who work together to achieve resident comprehensive goals).During a review of the facility's policy and procedure (P&P) titled, Admission, dated 2/2023, the P&P indicated, Purpose. Obtain information about the resident to establish baseline data for the MDS and provide the basis for interdisciplinary assessment, care planning, and rehabilitation of each Resident. Licensed Nurses Procedure . Do a complete assessment of body systems and complete admission form and nursing notes.During a review of Resident 83's electronic medical record (eMR), no admission nursing note was found.During an on 7/24/25 at 4:42 p.m. with the Assistant Director of Nursing (ADON), the ADON stated he was aware there was no admission nursing note. ADON also stated there should have been one.

Based on observation, interview, and record review, the facility failed to ensure one of five sampled residents (Resident 6) had an appropriately sized waste bin for safely discarding used personal protective equipment (PPE), a gown worn over clothing for protecting the wearer from infection.This failure had the potential to result in the increased risk of spreading infection to residents, staff, and visitors.During an observation on 7/23/25 at 2:28 p.m. in Resident 6's room, there was a small, beige, uncovered, waste bin overflowing onto the floor with a discarded yellow PPE gown. During a review of the facility's policy and procedure (P&P) titled, Infection Prevention and Control Program, dated 1/2025, the P&P indicated, The infection prevention and control program is a facility-wide effort involving all disciplines and individuals. The facility will use effective methods for the safe storage, transport and disposal of garbage, refuse and infectious waste.During a concurrent observation and interview on 7/23/25 at 2:30 p.m. with a certified nursing assistant (CNA 1) in Resident 6's room, the waste bin with the discarded yellow PPE gown hanging out it and onto the floor was observed. CNA 1 stated Resident 6 was on enhanced transmission precautions (ETP) wearing of PPE gown and gloves to reduce the spread of multi-drug-resistant germs) and the gown should have been discarded into a larger trash can with a lid. During an interview on 7/23/25 at 2:35 p.m. with the Administrator (ADM), the ADM stated he was aware of the PPE gown hanging out of the waste bin because CNA 1 had informed him. ADM further stated the waste bin should have a lid on it.

Based on observation and interview, the facility failed to ensure two of two sampled residents (Residents 72 and 49) had a comfortable environment when foul smelling dirty linen was left in the linen cart in the hallway. This failure resulted in an uncomfortable living environment. During a review of the facility's policy and procedure (P&P) titled, Environmental Conditions / Environmental Rounds, dated 1/2025, the P&P indicated, It is the policy of this facility that the facility must provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public.During an interview on 7/23/25 at 10:15 a.m. with Resident 72, Resident 72 stated the smell out in the hallway gets really bad when staff put dirtied linen in the hamper and leave it there. Resident 72 further stated the staff should at least take it down to the end of the hallway.During a concurrent observation and interview on 7/23/25 at 10:56 a.m. with a licensed nurse (LN 1), LN 1 stated there was a bad smell in the hallway. LN 1 pointed towards the blue linen collection bins, waved her hand and stated, It's probably coming from this area. LN1 confirmed the bad smell was coming from the dirty linen cart. During an interview on 7/23/25 at 11:10 a.m. with the Assistant Administrator (AADM), the AADM stated one of the residents had a bad stomach and the smell was probably from cleaning up the resident. AADM stated the dirty linen cart should have been removed from the resident area. During an interview on 7/24/25 at 9:04 a.m. with Resident 49, Resident 49 stated, The smell in the hallway gets to be too much at times. During a review of the facility's P&P titled, Laundry Services, dated 1/2025, the P&P indicated, Soiled linen should be removed from resident-care areas at least daily and may need to be removed more frequently.

Based on interview and record review, the facility failed to maintain complete and accurate medical records for one of three sampled residents (Resident 1), when documentation of interventions for a change in condition were not accounted for. This failure had the potential to result in Resident 1 not receiving proper treatment during a change of condition. Findings: During a review of Resident 1's Medical Records (MR), MR indicated, Resident 1 was admitted to the facility on [DATE] with the following diagnoses: palliative care (medical care to improve the quality of life for people with a serious illness), amyotrophic lateral sclerosis (progressive, fatal disease that affects nerve cells in the brain and spinal cord), dysphagia (difficulty swallowing), dysarthria (speech disorder that makes it hard to form and pronounce words due to muscle problems) and anarthria (complete loss of speech), cognitive communication deficit (reduced awareness and ability to initiate and effectively communicate needs), gastrostomy tube ([g-tube] a tube used to provide an alternative route for delivering nutrition, fluids, and medications directly to the stomach), muscle weakness, and need for assistance with personal care. Review of Resident 1's Minimum Data Set (MDS) (a standardized assessment tool to evaluate the health and functional abilities of residents in nursing homes), dated 10/4/2024, indicated, short term and long term memory problem, and cognitive skills for daily decision making severely impaired. Review of Resident 1's History and Physical (H&P), dated 3/1/2024, indicated, Resident 1 is able to make own decisions. During a concurrent interview and record review on 10/22/2024 at 1 p.m. with the Director of Nursing (DON), Resident 1's medical chart was reviewed. Nursing progress notes (NPN), dated 8/11/24, indicated Sent to ED for further evaluation due to g-tube (gastrostomy tube) being clogged since yesterday. The DON verbalized received a phone call from Licensed Nurse (LN 2) regarding Resident 1's g-tube being clogged and stated, We tried ourselves with milking it, warm water, soda as an acid to try to break it down and were unsuccessful and sent (Resident 1) out the next morning. Further review of the NPN indicated, no documentation of interventions to unclog Resident 1's g-tube. The DON stated, There is no documentation prior to 8/11/24 . I don't know why. During an interview on 10/22/2024 at 2:53 p.m. with the Administrator (ADMIN) and the DON, ADMIN stated, We received a phone call that night and steps were taken to unclog it, and after many attempts we proceeded to send (resdient) out. The ADMIN was unable to recall the time of the phone call. The DON verbalized there is no documentation of Resident 1's g-tube being clogged and there is no documentation of the phone call. The DON verbalized was not sure of the cause of Resident 1's g-tube becoming clogged. During a concurrent interview and record review on 10/22/2024 at 2:53 p.m. with the DON and the ADMIN, the facility's policy and procedures (P&P) titled, Care and treatment quality of care, change of condition reporting, revised 11/2023 and P&P titled, Charting and Documentation, revised 11/2023 were reviewed. P&P titled, Care and treatment quality of care, change of condition reporting indicated, 4. All nursing actions will be documented in the licensed progress notes as soon as possible after resident needs have been met. P&P titled, Charting and documentation indicated, Rules for charting: 2. Daily notes are required as the necessary arises . 5. Continuous nurse's notes are required on all residents as the necessary arises. The DON stated, I can ' t say, if the P&Ps were followed. The ADMIN stated, The documentation wasn't as robusk as it should have been. During a concurrent phone interview and record review on 11/4/2024 at 3:53 p.m. with the DON, Resident 1's Medication Administration Record (MAR), dated August 2024, was reviewed. The MAR indicated, an X on 8/10/2024 on the noc shift (nocturnal night shift between evening and early morning) and an X on 8/11/2024 on the day shift. The DON verbalized the X means they weren ' t able to give Resident 1 the enteral (nutrition) feeding via g-tube, and the noc shift starts at 7 p.m.

Based on observation, interview and record review, the facility failed to ensure: 1. Pasteurized eggs were used for egg preperations not cooked through completely according to the facility's policy and procedures (P&P). 2. Food was stored properly in accordance with professional standards of food service safety when an uncovered and undated bag of shredded mozzarella cheese was found in the refrigerator and an opened staff personal water bottle was stored in the freezer. 3. Resident food refrigerator temperatures located in the nursing station were monitored daily and corrective actions implemented for out-of-range temperature readings by the food and nutrition representative according to the facility's P&P on foods brought by family or visitor. 4. An appropriate drainage piping material was used to drain the ice machine and an appropriate air gap was maintained between the ice machine and floor drains to prevent contaminated water from backing up into the ice machine should drainage problems arise. These failures had the potential to place the residents at an increased risk for contracting foodborne illness (any illness caused by consuming food or beverages contaminated with harmful pathogens - such as bacteria, viruses and fungi - or their toxins). Findings: 1. During a concurrent observation and interview on 06/04/24 at 09:05 a.m. with the Dietary Supervisor (DS) and Registered Dietician (RD), the inside of refrigerator #2 was observed. There was an open box of unpasteurized eggs. RD acknowledged the eggs were not pasteurized and there were no fresh pasteurized eggs in the facility. During an interview on 06/04/24 at 10 a.m. with RD and Morning [NAME] (AMC), RD verbalized the facility only cooks fried eggs cooked through. AMC verbalized if a resident requests an over easy (fried egg with under cooked yolk) egg or other egg not fully cooked he will cook it on their request. RD acknowledge that they stopped buying pasteurized eggs because of expense. During a concurrent interview and record review on 06/04/24 at 5:15 p.m. with RD, the P&P titled, Procedure For Refrigerated Storage was reviewed. The P&P indicated, 11. Raw eggs shall be obtained pasteurized . RD verbalized and acknowledged the facility P&P was not followed. 2. During a concurrent observation and interview on 06/03/24 at 09:57 a.m. with the RD in the kitchen, inside the kitchen refrigerator #5 was an open bag of mozzarella cheese stored uncovered and in Freezer #8 an opened bottle of water was found on the floor of the freezer. RD acknowledged that the cheese found in refrigerator #5 should not be opened stating, should be rolled with a clasp and labeled. RD acknowledged that the open bottle of water found in freezer was half full and was a staff members personal water and should not be in the freezer. During a review of the facility's P&P titled, Procedure for Refrigerated Storage, dated 2023, the P&P indicated, . Food should be covered and stored loosely . 3. During a concurrent interview and record review on 06/04/24 at 4:00 p.m. with Assistant Director of Nursing (ADON), resident refrigerator temperature logs were reviewed. ADON verbalized the resident refrigerator is kept on Nurses Station 1 and it is the responsibility of the nurses every a.m. and p.m. shifts to check temperatures in both refrigerators and the freezer. The ADON acknowledged the refrigerator logs have been checked but only on PM shift from January 2024 through June 2024. During a concurrent interview and record review on 06/06/24 at 11:55 a.m. with the Assistant Administrator (AADM) AADM, resident refrigerator temperature logs and facility P&P titled, Foods [NAME] by Family or Visitor, were reviewed. AADM acknowledged that according to this policy, the temperature logs for the resident refrigerator should be checked daily by nursing staff and verified by a dietary representative. AADM acknowledged that any out of range temperatures should be reported to maintenance for corrective action and documented on the log. AADM acknowledged that the refrigerator temperature on 1/24/24 was 46 degrees Farenheit (F) and on 1/25/24 the temperature was 44 degrees F and no documentation of correction actions were noted on log. AADM acknowledged there was no documentation of corrective action for out of range temperatures on these dates. A review of the facility's P&P titled, Food Brought by Family or Visitor, dated 05/09/2018, the P&P indicated, 9. The temperature of the refrigerator and freezer will be monitored and logged by Station 3 Nursing staff no less than once a day and verified by a food and nutrition representative once daily in accordance with the facility professional food safety standards. Any deviations from the correct temperature's standards will be reported to the Maintenance Department and / or the DSS (Department Staff Services) for guidance and correction. 4. During an observation on 06/03/24 at 10:45 a.m., in a separate locked closet outside of the kitchen. [NAME] plastic pipe [PVC - Polyvinyl chloride] drain from ice machine draining into floor drain black plastic pipe with black funnel attached to the black pipe in floor drain was observed. The white drainage pipe appeared to be approximately 1 inch below the flood level rim of floor drain. During a review of an email communication on 06/04/24 at 11:33 a.m. with the Department of Health Care Access and Information (HCAI), the e-mail indicated, PVC and ABS [Acrylonitrile Butadiene Styrene - type of drainage pipe] are both prohibited. During a concurrent observation and interview on 06/05/24 at 10:01 a.m. with the Director of Maintenance (DM),the ice machine was observed. DM acknowledged the air gap from the ice machine should be one inch above the top of the floor drain. DM also acknowledged the drainage pipe is below the top of the floor drain and there is not an appropriate air gap. DM verbalized the plastic PVC pipe to drain the ice machine was appropriate material to drain the ice machine. During a review of an email communication on 06/06/24 at 08:20 a.m. from HCAI to surveyor, the email indicated, ABS and PVC drainage fittings which is a code violation per CPC 701.2(2)(b) [California Plumbing Code]. During a concurrent interview and record review on 06/06/24 at 09:45 a.m. with DM, the CPC 701.2(2)(b) code was reviewed. DM acknowledged the CPC code 701.2(2)(b) is the plumbing regulation to be followed and that per PCP 701.2(2)(b) PVC pipe should not be used to drain ice machine. During a review of the Food and Drug Administration Food Code (FDAFC), dated 2022, the FDAFC indicated, 5202.13 Backflow Prevention, Air Gap. An air gap between the water supply inlet and the flood level rim of the PLUMBING FIXTURE, EQUEPMENT, or non FOOD EQUIPMENT shall be at least twice the diameter of the water supply inlet and may not be less than 25mm (1 inch). During a review of the Food and Drug Administration Food Code Annex (FDAFCA), dated 2022, the FDAFCA indicated, Backflow Prevention, Air Gap . Providing an air gap between the water supply outlet and the flood level rim of a plumbing fixture or equipment prevents contamination that may be caused by backflow. During a review of CPC 2022, Chapter 7, 701.2 Drainage Piping, the CPC indicated, Materials for drainage piping shall be in accordance with one of the referenced standards in Table 701.2 except that: . (2) ABS and PVC DWV piping installations shall be installed in accordance with applicable standards referenced in Table 701.2 and the firestop protection requirements in the California Building Code. (b) [OSHPD 1,2,3,4 & 5] ABS and PVC installations are not allowed.

Based on interview and record review, the facility failed to obtain an informed consent for the use of psychotropic medications (medications which affects mood or behavior) for one of 20 sampled residents (Resident 37). This failure violated Resident 37's right to make an informed decision regarding the use of psychotropic medications and had the potential to result in resident misinformation regarding its benefits and side effects. Findings: During a review of Residen 37's, Admission Records, dated 02/28/24, the records indicated Resident 37 was admitted to the facility on [DATE], with admission diagnoses including but not limited to: Other psychotic disorder not due to a substance or known physiological condition, Vascular Dementia (problems with thought processes caused by brain damage from impaired blood flow to your brain), Unspecified severity with agitation, Other specified depressive episodes, and Chronic Post-traumatic Stress Disorder (PTSD - a mental health condition triggered by a terrifying event, causing flashbacks, nightmares and severe anxiety). During a review of Resident 37's, Order Summary Report (OSR), dated 02/28/24 the OSR indicated the physician orders, Seroquel (antipsychotic - a medication used to treat certain mental and/or mood disorders) 25 mg (milligram - unit of measure), give 1/2 tablet every 8 hours as needed for agitation/anxiety and Olanzapine (antipsychotic) 5 mg tablet, give 1 tablet at bedtime for PTSD. During a concurrent interview and record review on 06/05/24 at 11:09 a.m. with the Assistant Director of Nursing (ADON), Resident 37's form, Facility Verification of Resident Informed Consent for Psychotherapeutic Medications, was reviewed and indicated, the informed consents for Seroquel and Olanzapine were not signed by Resident 37 (or the resident's representative) prior to the resident initially receiving the medications. ADON confirmed the informed consents for the medications were not signed and verbalized they should have been signed by the resident (or the resident's representative) prior to initiating the medications. During a review of the facility's policy and procedures (P&P) titled, Psychotropic Drug Use, dated 11/2023, the P&P indicated in part, Upon initial comprehensive assessment, the Social Services designee shall review new admissions for any psychiatric, mood or behavior disorders, mental and psychosocial difficulties, and/or physician's orders for psychotropic medications . to ensure: . Informed consent was obtained prior to medication use.

Based on interview and record review, the facility failed to complete and accurately document a Physician Order for Life Sustaining Treatment (POLST - care directives during life threatening situations) and Advance Directive (legal documentation consistent with the known requests or desires of the patient's medical preference) for two of 20 sampled residents (Residents 5 and 37). These failures had the potential to result in the delay of necessary treatment compatible with the legally recognized decision maker wishes during an emergency situation. Findings: During a review of Resident 5's, Admission Record, dated 04/20/24, the Record indicated in part, Resident 5 was admitted to the facility on [DATE] with admission diagnoses including but not limited to, Urinary Tract Infection (UTI - an infection in the urinary system of the body), generalized muscle weakness, Type 2 Diabetes Mellitus with other skin complication, and Congestive Heart Failure. During a concurrent interview and record review on 06/04/24 at 12:11 p.m. with licensed nurse (LN 3), Resident 5's Clinical Record was reviewed. Resident 5's record did not include the resident's POLST. LN 3 verbalized the POLST and consent forms were signed today. LN 3 produced the signed POLST form, dated 06/04/24, confirming it was only signed by the resident today. During an interview on 06/04/24 at 12:45 p.m. with Resident 5, Resident 5 verbalized just signed a bunch of papers that were not previously signed on admission to the facility on [DATE]. During a concurrent interview and record review on 06/05/24 at 3:15 p.m., with with the Assistant Director of Nursing (ADON), Resident 37's clinical record was reviewed. ADON acknowledged Resident 37's POLST form was not signed and noted the resident as having the capacity to make healthcare decisions. During a concurrent interview and record review on 06/05/24 at 3:15 p.m. with ADON, Resident 37's Physician Orders were reviewed. A Physician Order dated 02/28/24 at 11:20 a.m. indicated, DNR (Do Not Resuscitate - restrictions to perform life-saving treatment if a patients stops breathing or heart stops beating). An order dated 02/28/24 at 2:41 p.m. indicated, Full Code (perform all life saving measures if a patient stops breathing or heart stops beating). Review of Resident 37's Advanced Directive dated 03/27/24 indicated, Patient 37 wished to have restrictions on end-of-life treatment (DNR). ADON acknowledged the change in physician orders from DNR to Full Code and the POLST form should have been updated to reflect the wishes of the resident. During a review of the facility's policies and procedures (P&P) titled, Advanced Directives, POLST, dated 11/2023, the P&P indicated, Prior to, upon, or immediately after admission, Social Services or Licensed Nursing Staff will ask residents, and/or their family members, about the existence of any advance directive . resident or surrogate decision maker will be offered and assisted by facility staff (usually SSD [Social Services Department] or Licensed Nursing Staff) to complete a POLST (Physician's Orders for Life Sustaining Treatment) document to formulate decisions regarding Life Sustaining Treatment. A copy of this document will be in the Medical Record of resident . The facility will also notify the attending physician of advance directives so that, if necessary, appropriate orders can be documented in the resident's medical record and plan of care.

This is the incorrect tag Based on observation, interview, and record review, the facility failed to follow their policy and procedure regarding loss or theft of resident property. Findings: During an observation on 6/3/24 at 2:10 p.m., a brown wallet containing a driver's license, social security card and military identification was observed in medication cart number one, located in a locked medication drawer. During a concurrent interview and record review on 6/3/24 at 2:15 p.m. with licensed nurse (LN 2), discharged residents in Point Click Care (PCC) (point click care is a cloud-based software platform used by some health care providers to monitor and track patient care) were reviewed. PCC indicated, Resident was discharged AMA (against medical advice) on 9/8/23. LN 2 verbalized, they did not know if the former resident has been contacted, the wallet should not have been kept in the medication cart. LN 2 further verbalized, the wallet should have been taken to social services. During a review of the facility's policy and procedure (P&P) titled, Theft and Loss Policy, dated 10/22, The P&P indicated, Loss or theft of resident property worth $25 or more will be documented and reported to the administrator (or designee) for investigation, police reporting or other appropriate action. Documentation of the lost or stolen residence property with a value of $25 or more shall include: A. Description of the lost or stolen article. B. Estimated value. C. Date and time the loss or theft was discovered. D. If determinable, the date and time the lost or theft occurred. E. Action taken.

Based on record review and interview, the facility failed to ensure a significant change in status was comprehensively assessed for one of four sampled residents (Resident 15) using the CMS (Centers for Medicare and Medicaid Services) specified Resident Assessment Instrument (RAI - Resident Assessment Instrument [a standardized tool used to evaluate and document clients in long term care {LTC} settings] process). This failure had the potential to result in compromised quality of care for Resident 15. Findings: During a review of Resident 15's Medical Record, the Medical Record indicated, Resident 15 was readmitted to the facility on [DATE] from the hospital. The psychologist's progress note dated 4/16/24, indicated, Pt. (patient) was taken off his anti-psych medications recently (when d/c'd [discharged ] from hospital) & he's become increasingly disorganized since then. Physician: please re-start Pt. on his previous level of Seroquel [an antipsychotic medication] that had been working very well. Further record review revealed the facility failed to initiate a comprehensive assessment after a significant change of condition. During an interview on 6/6/24 at 11 a.m. in the DON's (Director of Nursing) office, with the DON, MDS1 (Minimum Data Set - nurses responsible for collecting and submitting assessment data for nursing home patients) and MDS2 nurses. The DON and MDS's 1 and 2 concurred the significant change in status assessment was not done for Resident 15 following a significant change of condition. During a review of the facility's policy and procedure (P&P) titled, Change of Condition - Assessment and Reporting, dated 11/2021, the P&P indicated, PURPOSE: To clearly define guidelines for a timely notification of a change in resident condition, and, Follow-up #3. Resident Assessment Instrument/Comprehensive Care Plan completed/modified as needed.

Based on record review and interview, the facility failed to ensure the Preadmission Screening and Resident Review (PASRR - a federally mandated process to help ensure that individuals are evaluated for a mental illness and/or intellectual disability and are not inappropriately placed in nursing homes for long term care) Level II evaluations (a person-centered evaluation that is completed for anyone identified by the Level I screening as having, or suspected of having serious mental illness, intellectual disability, developmental disability, or related condition) were completed for three of 20 sampled residents (Residents 15, 37 and 66) when: 1. A significant decline in Resident 15's mental health condition was assessed. 2. A positive PASRR Level I (a preliminary assessment for individuals to identify serious mental illness, intellectual disability, developmental disability, or related condition prior to admission to a nursing facility) evaluation was indicated for Residents 37 and 66. These failures in screening for mental health illesses and/or disabilities had the potential to result in these residents not receiving appropriate care and treatment. Findings: 1. During a review of Resident 15's medical record, the medical record indicated Resident 15 was readmitted to the facility, on 4/4/24 from the hospital. The psychologist's progress note dated 4/16/24, indicated, Pt. (patient) was taken off his anti-psych medications recently (when d/c'd from hospital) & he's become increasingly disorganized since then. Physician: please re-start Pt. on his previous level of Seroquel [an antipsychotic medication] that had been working very well. Further record review revealed, the facility failed to initiate a PASRR screening and comprehensive assessment after the significant mental change/change of condition was noted by the psychologist. Admitting diagnoses included in part, Psychosis (mental disorder characterized by a disconnection from reality) and Depression (mental state of low mood and aversion to activity). During an interview on 6/6/24 at 11 a.m. in the DON's (Director of Nursing) office, with the DON, MDS1 (Minimum Data Set - nurses responsible for collecting and submitting assessment data for nursing home patients) and MDS2 nurses. The DON and MDS's 1 and 2 concurred the PASRR screening of Resident 15 for the significant mental change of condition on 4/16/24, as noted by the psychologist, was not done by the facility. During a review of the facility's policies and procedures (P&P) titled, PASRR, dated 11/2023,the P&P indicated, POLICY: It is the policy of this facility to ensure that each resident is properly screened using the PASRR specified by the State, and, PROCEDURES: #3. a. If a resident temporarily went somewhere outside the NF, a new PASRR would not be required unless upon return, there was a significant change in the resident's physical or mental condition. If this happens, then the NF initiates the RR process by submitting a Level 1 Screening, and if needed, arrange for a Level 2 Evaluation to be performed by the state approved contractor to help ensure the individual receives services in the most integrated setting. 49405 2.a. During a review of Resident 37's form titled, Preadmission Screening and Resident Review (PASRR) Level I Screening, dated 02/26/24, the PASRR indicated, a Positive (resident with a mental disorder condition) result. During a concurrent interview and record review on 06/05/24 at 11:26 a.m. with Assistant Director of Nursing (ADON), Resident 37's Clinical Documents, was reviewed. The Documents indicated, a letter from the Department of Health Care Services, dated 02/26/24, Re: Positive Level I Screening Indicates a Level II Mental Health Evaluation is Required. ADON acknowledged that a PASRR II evaluation was overlooked and should have been completed and not done. 49376 2.b. During a review of Resident 66's Preadmission Screening and Resident Review (PASRR) Level I Screening, dated 4/01/2024, the PASRR indicated, Resident 66 had a positive Level I screening, due to suspected mental illness (MI). During a review of Resident 66's Positive Level I Screening Indicates a Level II Mental Health Evaluation is Required, dated 04/01/2024, and addressed to Resident 66 the Level I Screening indicated, Resident 66 was positive for suspected mental Illness (MI). During a review of Resident 66's, letter of correspondence from the PASSR Section of the Department of Health Care Services (DCHS), dated 4/2/24, the letter indicated in part, Unable to Complete Level II Evaluation . the individual currently has a duplicate PASRR on file . The case is now closed. To reopen, please submit a new Level I Screening. During an Interview on 06/06/2024 at 9 a.m. with ADON, ADON stated, The PASRR Level I is the only one the facility has on file, and there is no other PASRR II or duplicate available. During an Interview on 06/06/2024 at 9:25 a.m. with DON, Nursing Consultant (NC), and Executive Director (ED), ED and DON stated the facility does not currently have a copy of the duplicate PASRR, and have had this issue in the past with other residents PASRR. During an interview on 06/06/2024 at 11:04 a.m. with the facility's PASSR Consultant (PC), PC verbalized that ([NAME] Medical Center) conducted the PASSR Level I and II evaluations for Resident 66 and was told that the resident's expected hospital stay would be less than 15 days. PC explained that if the resident's hospital stay was less than 15 days, the facility would have no obligation to resubmit a new Level I screening. PC further verbalized that since the resident stayed in the hospital more than 15 days, the facility did in fact have an obligation to resubmit a new Level I PASRR screening.

Based on record review and interview, the facility failed to ensure the State mental health authority was notified after a significant decline in the mental health condition of one of four sampled residents (Resident 15) was assessed. This failure had the potential to result in Resident 15 not receiving the necessary mental health care and services which had the potential to affect Resident 15's quality of life and resulted in the mental significant change of condition not having been properly screened/evaluated and reported to the state mental authority. Findings: During record review of Resident 15's Psychologist Progress Notes, dated 4/16/24, the Progress Note indicated, Pt. was taken off his anti-psych medication (when d/c'd from hospital) & he's become increasingly disorganized since then. Physician: please re-start Pt. on his previous level of Seroquel that had been working very well. Admitting diagnoses included in part, Psychoses (mental disorder characterized by a disconnection from reality) and Depression (mental state of low mood and aversion to activity). The facility documented the change of condition for 72 hours, as reflected in the reviewed nursing documentation. However, the facility failed to initiate a PASSAR screening, to accurately screen/evaluate Resident 15's mental health status. During an interview on 6/5/24, at 11 a.m., in the DON's office, with the DON, MDS1 nurse, and MDS2 nurse (Minimum Data Set [nurses assigned to collect and assess information for the health and well-being of residents in Medicare and Medicaid certified nursing homes]). The DON and both MDS nurses concurred the PASSAR screening of Resident 15 for the significant mental change of condition on 4/16/24, as noted by the psychologist, was not done by the facility. During a review of the facility's policy and procedure titled, Change of Condition - Assessment and Reporting, dated 11/2021, the facility's policy and procedure indicated, PROCEDURES: Follow-up #3. Resident Assessment Instrument/Comprehensive Care Plan completed/modified as needed.

Based on observation, interview, and record review, the facility failed to ensure: 1. A box of expired Povidone-Iodine prep pads. (antiseptic pads saturated with povidone iodine solution to help control bacteria and minimize infection) was discarded. 2. An opened vial of purified protein derivative (PPD - solution used in a skin test to help diagnose tuberculosis [a serious lung infection caused by bacteria]) solution was dated. 3. An open container of glucose test strips (used in a device to measure the amount of sugar in the blood) was dated. 4. Barium Sulfate (a contrast agent used to diagnose disorders of the esophagus, stomach and intestines) stored in the medication refrigerator had a documented physician order for specific resident use. These failures had the potential for the residents to receive expired, ineffective and unprescribed medications and treatments. Findings: During an inspection on [DATE] at 9:30 a.m. of the medication storage area, the following were observed: 1. One box of expired Povidone-Iodine prep pads with an expiration date ,d+[DATE]. 2. One vial of PPD was opened and not dated. During a review of the facility's policy and procedures (P&P) titled, Storage of Medications, dated 2023, The P&P indicated in part, Outdated, contaminated or deteriorated medications and those in containers that are cracked, soiled or without secure closures are immediately removed from stock disposed of according to procedures for medication disposal. The P&P further indicated, All PPD bottles are to be dated when opened and discarded after 30 days of opening. 3. One container of diabetic glucose test strips that was opened and undated. During a review of the facility's P&P titled, Infection Control, Glucometer Cleaning and Decontamination, dated ,d+[DATE], the P&P indicated in part, Test strips will be used according to manufacturer's guidelines. During a review of manufacturer's guidelines for diabetic glucose test strips, the guidelines indicated, Use within three months of opening the vial. 4. Barium Sulfate, stored in the facility's medication refrigerator had no physician order for specific resident use. During a review of the facility's P&P titled, Resident Assessment, Physician Orders, dated ,d+[DATE], the P&P indicated in part, It is the policy of this facility that drugs or biologicals shall be administered only upon written order of a person duly licensed and authorized to prescribe such drugs . Drugs and biologicals orders must be recorded on the physicians order sheet in the resident chart. During a concurrent interview and record review on [DATE] at 1:05 p.m. with the Director of Nursing (DON), physician orders for all residents were reviewed. After a thorough review of all resident physician orders, DON verbalized that no orders were found in the facility's electronic or paper charting system for Barium Sulfate. 47112

Based on observation and record review, the facility failed to: 1.Store Schedule II Drugs (schedule II drugs, substances, or chemicals are defined as drugs with a high potential for abuse, with use potentially leading to severe psychological or physical dependence) under double lock per facility's policy and procedure (P&P). 2.Sign the drug count sheet after administering medication per facility P&P. 3.Maintain refrigerator temperatures. These failures had the potential to result in (1) schedule II drugs being available to residents and visitors; (2) for drug diversion; and (3) medications to not be effective. Findings: During an inspection on 6/3/24 at 9:30 a.m. of the medication storage area, the following were observed: 1.Schedule II Drugs were not stored under double lock. During a review of the facility's P&P titled, Medication Administration, dated 11/2023, the P&P indicated, Medications listed in schedules II, III, IV, and V are stored under double lock in a locked cabinet or safe designated for that purpose, separate from all other medications. 2.One controlled drug count sheet had not been signed after medication was administered as directed by the facility's P&P. Further review of the facility's P&P titled, Medication Administration, dated 11/2023, the P&P indicated, When a controlled medication (a controlled medication is a drug or other substance that is tightly controlled by the government because it may be abused or cause addiction) is administered the licensed nurse administering the medication immediately enters all of the following information on the accountability record: *Date and time of administration *Amount administered. *Signature of the nurse administering the dose, completed after the medication is administered. 3. The facility refrigerator log listed out of range temperatures, for April, May and June of 2024 resulting in multiple episodes of the refrigerator being out of range for optimal medication storage. During a review of the facility's P&P titled, Storage of Medications, dated 2023, the P&P indicated, Medications requiring refrigeration or temperatures between 2 C (36 F) and 8 C (46 F) are kept in a refrigerator with a thermometer to allow temperature monitoring. 47112

Based on observation, interview, and record review, the facility failed to implement transmission-based precautions (infection control measures specific to how an infection is spread) for one of 20 sampled residents (Resident 5) when the resident was diagnosed with a known Multidrug Resistant Organism (MDRO - a germ that is resistant to many antibiotics). These failures had the potential to result in the spread of harmful microorganisms to staff, residents and visitors. Findings: During a concurrent interview and record review on 06/05/24 at 10:00 a.m. clinical record with Assistant Director of Nursing (ADON), Resident 5's History and Physical (H&P), dated 04/20/24, was reviewed. Resident 5's H&P indicated, . Patient was found to have UTI [urinary tract infection] with history of ESBL ., .continue with contact isolation . ADON acknowledged Resident 5 was colonized (presence of bacteria without causing an active infection but can be spread to others) with Extended-spectrum beta-lactamases (ESBL - enzymes (special proteins) that are made from bacteria that are resistant to antibiotics) on admission and should have been placed on Enhanced Barrier Precautions (EBP - an infection control intervention designed to reduce transmission of MDROs in nursing homes, https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/faqs.html). During an interview on 06/05/24 at 10:09 a.m. with Licensed Nurse (LN 2), LN 2 verbalized Resident 5 is not on any isolation including, EBP. LN 2 verbalized Resident 5 had completed treatment for an ESBL infection. During an interview with Infection Preventionist (IP) on 06/05/24 at 10:35 a.m. IP acknowledged that Resident 5 is not on contact isolation and not on EBP. IP acknowledged that ESBL is a condition that is considered colonized (germs on or in the body but do not have symptoms of infection) and resident should have been placed on EBP on admission. During a review of facilities policy and procedure titled, IPCP Standard and Transmission-Based Precautions, dated 04/2024 indicates, . 3. Enhanced Barrier Protection (EPB): used in conjunction with standard precautions [precautions required to achieve a basic level of infection control used for all residents] and expand the use of PPE [personal protective equipment] through the use of gown, and gloves during high-contact resident care activities that provide opportunities for indirect transfer of MDROs to staff ., a. PPE: The use of gown and gloves for high-contact resident care activities is indicated, when Contact Precautions do not otherwise apply . ii. MDRO infection or colonization. The policy states, b. Multi-drug Resistant Organisms (MDRO) - the MDROs for which the use of EBP applies are based on local epidemiology. At a minimum, they should include resistant organisms targeted by CDC . ESBL - producing Enterbacterales .

Based on interviews and record review, the facility failed to notify the resident representative (RR - person designated as being responsible for another person's medical and/or financial decisions) of one of two sampled resident (Resident 1) after a change of condition (CoC) when Resident 1 underwent debridement (removal of damaged tissue) on the sacrum (buttocks). This facility failure resulted in Resident 1's resident representative not being informed of their CoC or of the risks and benefits of the treatment options available to them. Findings: During a review of the facility's policy and procedure (P&P) titled, Change of Condition Reporting, dated 11/22, the P&P indicated, Purpose: To clearly define guidelines for timely notification of a change in resident condition . Licensed nurse will inform family of change of condition and document notification. During a review of Resident 1's Minimum Data Set ((MDS) an assessment tool for a resident), dated 11/23, the MDS indicated, Resident 1 had a Brief Interview for Mental Status BIMS of 6 (a system that measures mental status in a nursing home, 0-7 suggests severe impairment, 8-12 suggests moderately impaired, and 13 -15 suggests cognitively intact). During a review of Resident 1's Progress Note (PN), dated 10/28/23, the PN indicated, Deep tissue pressure injury (localized areas of tissue damage), debrided (removed damaged tissue) by (named doctor). During an interview on 11/27/23 at 5:00 p.m. with Director of Nursing (DON), DON stated a CoC was not documented after the debridement. DON further stated there should have been documentation. During an interview on 1/2/23 at 2:15 P.M. with treatment nurse (LN 1), LN 1 stated he did not notify the family after the DTI debridement. During an interview on 1/2/23 at 2:30 PM. with Assistant Director of Nursing (ADON), ADON stated he did not notify because expected the treatment nurse to notify the family RR.

Based on observation, interview, and record review, the facility failed to implement its policy for activities when: 1. One of eighteen sampled residents (Resident 59) was not observed in any activities during onsite four-day survey. 2. The activity director was not documenting activity pursuit patterns or activity attendance for any of the 75 residents in the facility. This failure has the potential for psychosocial and physical harm to all 75 residents. Findings: During a review of the facility's policy and procedure (P&P) titled, Activity Assessment, dated 01/2021, the P&P indicated, POLICY: It is the policy of this facility to provide ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities based on the comprehensive assessment and care plan and the preferences of each resident. PROCEDURES: 4. A quarterly and annual assessment shall be conducted using the Activity - Quarterly or Annual Evaluation UDA (User Defined Assessment consists of questions compiled together under various headings to create questionnaires that may be completed within the software) to include: a. Activity Pursuit Patterns and b. Activity Attendance/Participation Summary. During a review of the facility's P&P titled, Activities Program, dated 11/2021, the P&P indicated, POLICY: It is the policy of this facility to implement an ongoing resident centered activities program that incorporates the resident's interests, hobbies and cultural preferences which is integral to maintaining and/or improving a resident's physical, mental, and psychosocial well-being, and independence. It is also the policy of this facility to create opportunities for each resident to have a meaningful life by supporting his/her domains of wellness (security, autonomy, growth, connectedness, identity, joy, and meaning). PROCEDURES: 8. Residents who wish to meet with or participate in social or religious activities, or other community activities, at or away from the facility, is encouraged to do so. During a review of Resident 59's Admission Record, dated 6/22/23, the admission record indicated, Resident 59 was 92-years-old with diagnoses including, unspecified dementia (a group of symptoms affecting memory, thinking and social abilities), muscle weakness, difficulty in walking, major depressive disorder (a mental condition characterized by a persistently depressed mood and long-term loss of pleasure or interest in life) and need for assistance with personal care. During a review of Resident 59's Minimum Data Set (MDS-a standardized assessment tool that measures health status in nursing home residents), dated 10/8/22, the cognitive section indicated, Resident 59's Brief Interview for Mental Status (BIMS -a cognitive assessment tool -a resident can score 0 to 15 points on the test. A score of 13 to 15 suggests the resident cognitively intact, 8 to 12 suggests moderately impaired and 0 to 7 suggests severe impairment) was a score of 6. Resident 59 required supervision to moderate assist with most activities of daily living (ADL-The tasks of everyday life. Basic ADLs include eating, dressing, getting into or out of a bed or chair, taking a bath or shower, and using the toilet). In addition, the Preferences for Customary Routine and Activities section indicated, it is very important to resident to have books/newspapers to read, do favorite activities, and go outside to get fresh air. During an observation and interview on 06/19/23 at 3:46 p.m. in Resident 59's room, 59 was observed in bed, awake. The TV was not on and resident was not observed in any activity. Resident 59 stated used to be very active in her church and greeted people all the time at the church. Resident began to cry and stated, Not one person has come to visit, not the pastor, no one, and that hurts. May be a long time ago because I was driving then. It was the Seventh Day Adventist Church. During an observation and interview on 06/20/23 at 3:42 p.m. with Resident 59's Representative, Resident 59 was observed lying in bed. Representative stated church is very important to Resident 59, she used to be a door greeter and is very upset no one from the church comes to visit. Representative stated has not seen Resident 59 in any activities and would like to. During observations from 6/19/23 to 6/22/23 from 10 a.m. until 4 p.m., Resident 59 was observed in bed, awake, without any activity being provided. These observations were conducted on 6/19/23 two occasions, 6/20/23 three occasions, and on 6/21/23 eight occasions. During an observation and interview on 06/21/23 at 2:49 p.m. in hallway outside of Resident 59's room with a certified nurse assistant (CNA 1) and Licensed Nurse (LN 2) CNA 1 confirmed Resident 59 is lying in bed awake with no activity. CNA 1 confirmed she does not document residents' activities. LN 2 does not know what kind of activities Resident 59 likes and confirmed she does not document activities of residents. During an interview and concurrent record review on 06/21/23 at 3:28 p.m. with the Activity Director (AD), the AD confirmed facility P&P, Activity Assessment, indicated, staff should be documenting residents' activities and are not. The AD confirmed there is no documentation to confirm Resident 59 participating in any activities. The AD stated, To be honest, I used to document but do not anymore.

Based on observation, interview and record review, the facility failed to ensure its medication error rate was less than five percent when: 1. Licensed Nurse 5 (LN 5) left medications intended for Resident 38 unattended on the medication cart. 2. LN 5 did not educate and provide Resident 38 water to rinse mouth out after inhalation of Ellipta powder medication. 3. LN 5 left Resident 38's medications unattended on bedside table and did not witness medication consumption. These failures resulted in a 10% medication error rate and had the potential for Resident 38 to have medication complications. Findings: Review of the facility's policy and procedures (P&P) titled, 6.0 General Dose Preparation and Medication Administration, revised 1/1/13, the P&P indicated in part, . Facility staff should not leave medications or chemicals unattended . Provide the resident with any necessary instructions (e.g., using an inhaler) . Observe the resident's consumption of the medications(s) . 1. During an observation and record review on 6/19/23, at 1:32 p.m., LN 5 entered Resident 38's room with back turned toward the medication cart and left a tablet of Clonidine (medication to control elevated blood pressure) 0.2 mg (milligrams) in a medication cup unattended on the surface of a medication cart outside of Resident 38's room. Record review of Resident 38's Physician's order dated 10/15/22 indicated, cloNIDine HCI tablet 0.2 mg Give 1 tablet by mouth three times a day . During an interview on 6/19/23 at 1:34 p.m. with LN 5, LN 5 acknowledged leaving Resident 38's medication unattended on the medication cart and stated, Clonidine, yes, I left it unattended on my med (medication) cart. I should not have done that. 2. During a medication pass observation on 6/20/23 at 8:10 a.m. LN 5 was observed administering Resident 38 Ellipta - Fluticasone Furoate (an inhaled medication to treat asthma and chronic obstructive disease) from a handheld powdered medication inhaler. LN 5 did not provide education to Resident 38 of the importance to rinse mouth with water without swallowing after using the inhaler and did not provide water and basin/cup to spit out rinse water before exiting the room. During a concurrent interview and record review on 6/20/23 8:26 a.m. with LN 5, Resident 38's physician's order dated 12/28/22 was reviewed. The order indicated in part, Breo Ellipta Inhalation Aerosol Powder Breath Activated . (Fluticasone Furoate-Vilanterol) 1 puff inhale orally one time a day for RAD (reactive airway disease) rinse mouth with water after use. LN 5 confirmed, No, I did not educate Resident 38 to rinse out mouth after inhaling powdered Fluticasone Furoate medication; provide water and container to spit out rinse water; and did not witness Resident 38 rinse mouth out and spit out the rinse water. Resident 38 was supposed to do that. It can cause oral fungus if not done. During an interview on 6/20/23 at 8:27 a.m. with Resident 38, Resident 38 stated, Usually I do rinse and spit, but I didn't today. 3. During the same medication pass observation on 6/20/23, at 8:10 a.m., LN 5 was observed placing Resident 38's Physician ordered medications Carvedilol 3.125 mg tablet (treats high blood pressure), clonidine 0.2 mg tablet (treats high blood pressure), and docusate sodium 100 mg gel cap (prevents and treats constipation) into a medication cup, LN 5 then placed the medication cup with medications onto Resident 38's bedside table, and exited Resident 38's room. LN 5 did not stay to witness Resident 38 consume the medications. When asked if Resident 38's medications were left unattended, LN 5 confirmed and acknowledged, I also left the medications unattended on the bedside table and did not witness the Resident 38 consume his medications before I left the room. During an interview on 6/22/23 at 9:49 a.m. with the director of Nursing (DON), the DON indicated, Licensed nurses are supposed to educate the need for rinsing out the mouth after inhaling the fluticasone inhaler and offer residents rinse water and receptacle for spitting out rinse water and remain with resident to ensure procedure is accomplished. Licensed nurses are never supposed to leave medication unattended in the resident's rooms and/or unattended on the medication cart. Licensed nurses are supposed to stay and witness the resident consume the medications administered. The policy and procedures were not followed and should have been.

Based on observation, interview, and record review the facility failed to store two boxes containing eggs inside of refrigerator and off the kitchen floor in accordance with professional standards of food safety for a total of 72 residents who received food from the kitchen. These failures had the potential to result in foodborne illnesses among residents. Findings: According to the Food Code 2022, Annex 3. Public Health Reasons/Administrative, 2-103.11, page 308 All food must be appropriately stored in a safe and secure manner within the food establishment. For example, time/temperature control for safety foods must be stored within refrigeration units and held at temperatures of 41 F or below. Also, 3-202.11 Temperature, page 376 indicated in part, USDA published a final rule (63 FR 45663, August 27, 1998 Shell Eggs; Refrigeration and Labeling Requirements) to require that shell eggs packed for consumer use be stored and transported at an ambient temperature not to exceed 7.2 C (45 F). Additionally, 6-501.12 Cleaning, Frequency and Restrictions, page 504 indicated, Primary cleaning should be done at times when foods are in protected storage . The facility policy and procedure titled, Dietary Services revised 8/2021, indicated in part, All foods stored in walk-in refrigerators and freezers shall be stored above the floor on shelves, racks, dollies, or other surfaces that facilitate thorough cleaning. During a concurrent observation and interview on 6/19/23 at 10:50 a.m. with kitchen aide 1 (KA 1) and the acting dietary manager (DM-A), two boxes were observed one on top of the other outside of the refrigerator and directly on the soiled kitchen floor while cleaning refrigerator number three. The boxes contained two varieties of eggs. The box directly on the soiled kitchen floor contained boiled eggs with another opened box on top containing a plastic bag of liquid eggs. KA 1 confirmed the above, made no comment, and did not remove/relocate the unrefrigerated boxes of boiled and liquid eggs stored on the soiled kitchen floor. The DM-A confirmed and acknowledged, Foods should be stored onto kitchen carts not on floor. The DM-A did not acknowledge that refrigerated eggs should remain inside of the refrigerator during cleaning.

Based on observation, interview, and record review, the facility failed to develop, and implement a person-centered activity care plan for one of 18 sampled residents (Resident 59). This failure had the potential for isolation, psychosocial and physical decline for Resident 59. Findings: During a review of the facility policy and procedure (P&P) titled, Care and Treatment, Care Planning, revised 11/2021, the P&P indicated, POLICY: It is the policy of this facility that the interdisciplinary team (IDT) shall develop a comprehensive Person-Centered Care Plan for each resident based on resident's needs to attain or maintain his or her highest practicable physical, mental, and psychological well-being. PROCEDURES: 4. To the extent possible, the resident, the resident's family and/or responsible party should participate in the development of the care plan. During a review of the facility's P&P titled, Activity Assessment, revised 01/2021, the P&P indicated, POLICY: It is the policy of this facility to provide ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities based on the comprehensive assessment and care plan and the preferences of each resident. PROCEDURES: 4. A quarterly and annual assessment shall be conducted using the Activity - Quarterly or Annual Evaluation UDA (User Defined Assessment consists of questions compiled together under various headings to create questionnaires that may be completed within the software) to include: a. Activity Pursuit Patterns and b. Activity Attendance/Participation Summary. During a review of Resident 59's Admission Record, dated 6/22/23, the admission record indicated, Resident 59 was 92-years-old with diagnoses including, unspecified dementia (a group of symptoms affecting memory, thinking and social abilities), muscle weakness, difficulty in walking, major depressive disorder (a mental condition characterized by a persistently depressed mood and long-term loss of pleasure or interest in life) and need for assistance with personal care. During a review of Resident 59's Minimum Data Set (MDS-a standardized assessment tool that measures health status in nursing home residents), dated 10/8/22, the cognitive section indicated, Resident 59's Brief Interview for Mental Status (BIMS -a cognitive assessment tool -a resident can score 0 to 15 points on the test. A score of 13 to 15 suggests the resident cognitively intact, 8 to 12 suggests moderately impaired and 0 to 7 suggests severe impairment) was a score of 6. Resident 59 required supervision to moderate assist with most activities of daily living (ADL-The tasks of everyday life. Basic ADLs include eating, dressing, getting into or out of a bed or chair, taking a bath or shower, and using the toilet). In addition, the Preferences for Customary Routine and Activities section indicated, it is very important to resident to have books/newspapers to read, do favorite activities, and go outside to get fresh air. During a review of Resident 59's Activities Care Plan, undated, the care plan indicated, Focus - (Resident 59's name) potential alteration in diversional activities r/t (related to) Prefers to initiate activities of choice independently. (Resident 59's name) likes to independently read the daily chronicle, watch TV, do word search puzzles, and receive visits from her son and other family members when able. (Resident 59's name) favorite activities include getting her nails done, reminiscing, and being outdoors at times. Goal - Will choose and participate in his/her preferred leisure activities daily over the next 90 days as evidenced by activity attendance logs/progress notes/assessments. Interventions/Tasks - Communicate his/her interests to health care team. During a review of Resident 59's Care Plan, undated, the care plan indicated,(Resident 59 name) is at risk for impaired cognitive function/dementia or impaired thought processes . undated, indicated, /needs supervision/assistance with all decision-making undated Son is POA (Power of Attorney). During an observation and interview on 06/19/23 at 3:46 p.m. in Resident 59's room, Resident 59 was observed in bed, awake. The TV was not on and resident was not observed in any activity. Resident 59 stated used to be very active in her church and greeted people all the time at the church. Resident began to cry and stated, Not one person has come to visit, not the pastor, no one, and that hurts. It was the Seventh Day Adventist Church. During an observation and interview on 06/21/23 at 2:49 p.m. in hallway outside of Resident 59's room with a certified nurse assistant (CNA 1), CNA 1 confirmed Resident 59 is lying in bed awake with no activity. CNA 1 confirmed she does not document residents' activities. During an observation and interview on 06/21/23 at 2:49 p.m. in hallway outside of Resident 59's room with a licensed nurse (LN 2), LN 2 confirmed resident is lying in bed awake with no activities. LN 2 does not know what kind of activities Resident 59 likes and confirmed she does not document activities of residents. During a review of the Activity-Quarterly Evaluation dated 10/8/22, 4/10/2023, and 10/8/2023 for Resident 59 the Attendance Participation Summary indicated, to refer to attendance records and describe residents participation/responses in activities. There were no attendance records in Resident 59's medical record. During an interview and concurrent record review on 06/22/23 at 11:40 a.m. with the Activity Director (AD), Resident 59's activities care plan and Activity- Quarterly Evaluations were reviewed. Also reviewed the facility's P&Ps titled, Activity Assessment and Care and Treatment, Care Planning. The AD confirmed does not have any documentation regarding Resident 59's initial activity assessment or interview with POA. The AD confirmed facility staff are not informed of Resident 59's Activities, and no staff are documenting Resident 59's attendance in activities, and stated, To be honest, I used to document but do not anymore. The AD confirmed the facility is not following and implementing the policies and procedures and should be.

Based on observation, interview, and record review, the facility failed to maintain sanitary conditions and prevent the potential for food borne illness (illness caused by ingestion of contaminated food or beverages) when the dietary department staff failed to: 1. Maintian chemical sanitizer levels at the correct concentration level of 50-100 ppm (parts per million). 2. To store food properly in refrigerated and dry storage areas. 3. Maintain clean and dirty separation for the coffee/juice serving cart. These failures place 58 of 58 residents at high risk to be served food on dishes not properly sanitized (free from filth or pathogens) placing residents at increased risk of food borne illnesses (illness caused by ingestion of contaminated food or beverages). Immediate jeopardy was called on 2/8/15 at 4:15 p.m. with the facility Administrator. On 2/8/15 at 5:35 p.m., the facility provided an acceptable plan of correction. The plan of correction was as follows: 1. Maintenance was notified and chemical dishwasher was shut down for repairs. 2. All dietary staff was inserviced on correct ppm levels and what to do if ppm levels are not within 50-100 ppm. 3. Three compartment sink was used to reclean and resanitize all dishes and cookware. 4. Facility will use disposable products (paper plates, plastic utensils, paper cups) when ppm levels are not met. 5. Staff retested dishwasher to ensure sanitizer was in compliance. 6. Dietary Manager (DM) and/or designee will test the dishwashing chemical after each load to ensure compliance. The IJ was removed on 2/8/16 at 5:35 p.m. The Facility will: a. Document the ppm (parts per million; concentration of chemical sanitizer) concentration reading and continued deficient finding(s) will be reported to the DM, MS and/or AD for corrective action(s) and follow-up. b. DM and /or designee will review the dishwasher chemical test readings daily to ensure compliance. c. Conduct daily random testing of the dishwasher chemical by the DM and/or designee. d. Monthly for 90 days, have the DM report results of any deficient finding(s) to the QAPI(Quality Assurance and Performance Improvement )/UR Committee. e. Committee shall make additional recommendations to the plan as determined by the review of the results of the finding(s) and reevaluate for continued compliance. Reevaluation will be continued if non-compliant. f. The DM is responsible to ensure compliance is achieved and sustained. Findings: 1. During an observation, concurrent interview and review or records on 2/8/16 at 11:30 a.m., with the dishwasher (DW) and the RD, it was noted the DW was taking dishes out of the dishwasher and was asked to test the sanitizer. The DW dipped the chlorine test strip in the liquid and compared the strip to the chart which read between 10 ppm and 50 ppm. The DW reported this was an acceptable sanitizer level. The RD was asked if this reading was acceptable. The RD reported this reading was unacceptable. The RD and DW did not respond to the question, What are you to do now that the chlorine sanitizer test failed? The The Dishwashing Sanitizing Log, dated February 2016, indicated the last time a chlorine test strip had been done was the morning of 2/6/16. The log showed 4 of 7 days in February had no documentation of testing the chlorine sanitizer. It was concurrently observed that the three compartment sink had large pots filled with brown water in two of the three compartments with two clean cutting boards and numerous clean pots and pans hanging over the dirty dish area. The RD confirmed the hanging cutting boards and pots and pans could be contaminated by splash/spray when dirty dishes or pots and pans are washed in the three compartment sink. During an interview with the Dishwasher (DW), on 2/8/16, at 12:45 p.m., the DW reported she would have written down the chlorine test strip indicator as 30 ppm this morning when tested . During an interview on 2/11/16, at 10:45 a.m., the RD reported she was unable to find any policy instructing kitchen staff on what to do if the chlorine sanitizer strip indicator was less than 50 ppm. 2. During an observation and concurrent interview with the RD, on 2/8/16, at 11:50 a.m., the RD confirmed the following items were in the patient food refrigerators in the kitchen: a. 2 white meat salad sandwiches, unlabeled and undated b. 1 metal container with shredded lettuce (per RD), unlabeled and undated c. Dough (per RD) in metal bowl, unlabeled and undated d. red sauce in a metal container, unlabeled and undated e. 1 tray of various drinks, not dated f. 1 tray of milk, not dated g. 1 opened container of pasta sauce, not dated h. 1 half gallon carton of half and half - with OUTDATES 1/30/16 written on it. The RD indicated all opened products should be labeled and dated and outdates are to be discarded on or before the written date. An observation and concurrent interview with the RD, on 2/8/16, at 11:53 a.m., in the dry goods storage area revealed: a. Crushed cookie crumbs, opened and unsealed b. Confectioner sugar, opened and unsealed c. Corn starch, opened and unsealed d. 1 Bag of cookies, opened and unsealed The RD acknowledged opened dry goods should be in sealed containers or bags to prevent insect and/or infestations. 3. The facility policy and procedure titled, Department Sanitation, dated, 10/01/15, indicated, 1.1 Trash is in covered containers . During an observation and concurrent interview on 2/8/16, at 11:15 a.m., with the registered dietician (RD), the hand washing sink was within inches of the coffee cart, that dispensed coffee and juices on top level, stored paper covered condiments (various sweeteners and sugar, hot chocolate, salt, pepper), paper covered straws, and napkins on the second level. The RD indicated the cart did not move and acknowledged there was potential contamination of condiments and coffee/juice serving areas when hands are being washed. No trash can was located near the handwashing sink. A staff member moved a tall trash can, the height of the sink, next to the handwashing sink and the coffee/juice serving cart. Coffee and other beverages were being poured and set on counter without covers.The trash can did not have a lid. The rim around the trash can area was covered with unknown brown black and white substances.

Based on record review and interview, the facility failed to provide necessary care and services to prevent avoidable skin breakdown from occurring for one of three sampled residents (Resident 1). Resident 1 who was identified by the facility upon admission as "at risk for developing pressure ulcers" received an order for [REDACTED]. 1. provide a sock on the resident's left foot, prior to applying the boot as ordered by the physician, 2. monitor the resident's left foot as ordered by the physician, and 3. assess the resident's left foot for 15 days. As a result of these failures, Resident 1 developed six wounds to the left foot. Three of the wounds were on the top of the foot, one on the heel, and one on two of the toes. These failures placed Resident 1 at risk for complications of pressure sores [MEDICAL CONDITION] and death. Findings: Record review on 12/8/14 revealed Resident 1's was admitted to the facility with [DIAGNOSES REDACTED]. A comprehensive assessment dated [DATE], revealed Resident 1 usually could make herself understood and clearly understood others. Resident 1 required extensive assistance of two staff for transfers and going to the bathroom. The facility's assessment dated [DATE] indicated Resident 1 had no pressure sores upon admission to the facility, but was at risk for developing pressure sores. Review of the admission nursing assessment revealed Resident 1 had skin redness on her tailbone area and her left heel. Resident 1's plan of care included high risk for developing pressure ulcers. The interventions for preventing pressure ulcers included daily observation of the resident's skin and off loading (relieve from pressure) the resident's heels. A nursing note dated 9/22/14, noted redness to both of Resident 1's heels. A new physician's orders [REDACTED]. The facility failed to provide documentation to indicate a plan of care was developed or revised to address the redness to both of Resident 1's heels. On 9/24/14, Resident 1 had an x-ray of the left ankle due to continued complaints of pain. The x-ray revealed a fractured ankle. Review of a physician's orders [REDACTED]. Resident 1 was ordered by a physician to wear a cast boot on the left leg, a sock under the boot for protection from skin breakdown, and monitoring of the skin condition of the resident's left leg every shift. Review of Resident 1's September 2014 Medication Administration Record [REDACTED]"FYI" (for information only). The MAR indicated [REDACTED]. Review of a wound assessment report, dated 9/16/14, revealed the bottom of Resident 1's left heel had a reddened area measuring four centimeters (cm) long by six cm wide. The report indicated during the assessment, Resident 1 experienced grimacing pain. Review of the October 2014, ADL (activities of daily living) flow sheet completed each shift by the certified nursing assistants (CNAs) revealed Resident 1 received one shower between 10/1 and 10/15/14, on 10/3, and was provided a bed bath every other days except two when no hygiene was received. There was no documentation in Resident 1's MAR indicated [REDACTED]. The MAR indicated [REDACTED]. The facility was unable to provide documentation to indicate it provided Resident 1 a sock under the boot to protect the left foot from skin breakdown from 10/1/14 to 10/15/14, monitored and assessed the skin condition under the boot every shift as ordered by the physician. Review of the facility's interdisciplinary team (IDT) meeting note dated 10/23/14, revealed Resident 1 began wearing a support boot when seen by the orthopedic doctor (a physician who specializes in injuries and diseases of the body's musculoskeletal system) on 9/30/14. The IDT notes indicated a skin assessment on 10/16/14 noted dry scabs on the top of the resident's left upper foot, and the third and fourth toes "possibly related to friction associate with the support boot." On 10/19/14, a dark discoloration, measuring 1.5 cm by 2.5 cm was noted on Resident 1's left heel, and the resident verbalized pain to the site. On 10/16/14, the facility performed wound assessment reports of Resident 1's left foot. It identified the left foot have developed four separate wound, described as "dry scabs." The wounds were: 1. on Resident 1's left ankle measuring 2 cm long by 1 cm wide, 2. on top of the resident's left foot measuring 1 cm long by 0.5 cm wide, 3. on left third toe measuring 0.5 cm long by 0.7 cm wide, 4. the left fourth toe measuring 0.4 cm wide by 0.4 cm long. The subsequent wound assessment, for Resident 1's left heel, dated 10/19/14, identified an unstageable suspected deep tissue injury (discolored intact skin due to damage of underlying soft tissue from pressure) measuring 1.5 cm long and 2.5 cm wide. No new interventions were initiated and implemented. There was no documentation indicating the skin condition of Resident 1's left heel between 9/22 and 10/16/14 was monitored or assessed. Review of a note by a podiatrist, (foot doctor) dated 11/10/14, revealed Resident 1 was being seen for ulcerations of the left foot. An assessment of the resident's left foot, by the podiatrist, identified three areas of eschar (dead tissue) on the top middle part of the resident's left foot, and eschar was also found on the residents third and fourth left toe. Additionally, there was superficial eschar on the left heel measuring 1.5 cm in diameter. During a concurrent interview and record review, on 12/8/14 at 2 p.m., a licensed nurse, (LN 1) confirmed doing the initial assessment for Resident 1's left foot skin breakdown on 10/16/14. LN 1 confirmed the physician's orders [REDACTED]. 2014 MAR. LN 1 further confirmed there was no documentation of the skin condition of Resident 1's left foot being assessed for 16 days after when the support boot was applied on 9/30/14 until 10/16/14, when the skin breakdown was reported to LN 1. LN 1 stated "the cause of the scabs was most likely caused from friction of the boot." LN 1 confirmed Resident 1 had been wearing the support boot 24 hours a day, every day between 9/30/14 and 10/16/14. During a concurrent interview and record review, on 12/9/14 at 10:10 a.m., a licensed nurse, LN 2 indicated the CNAs were not supposed to touch a resident's support boot. LN 2 confirmed there was no documentation of an assessment of the skin condition of Resident 1's left foot between 10/1/14 and 10/16/14, either on the resident's MAR indicated [REDACTED]. During a concurrent interview and record review, on 12/9/14 at 11 a.m., LN 3 confirmed she performed treatments for Resident 1's heels between 10/1 and 10/11/14. LN 3 indicated the support boot would have to be removed to apply the skin barrier to Resident 1's heels. LN 3 confirmed the treatment record lacked documentation of the skin prep being applied to the resident's heels on 10/5 and 10/6/14. LN 3 confirmed the treatment record indicated the heel prep was not applied to Resident 1's heels during four evening shifts, 10/7, 10/8, 10/9 and 10/10/14 and two morning shifts, 10/12 and 10/13/14. During an interview, on 12/9/14 at 8:55 a.m., CNA 1 indicated CNAs do not take off a support boot, only nurse's do. During bathing a plastic bag was wrapped around it. During an interview, on 12/9/14 at 9:15 a.m., a picture of Resident 1's support boot was shown to CNA 2. CNA 2 stated, "CNA's can't take them (support boot) off. Only therapy and a nurse take the boot off a resident." CNA 2 indicated when bathing or showering a resident wearing a support boot a plastic bag was put over the boot so the boot didn't get wet. During an interview, on 12/9/14 at 9:15 a.m., a picture of Resident 1's support boot was shown to CNA 3. CNA 3 indicated CNAs never take a support boot off a resident, only a nurse or a physical therapist removes the support boot. CNA 3 further indicated a plastic was placed over the boot during showering and the boot was covered with a blanket when giving a bed bath.