Every finding on record at Villa Rancho Bernardo Care Center

The following reflects the findings of the California Department of Public Health during an abbreviated standard survey. Complaint Numbers: The inspection was limited to the specific complaint and Facility Reported Incident investigated and does not represent the findings of a full inspection of the facility. One deficiency was issued for the complaint number: (Refer to Ftag F609). Findings:During a record review, the admission Record indicated Resident 1 was admitted on [DATE] with diagnoses which included hemiplegia and hemiparesis (paralysis affecting one side of the body) following cerebral infarction (a stroke) and unspecified dementia (a condition which affects memory, thinking, and the ability to perform daily activities).During a record review, the Minimum Data Set (MDS- a federally mandated assessment tool), indicated Resident 1 had a Brief Interview for Mental Status (BIMS- a tool to assess cognition, or thinking skills) of 0 which indicated Resident 1 had severe cognitive impairment.During a joint observation and interview with Resident 1 on 2/26/26 at 9:27 A.M., Resident 1 was observed sitting in a wheelchair, in the dining room. There was a fading grayish green area of discoloration observed above Resident 1's right eyebrow. Resident 1 stated she did not remember how she sustained the discoloration above her eyebrow.During an interview with Resident 1's family member (FAM 1) on 2/26/26 at 10 A.M., FAM 1 stated he believed Resident 1 sustained the discoloration to the right eye because she fell out of bed during the night shift on 2/12/26-2/13/26. FAM 1 stated per the facility, there was no record of Resident 1 sustaining a fall. FAM 1 further stated the facility believed Resident 1 either bumped her eye on the bed's side rail, or accidentally hit herself with her hand. During a telephone interview with the Social Services Director (SSD) on 2/26/26 at 10:59 A.M., the SSD stated on 2/13/26, the facility was notified by Resident 1's family member (FAM 2) that there was discoloration on the right side of her eye. The SSD stated FAM 2 believed Resident 1 fell out of bed sometime during the NOC shift on 2/12/26-2/13/26, but the facility had no record of a fall. The SSD stated, [Resident 1] has vascular dementia that can wax and wane. When she first came in she was confused and barely able to answer questions. The SSD stated, [The Interdisciplinary Team- IDT- a group of professionals with different areas of expertise] had discussions that [Resident 1] could have bumped her head on the side rail, it's possible that she hit herself when removing her hand mittens. There's still a possibility that [Resident 1] could have fallen, we just don't know for sure. The SSD further stated on 2/16/26, while updating FAM 2 on the facility's investigation, [Resident 1's family] felt there was neglect.so that's when we reported it [to CDPH].During an interview with the Assistant Director of Nursing (ADON) on 2/26/26 at 2:43 P.M., the ADON stated we couldn't conclude the definite cause [of the injury] because it was not witnessed. We are looking at the possibilities. The ADON stated the facility determined Resident 1's injury was probably caused by either the side rail, or from Resident 1 accidentally hitting herself in the face. The ADON stated the facility had concluded the investigation into Resident 1's injury, and the facility was still not 100% certain of the cause. During an interview with the Director of Nursing (DON) on 3/4/26 at 3:07 P.M., the DON stated the facility concluded Resident 1 probably hit her head on the side-rail, or accidentally hit herself with her hand. The DON acknowledged Resident 1 could not verify what happened, and there were no witnesses to verify how Resident 1 sustained the injury to the right side of her head. The DON acknowledged Resident 1's injury was unwitnessed and unexplained, but stated it was not reported to CDPH (California Department of Public Health) because she did not think it was reportable. During an interview with the Administrator (ADMIN) on 3/4/26 @ 3:07 P.M., the ADMIN acknowledged he was the facility's abuse coordinator. The ADMIN stated the facility did not consider Resident 1's injury reportable because, [the injury] was light in nature .During a review of the facility's policy titled Compliance with Reporting Allegations of Abuse/Neglect/Exploitation revised 12/19/22, the policy indicated, It is the policy of this facility to report all allegations of abuse/neglect/exploitation or mistreatment, including injuries of unknown sources.are reported immediately to the Administrator of the facility and to other appropriate agencies in accordance with current state and federal regulations within prescribed timeframes.Injuries of unknown source: Includes circumstances when both the following conditions are met: i. The source of the injury was not observed by any person or could be explained by the resident. Ii. The injury is suspicious because of the extent of the injury, location of the injury.The Administrator or designee will: a. Notify the appropriate agencies immediately: as soon as possible, but no later than 24 hours after the discovery of the incident.During a record review, the facility's policy titled Abuse, Neglect, and Exploitation revised 12/19/22, the policy indicated, Reporting/Response.A. The facility will have written procedures that include.Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies.Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury.During a record review on 2/26/26, the facility's policy titled Unexplained Injuries, revised 12/19/22, indicated, Policy: All unexplained injuries, including bruises, abrasions, and injuries of unknown source will be investigated.if the injury is of unknown source, reporting and investigating procedures shall be implemented in accordance with the facility's abuse policies and procedures.

Based on interview and record review, the facility failed to ensure the Minimum Data Set (MDS- standard assessment to facilitate resident's care) related to hospice (medical care for residents expected to live six months or less) services were coded accurately for one of 3 sampled residents reviewed for hospice (Resident 212). As a result, Resident 212 did not reflect their current health status, which may lead to unmet hospice care needs. Findings: Resident 212 was admitted to the facility on [DATE] with diagnoses that included Dementia (memory problem) per the Admission Record. A review of Resident 212's medical records was conducted. Per the MDS assessment, dated 8/16/24, Section O Special Treatments, Procedure, and Programs, Resident 212 was not coded under hospice care. A review of Resident 212 Hospice Binder: Resident 212 received hospice care and service since 9/6/23, and there was no evidence that hospice services were discontinued. Per the November 2024 Order Summary, Resident 212 did not have hospice orders. On 11/7/24 at 8:04 A.M., a joint interview and record review was conducted with Licensed Nurse (LN) 1. LN 1 stated Resident 212 was on hospice services since 9/6/23. LN 1 further stated she made a mistake and clicked the discontinued order in the physician order on 4/26/24. LN 1 stated Resident 212 was on hospice and remained under hospice care. On 11/7/24 at 10:25 A.M., an interview was conducted with the MDS 1. MDS 1 stated she did the MDS assessment on 8/16/24, and she did not see a physician order for hospice. MDS 1 stated she coded Resident 212 as not receiving hospice care. MDS 1 further stated Resident 212 should have been coded under hospice care. On 11/7/24 at 11:25 A.M., an interview was conducted with the Director of Nursing (DON). The DON stated Resident 212 was receiving hospice care and the facility has a list of resident's name under hospice care. The DON further stated Resident 212 should have a physician order for hospice care, and MDS should have been coded for hospice accurately. Per the facility's policy and procedure, dated 12/19/22, titled MDS 3.0 Completion, Residents are assessed, using a comprehensive assessment process, in order to identify care needs and to develop an interdisciplinary care plan . Per the facility's policy and procedure, dated 12/19/22, titled Documentation in Medical Record, .Document shall be accurate, relevant, and complete .

Based on interview and record review, the facility failed to create person-centered care plans (a document that outlines the care and support a patient will receive) regarding non-pharmacological interventions (a healthcare treatment that doesn't involve medication) for three of 35 sampled residents (Residents 240, 290 and 440). This failure had the potential to decrease the types of supportive interventions these residents received while at the facility. Findings: Resident 240 was admitted to the facility on [DATE] with diagnoses that included depression (a serious mental health condition that causes a persistent low mood). Resident 290 was admitted to the facility on [DATE] with diagnoses that included depression. Resident 440 was admitted to the facility on [DATE] with diagnoses that included depression. On 11/6/24 at 1:44 P.M., an interview and concurrent record review were conducted with the Licensed Nurse (LN) 4 and the Assistant Director of Nursing (ADON) who stated Resident 240 was receiving two antidepressant medications for treatment of depression, Resident 290 was receiving one antidepressant medication for treatment of depression and Resident 440 was receiving three medications for depression. LN 4 and the ADON stated Residents 240, 290 and 440's care plans did not include individualized and non-pharmacological interventions. The ADON further stated there were no orders from the providers, and no documentation in the Medication Administration and Treatment Records (a daily documentation record used by a licensed nurse to document medication and treatment given). A review of the facility policy titled Comprehensive Care Plans revised on 12/19/22 indicated, It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident . that includes . resident specific interventions . A review of the facility policy titled Use of Psychotropic Medication revised on 12/19/22 indicated, Residents who use psychotropic drugs shall also receive non-pharmacological interventions to facilitate reduction or discontinuation of the psychotropic drugs.

Based on observations, interview and record review, the facility failed to flush a gastronomy tube (GT- artificial external opening in the stomach for nutritional support) between each medication administered with water for one resident of four sampled residents reviewed for GT (Resident 1). This failure had the potential for Resident 1's GT to malfunction. Findings: Resident 1 was admitted to the facility on [DATE] with diagnoses of dysphagia (difficulty swallowing) and a gastrostomy tube, per the resident's Admission Record. On 11/6/24 at 8:43 A.M., a concurrent observation and interview of a medication administration was conducted with Licensed Nurse (LN) 11. LN 11 administered the following medications via GT: -Polyethylene glycol (constipation prevention) 17 grams (gm) mixed with 240 milliliters (mLs) of water -Multivitamin with minerals (supplement) mixed with 15 mLs of water -Cetirizine (itchiness relief) 10 milligrams (mg) mixed with 15 mLs of water -Calcium carbonate (supplement) 1,250 mg mixed with 30 mLs of water -Gabapentin (pain management) 300 mg mixed with 15 mLs of water During administration of each medications via Resident 1's GT, LN 11 did not flush the GT between each medication with water. On 11/6/24 at 9:10 A.M., LN 11 confirmed it was a nursing standard of practice to flush a resident's GT between each medication that was administered. A record review of Resident 1's medication orders was conducted. On 3/22/24, the physician ordered Enteral (method of food or medication administration) Feed Order- every shift Enteral Feeding: flush enteral tube with 15-30 mLs of water before and after medication administration and 5 mLs water between each medication. On 11/07/24 at 11:44 A.M., the Director of Nursing (DON) stated that a resident's GT needs to be flushed with water between each medication during medication administration. The facility policy titled, Medication Administration via Enteral Tube, dated 12/19/22, indicated nurses must .Flush enteral tube with at least 15 mLs of water prior to administrating medication .and .Flush tube again with at least 15 mLs water .

Based on observation, interview and record review, the facility failed to ensure behavior monitoring was in placed for a psychotropic (drugs that affect a person's mental state) medication in one of five reviewed for unnecessary medications (Resident 279). This failure had the potential for Resident 279 to continuously received the medication without proper monitoring and possibly affect Resident 279's health condition and or decline. Findings: A record review of the facility's Admission Record indicated Resident 279 was admitted to the facility on [DATE] with diagnoses that included Depression (a group of condition associated with the elevation or lowering of a person's mood) and Essential Hypertension (elevated blood pressure). An observation on 11/5/24 at 9:30 A.M., in Resident 279's room was conducted. Resident 279 was lying in bed, asleep . An observation on 11/6/24 at 2 P.M., in resident 279's room was conducted. Resident 279 was asleep with no behaviors. A record review of Resident 279's Minimum Data Set (MDS- a federally mandated assessment tool) dated 10/1/24 indicated a brief interview for mental status (BIMS) a score of 11 which indicated Resident 279's cognition was moderately impaired. A record review of resident 279's medication review report dated 10/1/24 to 10/31/24 indicated the following: .Mirtazapine (an antidepressant medication) oral tablet 7.5 milligram (mg-unit of measurement), 1 tablet via GT at bedtime for depression . An interview on 11/6/24 at 11:12 A.M., with Licensed Nurse (LN) 2 was conducted. LN 2 stated Resident 279 had no behavior monitoring for his mirtazapine usage. LN 2 stated she would call Resident 279's medical doctor to have the medication discontinued. LN 2 stated she did not know why Resident 279 had the medication in the first place since he was on tube feedings. A record review of the progress notes titled, type of assessment: psychotropic medication -present on admitted d 9/27/24 at 10:38 A.M., indicated mirtazapine was used for insomnia, not sleeping; behavior observed; sad tearful. A record review of Resident 279's care plan indicated Resident 279 was on antidepressant medication related to depression with no behaviors documented. An interview on 11/7/24 at 10:57 A.M. with the Director of Nursing (DON) was conducted. The DON stated it was important to have the specific behavior monitoring to know if the medication was effective. A record review of the facility's policy titled, Use of Psychotropic Medication, dated 12/19/22, indicated .and the medication is beneficial to the resident as demonstrated by monitoring and documentation . 11 .d. In accordance with nurse assessments and medication monitoring parameters consistent with clinical standards .

Based on observation, interview and record review, the facility failed to ensure medications were not left unattended in one of six residents observed for medication storage (Resident 18). This failure had the potential to affect residents' safety and may lead to drug diversion. Findings: A record review of the facility's Admission Record indicated Resident 18 was admitted to the facility on [DATE] with diagnoses that included Dementia (a progressive state of decline in mental abilities) and Heart Failure. An observation on 11/4/24 at 9:25 A.M., in Resident 18's room was conducted. Resident 18 had two medications, one round pill and one yellow pill inside a small clear cup sitting on Resident 18's bedside table. Resident 18 stated, the nurse left the medications there for her to take after breakfast. Resident 18 stated she did not know what the medications were and what for. An interview on 11/6/24 at 10:10 A.M., with Licensed Nurse (LN) 2 was conducted. LN 2 stated it was important not to leave medications unattended in a resident's room for their safety. An interview on 11/6/24 at 12:01 P.M., with the Director of Nursing (DON) was conducted. The DON stated medications were not to be left unattended anywhere in the facility including resident's rooms for their safety. A review of the facility's policy dated 12/19/22 titled, Medication Storage indicated Policy Explanation and Compliance Guidelines .1 .c. during a medication pass, medications must be under the direct observation of the person administering the medications or locked in the medication storage area / cart .

Based on observation, interview and record review, the facility failed to ensure a clinical record was complete for one of 35 residents reviewed for medical record accuracy (Resident 153) when a physician's order for rolled washcloth was not monitored. This failure had the potential for Resident 153 to not have the adequate care and to not communicate Resident 153's care needs amongst healthcare providers. Findings: A record review of Resident 153's Admission Record indicated Resident 153 was admitted to the facility on [DATE] with diagnoses that included Muscle Weakness and Contracture (a stiffening /shortening at any joint, that reduces the joint's range of motion) of muscle, upper arm. A joint observation and interview on 11/4/24 at 8:50 A.M., with Resident 153 was conducted. Resident 153 had rolled washcloths on both her hands. Resident 153 stated she had the contractures for years now due to her arthritis (pain and stiffness of joints). A record review of Resident 153's Minimum Data Set (MDS- a federally mandated assessment tool) dated 8/14/24, Section GG - Functional Abilities and Goals indicated Resident 153's had impairments on both upper extremities. An interview on 11/6/24 at 8:37 A.M., with Certified Nursing Assistant (CNA) 4 was conducted. CNA 4 stated, the nurses did the rolled washcloths on both her hands but was not sure when and how often the washcloths were removed. An interview on 11/6/24 at 3:00 P.M., with Licensed Nurse (LN) LN 2 was conducted. LN 2 stated, nursing placed the rolled washcloths on both Resident 153's hands daily and checked them every shift for placement but it was not documented anywhere in Resident 153's medical record. LN 2 stated if it was not documented, it was not done. LN 2 stated it was important to have the rolled washcloths on both Resident 153's hands to prevent further contractures and to maintain Resident 153's skin integrity. An interview on 11/6/24 at 3:30 P.M., with LN 3 was conducted. LN 3 stated nursing should follow the doctor's orders either medication or treatment and document. LN 3 stated the nurses placed the washcloth and checked placement every two hours to check for skin breakdowns and or integrity. A record review of Resident 153's medication review report dated 10/1/24 to 10/31/24 indicated Resident 153 had the order for OK to use rolled washcloth to contractures on bilateral hands and fingers. An interview on 11/7/24 at 3:00 P.M., with the Director of Nursing (DON) was conducted. The DON stated we did not have the monitoring of the rolled washcloths documented anywhere in Resident 153's medical record. The DON stated it was important to document to ensure treatment was effective or not. The DON further stated, also to prevent further contractures and ensure Resident 153's skin integrity preventing skin breakdowns. A record review of the facility's policy titled , Consulting Physician/Practitioner's orders dated 12/19/22 indicated .3d. follow facility procedures for verbal or telephone orders including .transcribing to medication or treatment administration record .

Based on interview and record review, the facility failed to ensure one medication was administered without error for one resident (1). As a result, Resident 1 was administered amlodipine (antihypertensive; medication used to treat high blood pressure; medication helps to lower the blood pressure) outside of the parameter (guideline/instruction) ordered by the physician. This failure had the potential to further lower Resident 1's blood pressure. Findings: Resident 1 was admitted to the facility on [DATE] with diagnoses which included a history of systolic heart failure (serious condition that occurs when the heart's left ventricle [one of the two chambers at the bottom of the heart that pump out blood] is weak and cannot contract normally), per the facility's Admission Record. A record review of Resident 1's Minimum Data Set (MDS- nursing assessment tool that is used to develop a plan of care) dated 6/28/24, 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 1 had severe cognitive (pertaining to memory, judgement and reasoning ability) deficits. A review of Resident 1's clinical record was conducted. Resident 1's physician's orders dated 6/27/24, included an order for Resident 1 to be administered Amlodipine Besylate (antihypertensive medication) Oral Tablet 5 mg (milligrams) give 1 tablet by mouth one time a day for HTN (hypertension; high blood pressure) hold (do not administer/do not give) for SBP [systolic blood pressure] < [less than] 110. Resident 1's Medication Administration Record (MAR) dated June 2024 indicated that on 6/27/24 at 9 A.M., licensed nurse (LN) 1 administered Amlodipine 5 mg to Resident 1. Per this record, Resident 1's blood pressure reading was 104/69. On 8/16/24 at 11:53 A.M., an interview was conducted with LN 1. LN 1 stated that prior to administering antihypertensive medications, vital signs such as blood pressure (BP) would need to be checked. LN 1 stated If it's pretty low according to the parameters we will hold (not administer) the medications because we don't want to make the blood pressure lower . and (we would) notify the MD (physician) . LN 1 acknowledged that based on Resident 1's MAR dated 6/27/24, a BP of 104/69 indicated LN 1 had administered the Amlodipine (antihypertensive medication) to Resident 1. LN 1 stated that she should have held the Amlodipine medication and not have administered it to Resident 1 due to the parameters and the MD order that indicated to hold the amlodipine if Resident 1's SBP was <110. LN 1 stated, .Complications from the amlodipine may further decrease the blood pressure of the patient .it could cause problems like dizziness, bradycardia [slow heart rate] and worse thing could be loss of consciousness and decreased circulation . serious side effects can arise. I do understand the seriousness of this medication error. An interview with the director of nursing (DON) was conducted on 8/16/24 at 12:08 P.M. The DON stated that her expectations was for the nurses to follow the medication orders and check the parameters. The DON stated, The nurses should (also) make the determination to administer medications according to the policy and procedures. The facility policy and procedure titled, MEDICATION ADMINISTRATION, revised, 12/19/22 indicated, . Policy Explanation and Compliance Guidelines .8. Obtain and record vital signs, when applicable or per physician orders. When applicable, hold medication for those vital signs outside the physician's prescribed parameters .

Based on observations, interviews, and record reviews, the facility failed to ensure the food served to residents were palatable and acceptable according to resident comments and facility policy. This failure had the potential to cause decreased food intake and negatively impact the resident's nutritional status. The facility census was 271. Cross reference F805, F806 Findings: During the initial survey screening process on 12/4/2023 at 8:15 A.M., multiple observations and interviews were conducted with the residents about the facility's food and meals. Resident comments included The food is bad; I don't eat the food here, my family brings me food; The food is bland, and I don't eat it; There is no variety; and My chicken was raw, undercooked. During a review of the facility's Daily Spreadsheet Menus dated 12/4/23, the Regular Diet lunch meal indicated .Dijon Pork cutlet, Macaroni and cheese, steamed string beans, and Bread or dinner roll . During an observation of the lunch meal preparation and concurrent interview on 12/4/23 at 9:28 A.M., Cook (CK) 1 was boiling macaroni pasta on the stove. CK 1 opened three large #10 cans (a #10 can contains approximately 12 and 3/4 cups of food) of cheddar cheese sauce and poured it on the cooked pasta after he drained it. A small to moderate portion of the pasta-and-cheese mixture was added to the food processor and blended with two and 1/2 cartons (32 ounces each) of non-dairy Mocha Mix liquid. CK 1 stated the mixture he blended was for the residents on puree (foods that are processed until smooth like pudding, without lumps, and do not require chewing) diets. During a review on 12/4/23 of the Macaroni and Cheese recipe, the recipe indicated the ingredients were margarine, all-purpose flour, dry mustard, Worcestershire sauce, 2% milk, shredded Cheddar cheese, and additional margarine and breadcrumbs for a topping. During an observation and interview on 12/4/23 at 11:15 A.M., there were four five-pound bags of shredded cheddar cheese in the walk-in refrigerator. CK 1 stated he did not use the shredded cheese because the canned processed cheese tasted better. During a review of the facility's Daily Spreadsheet Menus dated 12/5/23, the Regular Diet lunch meal indicated .Tomato Swiss Steak, Buttermilk Mashed Potatoes, Peas and Mushrooms, and Bread or dinner roll . During a concurrent interview and observation on 12/5/23 at 10:04 A.M. with CK1, CK 1 stated the lunch meal preparation entree, Tomato Swiss Steak, and the side dishes Buttermilk Mashed Potatoes, and Peas and Mushrooms, were all in one oven cooking. The pureed food items were also prepared and were in the oven, along with the alternative entree, Baked Chicken Breast. CK1 stated the Buttermilk Mashed Potatoes on the menu were not made from scratch. CK 2 stated he used Instant Mashed Potatoes with Reduced Fat 2% Buttermilk instead. During an observation of the lunch meal tray line on 12/5/23 at 11:40 A.M., the Tomato Swiss Steak entree consisted of pre-formed oblong shaped textured beef patties with a brown gravy over the top, the green peas were observed in a pan without the mushrooms, and the Regular dessert, Apricot bar, was in small plastic cups with lids and contained apricot slices with a pastry dough bread pudding top During a test tray evaluation on 12/5/23 at 1:14 P.M. of the Regular and Puree diet lunch meals, and the Alternate entree Chicken breast, the food temperatures, flavor, and palatability were discussed with the Registered Dietitian (RD), Food & Nutrition Services Director (FSD), and the Administrator (ADM). The peas side dish had small, diced pieces of mushroom scattered in the peas. The flavor of mushroom was undetectable. The Tomato Swiss Steak entree was a pre-formed oblong processed beef meat patty, with brown gravy poured on it. The Surveyors, RD, and FSD stated the entree tasted something like beef; but the gravy did not taste like tomato, and the entree tasted salty. The Alternate chicken breast entree was dry and difficult to chew, but heavily seasoned. The mashed potatoes tasted bland and flavorless. And the dessert Apricot Bar was served with a spoon in a plastic cup with a lid and consisted of canned apricot slices and a bread/pastry dough top, that resembled bread pudding. During a concurrent observation and interview on 12/6/23 at 9:08 A.M. with CK 2, CK 2 stated he finished cooking the lunch meal entree, Cheese Ravioli, and it was in the oven. CK 2 also stated the puree meal items were also cooked and in the oven. CK 2 stated the puree meal was made by adding parmesan cheese to the ravioli and the tomato sauce would be added on the tray line, since some residents don't like tomatoes. CK 2 stated frozen Cheese Ravioli was used to make the lunch entree by cooking them first in the steamer, then in the oven. During an interview with the Registered Dietitian (RD) on 12/6/23 at 4:45 P.M., the RD stated overcooking menu items can decrease their nutritional value, appearance, and palatability by drying food out or turning food to mush. The RD also stated it was her expectation that the approved recipes for the menu be followed for taste and nutritional quality. During an interview on 12/7/23 at 12:25 P.M. with the Food and Nutrition Service Director (FSD), the FSD stated the first meal delivery cart leaves the kitchen at 11:45 A.M., and the last meal delivery cart leaves the kitchen at 1:10 P.M. The food was set in the warming tables by 11:30 A.M., according to the Tray Delivery Schedule. The total warming tray holding time was one hour and 40 minutes because holding time could affect the food. During a review of the facility policy and procedure (P&P), titled Food Preparation, dated 2018, the P&P indicated .Food shall be prepared by methods that conserve nutritive value, flavor and appearance. Procedure: 1. The facility will use approved recipes, standardized to meet the resident census.5. Prepare foods as close as possible to serving time to preserve nutrition, freshness, and prevent overcooking.7. Hold foods prior to service for as short a time period as practical. A maximum 1 hour holding time is recommended. During a review of the facility policy and procedure (P&P), titled Meal Service, dated 2018, the P&P indicated .Meals that meet nutritional needs of the resident will be served in an accurate and efficient manner .

Based on observation, interview and record review, the facility failed to ensure safe and sanitary conditions were maintained for food storage according to standards of practice when: 1. A rubber tray with twenty five cups of milk and other drink beverages had a use-by date of [DATE], and a large plastic bin filled with individual plastic cups of canned sliced pears with a use-by date of [DATE], were found in the walk-in refrigerator on [DATE]; 2. Three serving scoops with brown crusted substances and residue were stored with clean serving utensils, and 3. The ice machine was not cleaned and maintained according to manufacturer's instructions and standards of practice. These failures had the potential to expose residents to contaminants that could cause foodborne illness. The facility census was 271. Findings: 1. During the initial tour of the kitchen on [DATE] at 7:55 A.M., an observation and of the walk-in refrigerator and an interview with the Registered Dietitian (RD) was performed. The refrigerator had a large rubber tray with twenty-five 8-ounce cups of milk and other drink beverages with plastic wrap over the openings, labeled prepared [DATE], use by [DATE] and a large clear rubber bin with 24 cups of sliced canned pears labeled prepared [DATE], use by [DATE]. The Registered Dietitian (RD) acknowledged the out-of-date expired labels, and stated the trays should have been removed. According to the 2022 Federal FDA Food Code, section ,d+[DATE].17 (A) (B) (C) (D) indicate .the day the original container is opened in the food establishment shall be counted as Day 1 .The date marked shall not exceed a manufacturer's use-by date .mark the date or day of preparation, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises . 2. During an observation and interview in the kitchen on [DATE] at 9:40 A.M., three scoop utensils were observed with gray and brown spotty hard residue and stored in a plastic bin with other clean cooking utensils. The Food and Nutrition Services Director (FSD) acknowledged the scoops were not clean and stated they should be clean. According to the 2022 Federal FDA Food Code, section ,d+[DATE].11, titled Equipment Food-Contact Surfaces and Utensils, Microorganisms may be transmitted from a food to other foods by utensils, cutting boards, thermometers, or other food-contact surfaces. Food-contact.should be cleaned as needed throughout the day but must be cleaned no less than every 4 hours to prevent the growth of microorganisms on those surfaces. 3. During a concurrent observation, interview, and record review in the kitchen on [DATE] at 2:55 P.M. of the ice machine and ice machine cleaning logs with the Maintenance Director (MDR), the MDR stated he deep cleaned all three of the facility's ice machines every three months. The MDR stated this machine in the kitchen was cleaned in [DATE], but he did not know the date. A review of the cleaning log indicated the ice machine was cleaned [DATE] without a specific date. All other entries on the cleaning log were month and year, from [DATE] through [DATE] , without a date. The MDR could not recall what the cleaning date was, and stated it was early in the month. The MDR verbalized the cleaning procedure as pouring the manufacturer's recommended solution for de-scaling through the top of the ice machine curtain, followed by pouring the manufacturer's recommended sanitizing solution through the machine, then running the machine through three cycles of ice creation, and discarding the ice as the final step. The MDR stated the ice created on and after the fourth cycle would be used. After checking the interior of the ice machine, the ice making grid was removed and noted to have a gray film. The interior gasket was wiped with a clean paper towel which came away stained brown. The MDR stated, I don't see how this could happen when following the cleaning process, including the de-scaler and the sanitizing solution like I do, it should have taken care of (this). During a concurrent observation and interview on [DATE] at 3:45 P.M. the first-floor ice machine across from the kitchen was opened, and the trays were removed. The trays had a pinkish/tannish colored substance that resembled slime on the bottom as well as the sides. The ice chute opening was observed to have dirty buildup of black and brown residue. The bottom part of the ice machine was also observed to be a different manufacturer than the top ice-making part of the machine. The bottom ice machine compartment did not have a reach-in ice bin to get ice from. It had an external ice dispenser spout for an individual cup to get ice. The MDR stated he used the same deep cleaning procedure to clean the bottom that he used for the top. The RD, MDR, and ADM acknowledged the black and brown residue inside the ice chute and inner ice tray. The RD stated the ice machine should be clean for the residents. During an observation on [DATE] at 3:56 P.M. of the second-floor ice machine interior ice curtain, the ice tray was visibly grimy with a dark gray and brown substance, and the cooling grid was visibly discolored with a grayish/tannish substance. The bottom compartment of the ice machine was made by a different manufacturer from the top ice-making part. The MDR stated again the deep cleaning process for the bottom was the same process he used for the top. The RD, MDR, and ADM acknowledged the discolored substances inside the ice machine, top compartment where the ice-making parts were located. During an interview with the Maintenance Director (MDR) on [DATE] at 1:55 PM, the MDR stated he did not use a brush to clean the inside of the ice machines as instructed in the manufacturer's guidelines. During an interview with the Registered Dietitian (RD) on [DATE] at 5:02 P.M., the RD stated the facility's ice machine should be cleaned monthly according to the manufacturer's guidelines and logged correctly with the cleaning date. During an interview with the facility's Administrator (ADM) on [DATE] at 5:05 P.M., the ADM stated the facility had a water management program and he would provide the report. The ADM stated a company tested the facility's water sources at multiple places and levels throughout the facility. During a review of the facility's water management program report titled Legionella Analysis Report, dated [DATE], the report indicated two sites in the facility were tested for legionella (a bacteria that can cause serious lung infection and flu-like symptoms) which included the kitchen sink and the first-floor utility sink. The ice machines were not tested in the report or part of the water management program. During a review of the CDPH AFL ,d+[DATE] Reducing Legionella Risks in Health Care Facility Water Systems, dated [DATE], the document indicated The California Department of Public Health (CDPH) expects health care facilities to comply with the Centers for Medicare Services (CMS) .requirements to protect the health and safety of its patients. SNFs (Skilled Nursing Facilities) must have a water management plan, which includes a facility risk assessment and testing protocols, available for review. Facilities unable to demonstrate measures to minimize the risk of Legionnaires' disease are out of compliance. During a record review on [DATE] of the kitchen, first and second floor ice machines' Manufacturer's Manuals, the cleaning and sanitizing instructions indicated, .Step 1: open the front panel.Step 2: Remove all ice from the in/dispenser. Step 3: Press the Clean button and select Turn off when complete. Add de-scaler to the water trough .Step 4: Wait until the cycle is complete (approximately 24 minutes). Then disconnect power to the ice machine. Step 5: Remove the parts for de-scaling. Step 6: Mix a solution of de-scaler and lukewarm water. Depending on the amount of mineral buildup, a large quantity of solution may be required .Step 7: Use half of the de-scaler and water mixture to de-scale all components .soak parts for 5 minutes (,d+[DATE] minutes for heavily scaled parts) .Use a soft bristle nylon brush, sponge, or cloth to carefully de-scale the parts .Rinse all removed components with warm water. Step 8: While components are soaking, use half of the solution to de-scale all food zone surfaces of the ice machine .Use a nylon brush or cloth to thoroughly de-scale the the following ice machine areas: side walls; base (area above the water trough); evaporator plastic parts including the top, bottom and sides; bin or dispenser. Rinse all area thoroughly with clean water. Step 9: Sanitizing: Mix a solution of sanitizer and lukewarm water. Step 10: Use half of the sanitizer/water solution to sanitize all removed components .Do not rinse parts after sanitizing. Step 11: Use half of the sanitizer/water solution to sanitize all food zone surface .Step 12: Replace all removed components .and wait 20 minutes. Step 14: Press the Clean button and select Make Ice when complete .Add chemical. Add the proper amount of ice machine sanitizer to the water trough .Step 14: Close and secure the front panel. The ice machine will automatically start ice making after the sanitize cycle is complete (approximately 24 minutes). During a review of the facility' policy and procedure (P&P) titled Maintenance Inspection dated [DATE], the P&P indicated .It is the policy of this facility to .assure a safe, functional, sanitary, and comfortable environment for the residents . According to the 2022 Federal FDA Food Code section ,d+[DATE].11, titled Equipment Food-Contact Surfaces and Utensils, Ice bins and components of ice makers need to be cleaned: (a) At a frequency specified by the manufacturer, or (b) Absent of the manufacturer specifications, at a frequency necessary to preclude accumulation of soil and mold . According to the 2022 Federal FDA Food Code Annex section ,d+[DATE].11, Ice makers and ice bins must be cleaned on a routine basis to prevent development of slime, mold, or soil residues that may contribute to an accumulation of microorganisms.

Based on observation, interviews, and documentation, the facility failed to ensure essential kitchen equipment was maintained in working operational condition when three of four ovens were not working or maintained according to standards of practice or facility policy. This failure affected the ability of the Food and Nutrition Services Department to prepare resident meals safely and efficiently, which had the potential for residents to receive undercooked food, and to develop food borne illness. The facility census was 271. Findings: During a concurrent observation and interview with Cook 1 (CK 1) on 12/4/23 at 8:50 A.M., there were two double stackable ovens next to the cooktop gas stove range with an oven underneath. The bottom oven in the stackable oven unit had an out of order, maintenance notified 12/3/23 sign taped to the bottom handle. CK1 stated the oven had not been working since last Thursday (11/30/23) but also stated it may have been not working longer than that. CK 1 attempted to light the lower left oven pilot light three times before it eventually lit and stayed fired. CK 1 further stated the timers did not work on any of the four ovens, and the numbers were worn off the knobs used to set the cooking temperatures. CK 1 stated he usually guesses how far to turn the knobs to heat to an estimated cooking temperature, so sometimes the food did not cook throughout. CK 1 stated he had to recook food items in the past, which caused food production delays. CK 1 further stated the oven under the gas burner range had not worked or been used in years, so he was uncertain if it worked anymore. During a concurrent observation and interview on 12/6/23 at 9:53 A.M. with Cook 2 (CK 2), CK 2 stated the bottom right oven of the stackable oven units was holding the pureed food. CK 2 stated he believed he started the initial temperature to 350 degrees, then adjusted turned the knob up to 400 degrees. CK 2 stated the oven knobs were worn off and the numbers were difficult to see. CK 2 clarified the temperature was not accurate, so CK 2 used a food thermometer to take the internal temperature multiple times throughout the cooking process to verify food safety. CK 2 also stated the oven temperatures were uneven, some areas get hotter than others. CK 2 was observed opening the right oven four times to check whether the dinner rolls being served at lunch were cooked. When CK 2 removed the rolls from the oven, they had uneven degrees of browning, from pale in the center to dark brown at the far edge. Also, some rolls were soft and doughy, and others were semi-hard. During a review of the facility's 2023 kitchen maintenance log on 12/7/23, the maintenance log indicated two repairs to the top oven in the stackable oven unit on 1/3/23 and 3/14/23. On 6/15/23, the log indicated oven not warming up and on 10/30/23, the log indicated oven not working without a repair correction date. During an interview with the Registered Dietitian (RD) on 12/6/23 at 10:24 A.M., the RD stated she was aware the maintenance department was working on and repairing the non-working oven in the kitchen. The RD further stated she was not aware of the severity of the oven issues regarding the temperatures not heating evenly, the worn knobs that were illegible, and the broken timer. The RD stated it was important for the facility to have cooking equipment that worked correctly to prepare the resident's meals. During an interview with the Administrator (ADM) on 12/7/23 at 12:15 P.M. , the ADM stated it was important for the Cooks to have working ovens to prepare meals and he was aware of the kitchen oven repair issues. According to the 2022 Federal FDA Food Code, section 4-501.11, titled Good Repair and Proper Adjustment, the section indicated, .(A) EQUIPMENT shall be maintained in a state of repair and condition that meets the requirements .; (B) EQUIPMENT components such as doors, seals, hinges, fasteners, and kick plates shall be kept intact, tight, and adjusted in accordance with manufacturer's specifications . During a review of the facility's policy and procedure (P&P) titled, Maintenance Inspection, dated 12/19/22, the P&P indicated, It is the policy of this facility to utilize a maintenance inspection checklist in order to assure a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. 1. The Director of Maintenance Services will perform routine inspections of the physical plant using the Maintenance Checklist. 2. The Administrator, or designee, will perform random inspections.3. All opportunities will be corrected immediately by maintenance personnel. A copy of the Maintenance Checklist was requested on 12/6/23 but was not provided.

Based on observation, interview, record review, and document reviews, the facility failed to ensure that low air loss mattresses (LAL - an air flow mattress used to prevent skin breakdown by distributing weight over the mattress to reduce pressure to the skin) were set according to the physician's order for five of five residents (Resident 197, Resident 203, Resident 7, Resident 69, Resident 216) reviewed for pressure ulcer. These failures increased the risk for skin breakdown for all residents. Findings: 1. A review of Resident 197's Admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included Heart Failure (occurs when the heart muscle doesn't pump blood as well as it should). A review of Resident 197's physician's order, dated 12/17/21, indicated, .LAL Mattress for skin management. License nurse to monitor proper functioning of LAL mattress. License nurse to monitor setting if LAL mattress per pt [patient] weight or comfort QS [every shift]. A record review of the Resident 197's Minimum Data Set (MDS, nursing assessment tool), dated 10/22/23, indicated Resident 197 was at risk for developing pressure ulcers and had severe impairment (diminishment or loss of function) in cognition (the understanding of thought processing with language, learning, attention and memory). An observation of Resident 197 was conducted on 12/05/23 at 9:34 A.M., in Resident 197's room. Resident 197 rested in bed with the LAL mattress setting for the resident's weight at 125 pounds (lbs). A record review of Resident 197's electronic medical record (EMAR) indicated Resident 197's weight at 110.4 lbs. on 12/2/23. A concurrent observation, interview and record review of Resident 197's medical record was conducted with licensed nurse (LN) 13 on 12/06/23 at 11:22 A.M. LN 13 confirmed that Resident 197's LAL mattress setting for the resident's weight at 175 lbs. LN 13 reviewed Resident 197's medical record and stated the resident's weight was at 110.4 lbs. and that the LAL mattress setting for the resident's weight was incorrect. 2. A review of Resident 203's Admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included Hemiplegia (the inability of a muscle or group of muscles to move voluntarily) and Hemiparesis (one sided weakness) following Cerebral infarction (occur when blood flow to the brain is blocked or there is sudden bleeding in the brain). A review of Resident 203's physician's order, dated 7/27/22, indicated, .LAL Mattress for skin management. License nurse to monitor proper functioning of LAL mattress. License nurse to monitor setting if LAL mattress per pt [patient] weight or comfort QS [every shift]. A record review of the Resident 203's Minimum Data Set (MDS, nursing assessment tool), dated 11/12/23, indicated Resident 203 was at risk for developing pressure ulcers and was severely impaired in cognition with daily decision making. An observation was conducted on 12/4/23 at 8:36 A.M., in Resident 203's room. Resident 203 rested in upright position with the tube feeding (TF) on and the LAL mattress setting for the resident's weight was at 175 lbs. An observation was conducted on 12/5/23 at 9:32 A.M., in Resident 203's room. Resident 203 was asleep in upright position with the TF on and the LAL mattress setting for the resident's weight at 125 lbs. A record review of Resident 203's EMAR indicated the resident's weight at 118 lbs. on 12/2/23. A concurrent observation, interview and record review of Resident 203's medical record was conducted on 12/6/23 at 11:27 A.M. with LN 13. LN 13 confirmed Resident 203's LAL mattress setting was set at a weight of 175 lbs. LN 13 reviewed Resident 203's medical record and stated that the resident's current weight was at 118 lbs. and that the LAL was weight setting was incorrect. 3. A review of Resident 7's Admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included Functional Quadriplegia (not a true paralysis, but the inability to move due to another medical condition). A review of Resident 7's physician's order, dated 12/17/21, indicated, .LAL Mattress for skin management. License nurse to monitor proper functioning of LAL mattress. License nurse to monitor setting if LAL mattress per pt [patient] weight or comfort QS [every shift]. A record review of the Resident 7's Minimum Data Set (MDS, nursing assessment tool), dated 9/10/23, indicated Resident 7 was at risk for developing pressure ulcers and was severely impaired in cognition with daily decision making. An observation was conducted on 12/4/23 at 8:52 A.M., in Resident 7's room. Resident 7 was awake in bed watching television. Resident 7's LAL mattress setting for the resident's weight was at 210 lbs. An observation was conducted on 12/5/23 at 9:31 A.M., in Resident 7's room. Resident 7 was resting in bed in an upright position with LAL mattress setting for the resident weight at 210 lbs., unchanged from the previous day. A record review of Resident 7's electronic medical record (EMAR) indicated Resident 7's weight was 124 lbs. on 12/2/23. A concurrent observation, interview and record review of Resident 7's medical record was conducted with licensed nurse (LN) 13 on 12/6/23 at 11:32 A.M. LN 13 confirmed the resident's LAL mattress settings for the resident's weight was set at 210 lbs. LN 13 reviewed Resident 7's medical record and stated that the resident's current weight was 124 lbs. LN 13 stated Resident 7's LAL mattress weight setting was incorrect. 4. A review of Resident 69's Admission Record indicated that resident was readmitted to the facility on [DATE] with diagnoses that included Spinal Stenosis (when the space inside the backbone is too small causing pressure to spinal cord [back bone] and nerves [carry sensations to brain and body]). A review of Resident 69's treatment orders did not include orders for a LAL mattress and/or monitoring in place. A record review of the Resident 69's Minimum Data Set (MDS - assessment tool), dated 11/19/23, indicated Resident 69 was at risk for developing pressure ulcers and was severely impaired in cognition with daily decision making. Resident 69 was also coded on the MDS for the use of a pressure reducing device for bed. An observation was conducted on 12/4/23 at 9:54 A.M., in Resident 69's room. Resident 69 was asleep in bed with the LAL mattress setting for the resident's weight set at 150 lbs. An observation was conducted on 12/5/23 at 9:22 A.M., in Resident 69's room. Resident 69 laid in bed with the LAL mattress setting for the resident weight set at 150 lbs., unchanged from the previous day. A record review of Resident 69's electronic medical record (EMAR) indicated Resident 69's weight was 108 lbs. on 12/2/23. A concurrent observation, interview and record review of Resident 69's medical record was conducted on 12/6/23 at 11:40 A.M. with licensed nurse (LN) 13. LN 13 confirmed the resident's LAL mattress weight setting was set at 150 lbs. LN 13 reviewed Resident 69's medical record and stated that the resident's weight was at 108 lbs. LN 13 stated Resident 69's LAL mattress weight setting was incorrect. 5. A review of Resident 216's Admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included Hemiplegia (the inability of a muscle or group of muscles to move voluntarily) and Hemiparesis (one sided weakness) following Cerebral infarction (occur when blood flow to the brain is blocked or there is sudden bleeding in the brain). A review of Resident 216's physician's order, dated 8/30/23, indicated .LAL Mattress for skin management. License nurse to monitor proper functioning of LAL mattress. License nurse to monitor setting if LAL mattress per pt [patient] weight or comfort QS [every shift]. A record review of the Resident 216's Minimum Data Set (MDS, nursing assessment tool), dated 12/3/23, indicated Resident 216 was at risk for developing pressure ulcers and had moderate impairment in cognition. An observation was conducted on 12/4/23 at 10:46 A.M., in Resident 216's room. Resident 216 was resting in upright position with the LAL mattress setting for the resident weight set at 125 lbs. An observation was conducted on 12/5/23 at 9:44 A.M., in Resident 216's room. Resident 216 was in bed watching TV with the LAL mattress setting for the resident weight set at 125 lbs., unchanged from previous day. A record review of Resident 216's electronic medical record (EMAR) indicated Resident 216's weight was 179 lbs. on 12/2/23. A concurrent observation, interview, and record review of Resident 216's medical record was conducted on 12/6/23 at 11:44 A.M. with licensed nurse (LN) 13. LN 13 confirmed the resident's LAL mattress settings for the resident's weight was set at 125 lbs. LN 13 reviewed Resident 216's medical record and stated the resident's current weight was 179 lbs. LN 13 stated Resident 216's LAL mattress weight setting was incorrect. An interview with LN 14 was conducted on 12/07/23 at 9:30 A.M. LN 14 stated if the LAL mattress setting was incorrect, the resident's comfort level could be compromised. LN 14 stated, the beds are used to prevent pressure ulcers so if the settings weren't set according to weight, not sure if they'd [residents at risk for pressure ulcers] develop pressure ulcers. During an interview with the Director of Nursing (DON) on 12/7/18 at 10:33 A.M., the DON stated that comfort should not be the guiding factor with setting the LAL mattresses. The DON stated the LAL mattresses should be set based on the resident's weight and manufacture recommendations to avoid complications. The facility policy and procedure titled, Pressure Injury Prevention and Management, dated 9/12/23, indicated Evidenced-based interventions for prevention will be implemented for all residents who are assessed at risk or who have a pressure injury present . A review of the manufacturer guidelines for Front Panel diagrams, provided by the facility: [Brand Name 55 and 65] Low Air Loss Mattress manual dated 2017 The Comfort Control LED displays the patient comfort pressure levels from 0 to 9 and provides a guide to the caregiver to set approximate comfort pressure level depending on the patient weight. If the patient's weight to height ratio is above average, increase the pressure by approximately 20% . A review of the manufacturer guidelines for Front Panel diagrams, provided by the facility: [Brand Name 600 and 800] Low Air Loss Mattress manual dated 2017 When the mattress is fully inflated, set the dial in accordance with the patient's size and weight .

Based on interview and record review, the facility failed to accurately code the Minimum Data Set (MDS - assessment tool) related to the use of an anticoagulant (medicine that prevent or reduce blood clots) for two of 35 residents (Resident 69 and Resident 106) reviewed for MDS accuracy. Resident 69 and Resident 106's MDS assessments, dated 11/19/23, incorrectly coded that both residents received an anticoagulant medication during the 7-day look back period of 11/13/23-11/19/23. These failures had the potential for staff to provide both residents with inappropriate care due to the wrong data inputted in the residents' MDS assessment. Findings: 1. A review of Resident 69's Admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included Spinal Stenosis (when the space inside the backbone is too small causing pressure to spinal cord [back bone] and nerves that carry sensations to brain and body). A record review of Resident 69's MDS assessment, dated 11/19/23, Section N Medications N0415E, indicated that Resident 69 received anticoagulant medications during the MDS 7-Day look back period of 11/13/23-11/19/23. An interview and record review of Resident 69's medical record was conducted with the Minimum Data Set Nurse (MDSN) on 12/06/23 at 2:40 P.M. The MDSN stated Resident 69's MDS assessment, dated 11/19/23, indicated the resident received an anticoagulant medication, because the resident received aspirin (medicine used to reduce pain, fevers and/or used to prevent brain/heart attacks due to clots) during the look back period of 11/13/23-11/19/23. 2. A review of Resident 106's Admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included Cerebral Infarction (A disruption [interruption] of blood flow to the brain due to problems with the blood vessels [channels that carry blood to the body] that supply it). A record review of Resident 69's MDS assessment, dated 11/19/23, Section N Medications N0415E, indicated that Resident 69 received anticoagulant medications during the MDS 7-Day look back period of 11/13/23-11/19/23. An interview and record review of Resident 106's medical record was conducted with the Minimum Data Set Coordinator (MDSC) and Minimum Data Ser Nurse (MDSN) on 12/6/23 at 2:44 P.M. The MDSC stated that Resident 106's MDS Assessment, dated 11/19/23, indicated the resident received anticoagulant medication, because the resident received Clopidogrel (medicine that prevents platelet [tiny blood cells that help your body form clots to stop bleeding] formation resulting in clots) and aspirin (medicine used to reduce pain, fevers and/or used to prevent brain/heart attacks due to clots) during the look back period of 11/13/23-11/19/23. The Resident Assessment Instrument (RAI)/MDS Manual October 2023 Section N was reviewed by the MDSC on 12/7/23 at 10:01 A.M. The manual indicated, .do not code antiplatelet medications such as aspirin/extended release ., or Clopidogrel as N0415E, Anticoagulant. The MDSC stated that Resident 69 and Resident 106's MDS assessments would need to be modified and resubmitted because both assessments were inaccurate and could affect the residents plan of care. During an interview and record review of Resident 69 and Resident 106's medical record on 12/7/23 at 10:44 A.M., with the Director of Nursing (DON), the DON confirmed that both residents did not receive anticoagulant medications during the look back period of 11/13/23-11/19/23. The DON stated Resident 69 and Resident 106's MDS assessments were inaccurately coded. A review of Centers for Medicare and Medicaid Services (CMS, a federal agency) Resident Assessment Instrument (RAI, a standardized assessment tool for resident) RAI Manual 3.0 October 2023, (Page N-8) Section N0415E: Medications.Do not code antiplatelet medications such as aspirin/extended release, ., or Clopidogrel as N0415E.

Based on interview and record review the facility failed to ensure the PASSAR Level 2 (PSL2) (Preadmission Screening and Resident Review- a form to determine if a resident has or is suspected of having a mental illness) was completed after PASSAR Level 1 (PSL1) was positive for one of 35 residents (Resident 183) reviewed for PASSAR. This failure had the potential to not ensure the appropriate mental health services for Resident 183. Findings: A review of Resident 183's Admission Record (AR) indicated Resident 183 was admitted on [DATE] with diagnoses including: Unspecified Dementia (a condition characterized by progressive or persistent loss of intellectual functioning), unspecified severity with other behavioral disturbances, and Depression (persistent sadness and a lack of interest or pleasure). On 12/4/23 at 3:30 P.M., an interview with Resident 183 was attempted. Resident 183 refused interview. On 12/6/23 at 11:15 A.M., a concurrent interview of Licensed Nurse (LN) 2 and record review of Resident 183's chart was conducted. Resident 183's PSL1 was in front of chart, indicating need for PSL2 screening. LN 2 was asked to locate PSL2 in chart, LN 2 did not find a PSL2 for Resident 183. LN 2 made request to Medical Records for copy of PSL2. Medical Records brought a copy of a document from the Department of Health Care Services entitled UNABLE TO COMPLETE LEVEL II EVALUATION, dated 2/4/2022. LN 2 stated that she could not find any notes in the chart where Resident 183 had been discharged on or before 2/4/23. LN 2 stated that PSL2 was never completed. On 12/7/23 at 12:10 P.M., a concurrent interview and record review of multiple documents was conducted with the Social Services Director (SSD). The facility policy entitled, Resident Assessment-Coordination with PASSAR Program, dated 12/19/2022 was reviewed with the SSD. The policy and procedure (P&P) indicated, . 6. The Social Service Director shall be responsible for keeping track of each resident's PASSAR screening status and referring to the appropriate authority . The SSD stated that she was unaware that she was responsible for tracking and coordinating PASSAR for residents. The SSD was unable to locate PSL2 in Resident 183's electronic medical record (EMR). The SSD reviewed the document entitled UNABLE TO COMPLETE LEVEL II EVALUATION, dated 2/04/2022. The SSD stated that she could not find documentation that Resident 183 was discharged on or before 2/4/23. The SSD stated that the expectation would be for Resident 183 to be rescreened for PSL1 since PSL2 was not completed per the P&P. The SSD stated the importance of PASSAR screenings was to make sure resident was placed in the appropriate setting, and was receiving appropriate services. On 12/7/23 at 12:20 P.M., a concurrent interview and record review of document UNABLE TO COMPLETE LEVEL II EVALUATION, dated 2/04/2022 was conducted with the Assistant Director of Nursing (ADON). The ADON stated that she was unsure of whose responsibility it was to follow up on the PASSARs, but she had just recently reactivated her access to PASSARs and had been receiving file exchange from hospitals. The ADON was unable to find the documentation that the resident had been discharged on or before 2/4/22. The ADON stated that the expectation was if a resident was discharged , the PSL1 would have to be repeated; if the patient was not discharged the PSL2 should have been completed with a copy in the chart. The ADON stated the importance of PASSAR screening was to make sure the residents were in a facility and setting that was appropriate for them, and that they were receiving services that were recommended per the PASSAR. On 12/7/23 at 12:00 P.M., an interview with the Director of Nursing (DON) was conducted. The DON stated that PSL2 screening had not been completed for Resident 183. The DON stated that the expectation was if Resident 183 was discharged , she should have been rescreened for PASSAR 1. The DON stated that, if the resident was not discharged , the PASSAR 2 should have been completed within 40 days of the admission. The DON stated the importance of screening the residents for PASSAR was to make sure the residents were placed in the appropriate setting and were receiving services according to PSL2. During a review of facility policy and procedure(P&P) entitled, Resident Assessment-Coordination with PASSR Program dated 12/19/2022, the P&P indicated, The facility coordinates assessments with the preadmission screening and resident review (PASARR) program under Medicaid to ensure that individuals with mental disorder, intellectual disability, or a related condition receives care and services in the most integrated setting appropriate for their needs .1. All applicants to this facility will be screened for serious mental disorders or intellectual disabilities and related conditions in accordance with State Medicaid rules for screening .a. PASARR Level I- initial pre-screening that is completed prior to admission . i. Negative Level I Screen- permits admission to proceed and ends PASARR process unless a possible serious mental disorder or intellectual disability arises late .ii. Positive level I screen -necessitates PASARR Level II evaluation prior to admission .b. PASARR Level II- a comprehensive evaluation by appropriate state-designated authority (cannot be completed by the facility) that determines whether the individual had MD (mental disability), ID(intellectual disability), or related conditions, determines the appropriate setting for the individual, and recommends any specialized services and/or rehabilitative services the individual needs .3. A record of the pre-screening shall be maintained in the resident's medical record .5.b.The Level II resident must be completed within 40 calendar day of admission .6.The Social Services Director shall be responsible for keeping track of each resident's PASARR screening status, and referring to appropriate authority .

Based on interview and record review, the facility failed to develop a patient-centered plan of care for one of 35 residents (Resident 152) related to language. This failure had the potential for Resident 152's care needs to not be addressed due to miscommunication. Findings: A review of Resident 152's Admission Record indicated the resident was admitted to the facility on [DATE] with a diagnosis of Cerebral Palsy (is a group of disorders that affect a person's ability to move and maintain balance and posture). Per the Admission Record, Resident 152's primary language was Chinese. A record review of the Resident 152's Minimum Data Set (MDS - assessment tool), dated 10/08/23, indicated under Section C100 Cognitive Patterns, Resident 152 was coded 0. Per the Resident Assessment Instrument (RAI)/MDS manual, Resident 152 was rarely/never understood. An interview was conducted on 12/04/23, at 9:00 A.M., with Certified Nursing Assistant (CNA) 11. CNA 11 stated that Resident 152 was verbal and did not speak English. CNA 11 stated that he did not speak the same language as Resident 152 but when needed, a staff member who was able to speak the same language, would be assigned to the resident so that they were able to verbally communicate. CNA 11 stated that if a translator was needed that he would inform the licensed nurses (LN). CNA 11 stated he was able to communicate with Resident 152 through hand gestures such as pointing to specific areas that Resident 152 was trying to communicate about or through body language. An observation was conducted on 12/4/23 at 9:53 A.M., in Resident 152's room. Resident 152 was yelling with head nodding side to side and stopped yelling once CNA 11 was out of room. An interview was conducted on 12/6/23 at 9:29 A.M., with LN 13. LN 13 stated communication boards were used for residents with language barriers and for long translations, (name of translation service name) would be called. LN 13 stated the information regarding the translation service could be located in the resident's charts. LN 13 stated the information included specific codes for specific language a resident spoke. An interview and record review of Resident 152's medical record was conducted on 12/6/23 at 9:45 A.M., with the Minimum Data Set Nurse (MDSN). The MDSN stated that Resident 152's care plan, revised on 8/26/21 indicated .resident has a communication problem r/t (related to) Language barrier . The MDSN stated that the Care Area Assessment (CAA, provides guidance on how to focus on key issues identified during a comprehensive MDS assessment), if triggered, would help the Interdisciplinary Team (IDT) in developing care plans related to nursing, activities, dietary, social services, and rehab. An interview and record review of Resident 152's medical record was conducted on 12/06/23, at 2:58 P.M., with the Social Service Director (SSD). The SSD stated that Resident 152's care plan, revised on 8/26/21, titled .Language barrier . was not personalized to Resident 152's needs. Per the SSD, indicating Resident 152's preferred language would be helpful in addressing the resident's communication needs. The SSD stated communication barriers could potentially result in frustrations and unmet resident needs. During an interview and record review of Resident 152's medical record with the Director of Nursing (DON) on 12/7/18 at 10:44 A.M., the DON stated patient-centered care plans should be developed in order to ensure that the specific care needs of the resident was addressed. A review of the facility's policy and procedures titled Comprehensive Care Plans indicated, .care planning will include an assessment of the residents's strengths and needs, and will incorporate the resident's personal and cultural preferences in developing goals of care .

Based on interview and record review, the facility failed to update the plan of care for one of 35 residents (Resident 101) related to activities of daily living (activities such as eating, toileting, dressing, etc.). This failure had the potential for Resident 101's ADL needs to not be addressed. Findings: A review of Resident 101's Admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included Alzheimer's Disease (a brain disorder that slowly destroys memory, thinking skills, and eventually, the ability to carry out the simplest tasks). A record review of Resident 101's Minimum Data Set (MDS - assessment tool), dated 9/14/23, indicated the resident required extensive assistance with eating and toileting. An interview and record review of Resident 101's medical record was conducted on 12/06/23 at 9:45 A.M., with the Minimum Data Set Nurse (MDSN). The MDSN stated that a significant change of condition (SCSA - when two or more factors of decline is captured with the overall resident's health status) MDS was completed to capture Resident 101's decline with eating and toileting. The MDSN stated that Resident 101's care plan was revised on 9/14/23, but did not reflect the resident's decline with eating and toilet. The MDSN stated Resident 101's care plan was not updated to reflect the current extensive assistance needed by the resident from staff in order to perform the activities related to eating and toileting. During an interview and record review of Resident 101's medical record with the Director of Nursing (DON) on 12/7/18 at 10:44 A.M., the DON stated Resident 101's care plan should have been revised when changes of condition was identified to reflect the resident's current health status. A review of the facility's policy and procedures titled Comprehensive Care Plans indicated, .The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS .

Based on observations, interviews, and record reviews, the facility failed to monitor and fully assess a sampled resident, Resident 221, with a severe weight loss of 17.3% in six months, according to the facility's policy. This failure led to further decline in Resident 221's nutritional and health status. Findings: According to the Academy of Nutrition & Dietetics, Nutrition Care Manual, dated 2022, Treatment of unintended weight loss is imperative to ensure optimal outcomes for the older adult. Unintended weight loss is linked to increased mortality (death) among older adults . residents in long-term-care facilities who continue losing weight have a higher mortality rate compared with those who stop losing weight. Weight loss of 5% or more within 30 days is associated with a tenfold increase in the likelihood of death. Unintended weight loss often results in protein-energy undernutrition (low protein or calorie intake resulting in insufficient nutrient absorption), as the older adult loses critical lean body mass and is more prone to pressure ulcers (injuries to the skin and underlying tissue due to consistent pressure), infections (when a virus or bacteria enters the body and causes harm), immune dysfunction (when the body's system does not fight off infections or illness), anemia (low levels of oxygen in the blood), falls resulting in hip fractures (breaks or tears), and other conditions. Per the facility's Admission Record, dated 12/7/23, Resident 221 was admitted on [DATE] with diagnoses of chronic osteomyelitis (swelling of bone tissue that is usually the result of an infection) left ankle and foot, type 2 diabetes (high blood sugar level), anemia (low oxygen in the blood), end stage renal disease (dysfunction of the kidneys) and hyperlipidemia (high concentration of fat content in the blood). During an observation and interview on 12/7/23 at 12:43 P.M., Resident 221 was sitting in his bed and looked physically thin. Resident 221 was eating his lunch with assistance from Certified Nursing Assistant (CNA 3). CNA 3 stated Resident 221 usually ate 90% of his meals, especially lunch when he doesn't have dialysis. Resident 221 drank about 75% of his novosource liquid supplement. During a review of Resident 221's physician's ordered diet, dated 9/23/23, the diet order indicated Dysphagia Mech Altered Texture, Thin consistency, CCHO; On 10/22/23, the Supplement diet order indicated Novosource Renal, Vanilla with meals for 237 mL During a review of Resident 23's Weights and Vitals Summary, dated 12/6/23, for April 2023 through November 2023 indicated: [DATE] - 153.0 pounds May 2023 -149.8 pounds Jun 2023 - 149.6 pounds [DATE] - 142.5 pounds [DATE] - 136.1 pounds [DATE] -134.2 pounds [DATE] - 126.5 pounds [DATE] - 126.7 pounds Resident 221 experienced a 26.5 pound weight loss (17.3%) from April 2023 to October 2023. During a review of Resident 221's Nutrition Care Plan, the care plan indicated Focus .significant weight loss 6/30/23: -4.2 pounds/-2.9% in one week .10/5/23: significant weight loss 9.1 pounds/6.8% weight loss in one month; initiated 7/20/23 and revised 11/3/23; Goal- .The resident will maintain adequate nutrition status as evidenced by maintaining weight within goal weight range (GWR) of 130-140 pounds, no signs/symptoms of malnutrition .initiated 10/19/23 . During an interview with the Registered Dietitian (RD) on 12/06/23 at 4:08 PM, the RD stated her expectation for managing resident's weight loss is to address it as quickly as possible. The RD stated Resident 221's weight loss could have been managed sooner by updating food preferences, implementing other nutrition interventions such as larger portions and liquid supplements, then monitoring the effectiveness of the interventions, as well as weekly weights. The RD stated Resident 221 goes to dialysis three times a week and received a bag lunch with a sandwich, crackers, and pudding on those days. The RD stated the resident may have decreased meal intake on those days. The RD stated there could have been a conversation with the Resident's sister about bringing in appropriate food items from home or outside to help increase the resident's food intake on dialysis days. The RD acknowledged Resident 221 was not on a weekly weight protocol when the weight loss was identified as significant weight loss a few months ago. During an interview on 12/6/23 at 4:20 P.M. with Resident 221's physician (PHYS), the PHYS stated Resident 221 was full code with a complicated medical history including toe amputations, uncontrollable diabetes, renal failure, among other conditions. The PHYS stated Resident 221 was on novosource supplements with meals to increase his calories and maintain his nutritional status. The PHYS stated he was not aware of the severe weight loss until recently but had addressed previous weight loss concerns in a his progress notes months ago. During an interview with the Director of Nursing (DON) on 12/07/23 at 12:46 PM, the DON stated the facility uses the facility's weights not the dialysis weights, when assessing the resident's weight status. The DON stated Resident 221 is full code, really medically compromised, and it was challenging for the sister to make decisions for him. The DON stated she was unaware the family was told not bring food in from the outside for Resident 221. The DON stated multiple interventions should have been used to manage Resident 221's weight loss. During a review of the RD's nutrition assessment progress notes dated 5/8/23 completed by the RD, the nutritional assessment indicated, .weight 149.8 pounds, BMI=22.8 .Resident with recent weight change .Additional comments: Cultural, religious, ethnic food preferences: none .Estimated nutrition needs: calories: 1700-2050, protein 82-102 grams .nutrition recommendations .add snacks between meals .Spoke with sister about bringing food in from the outside for the resident .RD advised family member not to bring food in from home because texture needed to be dysphagia mech soft . During a review of the RD's nutrition assessment progress notes, dated 7/20/23 completed by the RD, the nutritional assessment indicated .weight 142.5 pounds, BMI=21.7 .Resident with recent weight change .weight loss .had significant weight loss times 30 days .Resident's nutrition-related lab values include: 6/22/23: hemoglobin 9.6 (low) .Additional comments: .weight loss is not beneficial due to end stage renal disease and hemodialysis and is below usual body weight . During a review of the RD's nutrition assessment progress notes, dated 10/19/23 completed by the RD, the nutritional assessment indicated .weight 125.1 pounds, BMI=19 .Resident with recent weight change .Additional comments: Cultural, religious, ethnic food preferences . During a review of the Physician's Progress Notes, dated 5/19/23, the progress note indicated, Current weight 142 pounds .#Protein-Calorie Malnutrition. On dietary supplements . No mention of weight loss or weight loss interventions in the progress notes. During a review of the Physician's Progress Notes dated 11/9/23 the progress note indicated Current weight 127 pounds .#Protein-Calorie Malnutrition. On dietary supplements . No mention of weight loss or weight loss interventions in the progress notes. During a review of the facility's policy and procedure (P&P) titled Weight Management Policy dated October 2022, the P&P indicated .5. A weight monitoring schedule will be developed upon admission for all residents: .c. Residents with weight loss - monitor weight weekly until weight is stabilized. d. If clinically indicated - monitor weight daily .7. Documentation: .b. The physician should be encouraged to document the diagnosis or clinical conditions that may be contributing to the weight loss .

Based on interview and record review, the facility failed to ensure a Medication Regimen Review (MRR - evaluation of a resident's medications with the goal of promoting positive outcomes and minimizing adverse consequences associated with medications) was completed and implemented by the attending physician for one of 35 residents (Resident 66). This failure had the potential for Resident 66 to experience side effects from the medications. Findings: Resident 66 was admitted to the facility on [DATE] with diagnosis of acute renal failure (a sudden episode of kidney failure or damage), per the facility's face sheet. On 12/6/23 at 7:58 A.M., a concurrent interview and review of Resident 66's MRR dated November 2023, was conducted with licensed nurse (LN) 21. Resident 66's MRR indicated inquiry related to continued usage of several medications, dose reduction, or discontinuation of medications, if appropriate, and possible side effects the resident may experience with continued use. LN 21 stated this record was faxed to the attending physician on 11/8/23. However, there was no documentation that the attending physician or nursing staff had carried out, followed up on, or implemented the MRR. On 12/6/23 at 8:10 A.M., an interview was conducted with LN 21. LN 21 stated that Resident 66's MRR was faxed to the attending physician but was not followed up on. On 12/7/23 at 11:00 A.M., an interview with the Director of Nursing (DON) was conducted. The DON stated that all MRRs should be reviewed by the attending physician and followed-up by the nurse. The DON stated that regardless of the MRR having a little or big impact on the resident's care, the attending physician should document if he/she agreed or disagreed with the MRR. The DON stated that the MRR was an important part of the resident's care, and acknowledged that a nurse should have followed up on Resident 66's MRR with the attending physician. Per the facility policy titled Medication Regimen Review, dated 12/19/22, indicated the Facility staff shall act upon all recommendations according to procedures for addressing medication regimen review .

Based on observation, interview, and record review, the facility did not ensure food was prepared in a form to meet the nutritional needs for a sampled resident, Resident 132. This failure had the potential to cause poor food intake because the resident did not receive meals that met the correct form according to the Resident 132's physician-ordered diet. Cross reference F804, F806 Findings: Per Resident 132's Facility Admission record, Resident 132 was admitted on [DATE] with health conditions that included: Type 2 (adult onset) diabetes (a chronic condition that affects the way the body processes sugar); diabetic retinopathy (an eye condition that can cause vision loss, up to blindness); generalized (all over) muscle weakness; and dementia (a general term for loss of memory, language, problem solving skills and other thinking abilities that interfere with daily life). During a review of Resident 132's Physician Order Sheet, dated 12/7/23, the therapeutic diet order indicated, CCHO (Consistent Carbohydrate), regular texture, thin liquids, and finger Foods for all meals. During an observation and interview on 12/5/23 at 1:45 P.M. with Resident 132, Resident 132 was resting in bed, with eyes closed and awake to voice. Resident 132 stated he had eaten his lunch but did not remember what it was. During a concurrent observation and interview on 12/5/23 at 1:50 P.M. with certified nursing assistant (CNA) 1, CNA 1 stated Resident 132 only ate a few bites of his meal. CNA 1 noted Resident 132 refused the meal. Resident 132's lunch meal had chopped meat with gravy in a cup on the side, white rice, green peas, a roll, and dessert in a cup. CNA 1 stated Resident 132 needs some assistance with eating but is encouraged to feed himself with his hands. During a review of the facility's document titled Diet Type Report, dated 12/4/23, the Diet report indicated one resident, Resident 132, on a finger foods diet. During an interview on 12/6/23 at 4:45 P.M. with the Registered Dietitian (RD), the RD stated her expectation was for the residents to receive the correct meal to meet their nutritional needs. During a review of the facility's policy titled Finger Food Diet, dated 3/25/2019, the P&P indicated .Follow regular diet recipes with the following Suggested Finger Food guidelines: Grains and Breads - pita pocket bread (use to fill with meat, rice, casseroles, salads, etc.); crepes, tortillas .or naan bread (use as wraps for salads or . fillings). Items not appropriate - any slippery or small foods difficult to pick up. The vegetables listed as appropriate for finger foods are all able to be cut in bite-size pieces. Peas are not included .

Based on observation, interview, and record review, the facility failed to accommodate one of 35 sampled residents' food preferences (Resident 140). This failure had the potential to result in decreased caloric and nutrient intake. Findings: A review of facility's document Admission Record (AR), dated 8/27/2023, indicated Resident 140 was admitted to the facility on [DATE], with diagnoses which include: End Stage Renal Disease(Disease where Kidneys are not functioning) , Dependence on Renal Dialysis (Treatment to filter blood of toxins), Type 2 Diabetes Mellitus(Disease where body unable to regulate own blood sugars), and Iron Deficiency Anemia(Low red blood cell count due to lack of Iron in diet). A review of Resident 140's Minimum Data Set (MDS- assessment tool) section C, Cognitive Patterns, dated 10/17/2023, indicated Resident 140's BIMS (A tool to measure resident's cognitive ability) was measured to be 15, meaning resident had intact cognition. On 12/4/23 at 4:05 P.M., a concurrent observation and interview with Resident 140 was conducted. Resident 140 was observed in bed, alert and was agreeable to interview. Resident 140 stated that she did not eat the food because .it is horrible tasting .I'm diabetic and on dialysis and there are certain things I cannot eat .I don't eat ground beef, but they still give it to me .Fish smelled spoiled when they brought it, I could smell it outside the room. Resident 140 stated she compensated by eating what she could tolerate and having her husband bring in outside food when he could. Resident 140 stated she was a Monday, Wednesday, Friday (MWF) dialysis schedule and she received an extra lunch bags every day despite telling the dietary aides that she only goes to dialysis on MWF. On 12/5/23 at 11:36 A.M., an observation and interview with Resident 140 was conducted. Resident 140 stated the facility staff brought her an extra bag of food with breakfast despite it not being her dialysis day. Resident 140 stated, .I told them many times. I never eat it, but they keep bringing it. They don't listen. Resident stated she ate only a piece of bacon and a piece of toast with breakfast, but nothing else. Resident 140's lunch was observed to be an oval shaped pressed meat patty. Resident 140's lunch ticket listed as one of her dislikes Ground beef. Resident 140 stated, I am not going to eat any of this. On 12/7/23 at 8:25 A.M., an interview with Certified Nursing Assistant (CNA) 42 was conducted. CNA 42 stated that Resident 140 only wanted to eat yogurt, cereal, and toast that morning. CNA 42 stated that if resident did not eat that much, she will report to the Licensed Nurse (LN), who will document, and give supplemental foods, such as a supplemental shake. On 12/7/23 at 8:30 A.M., an interview with Resident 140 was conducted. Resident 140 stated that on 12/6/23 and 12/7/23 she ate only cereal, cottage cheese, yogurt, and fruit cocktail for all three meals. Resident 140 stated that she received ravioli with tomato sauce yesterday for lunch, but she did not eat it because she was on dialysis, and she was afraid of the high potassium levels from eating the tomato sauce. On 12/7/23 at 8:40 A.M., an interview with LN 2 was conducted. LN 2 stated that Resident 140 had talked with the dietician twice already in recent history. LN 2 stated that when resident did not eat enough for that day, she would offer Novasource renal shake 1-2 bottles three times a day. A review of Nutrition Progress note, dated 10/18/23 indicates .Inadequate PO intake r/t (related to) food pref, food pref (preferences) have been updated with the kitchen .Res(Resident) is continuing to lose weight at this time .Res Maln (malnourished) at this time r/t sig (significant) wt (weight) loss, poor PO(Per Oral) intake . On 12/7/23 at 9:05 A.M., an interview with the Register Dietitian (RD) was conducted. The RD stated that she had talked with Resident 140 and Renal Dietician multiple times, and it was agreed that they would liberalize Resident 140's diet because the resident was picky. The RD was shown picture of Resident 140's lunch from 12/5/23 and a picture of corresponding lunch ticket indicating dislikes of ground beef. The RD stated that the patty was not ground beef, but a patty of pressed beef. The RD stated when resident did not eat the food, she would be offered supplement shakes. The RD stated that the expectation was that Resident 140 should receive food that accommodated her preferences and should not receive foods that she did not prefer. The RD stated the importance of honoring Resident 140's food preferences was so the resident would eat the food that was provided and be well nourished. On 12/7/23 at 12:30 P.M. an interview with the Director of Nursing (DON) was conducted. The DON stated that the expectation was resident should receive food that they prefer, and not receive foods they did not prefer. The DON stated that the importance of maintaining residents' food preferences was to meet their nutritional needs and maintain their health. A review of facility policy and procedure entitled, Initial Resident Visitation/ Nutritional Screening dated 9/2021, indicates .6. Obtain food preferences, allergies, or intolerances and note on Dietary Interview/ Pre-Screen (Form 101) or other designated form and tray card. The interview form is filed in medical record preferably.

Based on interview and record review, the facility failed to recognize a change in condition (CIC, a shift in health status), and arrange immediate transportation to a hospital for one of three sampled residents reviewed for CIC (Resident 1). In addition, the facility did not immediately notify the Medical Doctor (MD) of all aspects of the CIC. As a result, there was a prolonged delay in providing medical treatment which prevented Resident 1 from receiving vital clinical therapy for a potential stroke. Findings: Resident 1 was admitted to the facility on [DATE], with diagnoses to include fractured (broken) ribs, per the facility Admission Record. On 12/29/21 at 11:10 A.M., an interview was conducted with Licensed Nurse (LN) 1. LN 1 stated she was assigned to Resident 1 on 12/6/21. LN 1 stated Resident 1 was able to communicate whether he had pain or not. LN 1 stated Resident 1 had multiple fractured ribs from a fall at home. LN 1 stated on 12/6/21, Resident 1 had been set up for breakfast as usual, but that day the Certified Nursing Assistant (CNA) had informed her Resident 1 was not swallowing his breakfast, and the food sat in his mouth. LN 1 stated she placed an order for a Speech Language Pathologist (SLP) to evaluate Resident 1. LN 1 stated, He looked the same, but his behavior was different. LN 1 stated Resident 1 was less responsive to her instructions than she remembered from previous shifts. LN 1 stated, .maybe I should have considered a stroke LN 1 stated when she called Resident 1's name, he just looked at her, while previously he would have responded with words. LN 1 stated she asked a nursing supervisor, LN 2, to assess Resident 1. LN 1 stated LN 2 went to Resident 1's bedside with her, assessed the resident, then called the physician. LN 1 stated she did not know what LN 2 told the physician, but he ordered intravenous fluids (IV). Per LN 1, LN 2 then spoke to a family member at the bedside, who declined the IV and instead requested a transfer to the hospital. LN 1 stated she called for transportation to the hospital, and was informed it would take two to three hours to arrive at the facility. Per LN 1, she called two or three other transportation companies who gave longer arrival times. On 12/29/21 at 1:40 P.M., an interview was conducted with Certified Occupational Therapy Assistant (COTA) 1. COTA 1 stated she had worked with Resident 1 on Friday 12/3/21, and he made eye contact and answered her questions. COTA 1 stated she attempted to get him to hold her hands, but he could not. COTA 1 stated she reported the problems to a nurse, but did not recall which nurse. The nurse informed COTA 1 that Resident 1 was being sent out to the hospital, so she assumed they were aware of the extent of his change in abilities. Per COTA 1, I saw him Friday for 30 minutes, then on Monday, he was completely different. He was mumbling, and couldn't hold up his head .I spoke to his daughter, I spoke to nursing, I'm not sure who. I thought they knew. On 12/29/21 at 2:20 P.M., an interview was conducted with SLP 1. SLP 1 stated she had evaluated Resident 1 on 12/6/21 after breakfast. SLP 1 stated Resident 1 was not responsive, and did not follow cues (reminders) regarding swallowing foods or liquids. SLP 1 stated based on her assessment of Resident 1, she downgraded his diet to pureed with close monitoring and reported her concerns to a nurse. SLP 1 was not able to recall which nurse she spoke to. On 12/29/21 at 2:40 P.M., a follow-up interview was conducted with LN 1. LN 1 stated she did not recall COTA 1 reporting concerns regarding Resident 1 to her. LN 1 stated SLP 1 did inform her of her recommendation to change Resident 1's diet, but they had no other discussion about him. Per LN 1, If I had thought, I should have called 911. I did not think it was necessary. A record review was conducted. Per a Clinical Admission Evaluation dated 11/30/21, Resident 1 was able to obey commands, and no signs/symptoms of a swallowing disorder. The same document indicated Resident 1 was able to move all of his arms and legs without problems. Per a facility document dated 12/01/21, titled Baseline Care Plan and Summary, Resident 1 was able to easily communicate with staff. A facility document dated 12/5/21 at 4:13 P.M., and titled Skilled Evaluation, indicated Resident 1 was able to obey commands, and his speech was clear. The document indicated Resident 1 had no signs or symptoms of a swallowing disorder and was able to move all of his arms and legs. A facility document dated 12/6/21 at 4:55 A.M., and titled Skilled Evaluation, indicated Resident 1 did not obey commands. A facility document dated 12/6/21 at 4:53 P.M. and titled Occupational Therapy Treatment Encounter Note(s), COTA 1 indicated, .Observed positioned up in w/c (wheelchair) for visit with daughter in dining room .Afterward patient positioned back to bed, noted with change in cognition and alertness. Pt presenting with incoherent, jumbled verbal responses when asked questions and unable to visual focus and eyes half lidded. Daughter and nursing reporting patient would be going out to hospital in early afternoon due to change in condition .Response to Session Interventions: required extra time to process new information .Complexities/Barriers Impacting Session: Cognitive status, Level of alertness . A facility document dated 12/6/21 at 4:25 P.M. and titled Speech Therapy Treatment Encounter Note(s), SLP 1 indicated, Note: pt (patient) may have had a COC on today's date .however due to significant decline in 24 hours .with close monitoring whether discharge to hospital is appropriate . A facility document dated 12/6/21 at 10:24 A.M. and titled Change in Condition Progress Note, authored by LN 1, indicated Resident 1 was unable to swallow. LN 1 wrote SLP had attempted to feed Resident 1 but he was still unable to swallow. LN 1 indicated the information had been reported to the physician, and she was waiting for orders. An additional call was made to the physician, who then ordered IV fluids. LN 1 documented a family member preferred Resident 1 be sent to the hospital, so she obtained an order from the physician to send him out. LN 1 documented it would take two to three hours for transportation to arrive. A facility document dated 12/6/21 at 10:28 A.M. and titled eINTERACT SBAR (Situation, Background, Appearance, Review) Summary for Providers (a summary of the change in health status used to report to the physician) indicated Resident 1 had an altered mental status with increased confusion or disorientation, general weakness and swallowing difficulty. The Neurological Evaluation did not assess speech changes, weakness or hemiparesis (a weakness of one side of the body, a common after-effect of stroke). Per a Nurses Progress Note dated 12/6/21 at 8:47 P.M., Resident 1 was picked up by the transportation company on 12/6/21 at 3:35 P.M., (approximately five hours after transportation was requested and approximately 10 hours after a change in condition was identified). Per a hospital document dated 12/6/21 at 11:41 P.M. and titled ED (Emergency Department) Provider Note, .Clinical picture concerning for altered mental status and CVA (cerebrovascular accident, a stroke) .he was outside of the window for thrombolytics (a medication to treat strokes, optimally given within 4.5 hours of a stroke) .on head CT (computed tomography, a type of x-ray) however there is a large hypodensity (a small, well-defined area in the brain that is less dense in appearance than the surrounding tissue) .suggestive of ischemic stroke. Feel that this is the likely cause of his altered mental status today .no severe electrolyte (minerals in the blood and body fluids) derangements that would explain patient's presentation today . A hospital document dated 12/7/21 at 7:39 A.M. and titled Neurology (a physician who specializes in treatment of the brain, spinal cord and nerves) Consult Note, indicated, .Reason for Consultation Stroke .Speech: nonsensical fluent (not making sense) speech .CT head .suggestive of recent infarction (a type of stroke) . A hospital document dated 12/7/21 at 12:56 P.M. and titled Addendum, Neurology Progress Note, indicated, MRI (magnetic resonance imaging, a test used to create clear images of medical conditions) brain .Most of these lesions appear to be acute (developed suddenly) . On 10/11/22 at 9:44 A.M., an interview was conducted with LN 2. LN 2 stated on 12/6/21, she was the nursing supervisor. LN 2 stated LN 1 asked for help with assessing Resident 1 due to his swallowing problem. LN 2 stated she and LN 1 asked Resident 1 to swallow liquids then cough, and he was able to do so. LN 2 stated she also assessed Resident 1's lung sounds, but she did not assess anything else. LN 2 stated she did not do a head-to-toe assessment, but she should have. LN 2 stated she did not assess Resident 1's arms or legs for weakness and did not evaluate his speech. LN 2 stated Resident 1's problems may have been related to dehydration. LN 2 stated she did not complete a CIC or an SBAR prior to speaking to the physician, but she should have. LN 2 stated, The purpose of the SBAR is so we can give complete information to the doctor. LN 2 stated she recalled reporting the swallowing problem to the physician, but not any other concerns. LN 2 stated, I didn't think about a stroke. A delay in care could worsen his condition. Six hours to send him to the hospital is not ok. On 10/27/22 at 4:14 P.M., an interview was conducted with the physician (MD). The MD stated LN 2 had called him for the primary reason of abnormal lab values. LN 2 had informed the MD of the lab results, as well as Resident 1 not eating well. Per the MD, There were no red flags from the conversation with (LN 2). The MD stated although he did not remember much of the conversation, he had the impression the poor intake was for that single day only. The MD stated the lab results combined with a report of not eating well were the reason he ordered IV fluids. When asked about Resident 1's change in mental status, weakness, and new inability to swallow foods and liquids, the MD stated, None of that was communicated to me. Per a facility policy, revised 2012 and titled Change in a Resident's Condition or Status, .1. The nurse supervisor/charge nurse will notify .physician when .d. A significant change in the resident's physical .condition .g. A need to transfer the resident to a hospital .5. The nurse supervisor/charge nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. a. Assessment related to the change in condition .

Based on interview, review of Centers for Medicare and Medicaid Services (CMS) QSO 20-38-NH testing guidelines memo, and review of the facility's COVID-19 testing documentation for staff and residents, the facility failed to ensure residents were tested according to current COVID-19 testing standards for COVID-19 outbreak testing of all residents from 01/29/21 to present. On 02/01/21, the facility tested residents located on the Lexington Unit of the facility as a part of outbreak testing because Resident (6) tested positive for COVID-19 on 01/29/21. On 02/08/21, the facility tested residents located on the Fairmont unit because of R7 testing positive for COVID-19 on 02/08/21. However, review of facility testing documentation, review of the facility's mitigation plan, and staff interviews revealed the facility failed to test all residents in the facility who had previously tested negative and lived in other units of the facility. The facility failed to follow their mitigation plan and CMS testing guidance found in QSO-20-38-NH. The facility only initiated outbreak testing for two of six units and failed to test residents on four of six units in the facility. The facility's failure to conduct outbreak testing of all residents has the potential to negatively impact 256 residents and staff in the facility by not identifying positive cases and initiating mitigating measures to prevent the spread of COVID-19 throughout the resident population. On 02/19/21 at 6:18 PM, the Assistant Administrator, Director of Nursing (DON), Assistant Director of Nursing (ADON), Infection Preventionist (IP)1, and IP2 were notified and issued an immediate jeopardy at F886, Resident and Staff Testing. The facility provided an acceptable plan for removal of the Immediate Jeopardy on 02/20/21 at 10:30 AM. The facility's plan for removal of the immediate jeopardy included COVID-19 testing of all residents in the facility. The COVID-19 test results for 156 residents who had not been previously tested during the outbreak testing revealed no newly identified positive cases of COVID-19. The removal plan was validated on 02/20/21 at 10:45 AM through interviews and review of additional testing documentation. The facility was notified that the immediate jeopardy was removed on 02/20/21 at 10:45 AM. After the immediacy removal, the noncompliance remained at a lower scope and severity of F (widespread with no actual harm with the potential for more than minimal harm that was not immediate jeopardy). The immediate jeopardy was determined to first exist on 01/29/21 when outbreak testing of residents should have started after a resident was first identified as positive for COVID-19. Findings include: Review of CMS QSO-20-38-NH, dated 08/26/20, revealed . An outbreak is defined as a new COVID-19 infection in any healthcare personnel (HCP) or any nursing home-onset COVID-19 infection in a resident. In an outbreak investigation, rapid identification and isolation of new cases is critical in stopping further [MEDICAL CONDITION] transmission. A resident who is admitted to the facility with COVID-19 does not constitute a facility outbreak . Upon identification of a single new case of COVID-19 infection in any staff or residents, all staff and residents should be tested , and all staff and residents that tested negative should be retested every 3 days to 7 days until testing identifies no new cases of COVID-19 infection among staff or residents for a period of at least 14 days since the most recent positive result. Review of the undated facility's policy titled, Infection Control Manual - Coronavirus(COVID-19),revealed the facility's mitigation plan required all residents to be tested when outbreak testing is initiated. The section of the policy titled, Response Driven Testing of Residents stated, As soon as possible after one (or more) COVID-19 positive individuals (resident or HCP) is identified in a facility, serial retesting of all residents and HCP who test negative upon the prior round of testing should be performed every seven days until no new cases are identified among residents in two sequential rounds of testing; the facility may then resume their regular screening testing schedule for HCP. On 02/19/21 at 1:40 PM, an interview was conducted with IP1. IP1 stated the facility conducted outbreak testing of residents on 02/01/21 after receiving notification that a R6 tested positive for COVID-19 at the hospital. IP1 stated the outbreak testing on 02/01/21 was only performed on the residents located on the Lexington Unit of the facility. IP1 further stated the facility began outbreak testing on the Fairmont Unit of the facility on 02/08/21 after R7 tested positive for COVID-19 on 02/08/21. IP1 stated the facility did not conduct testing of residents located on any of the other units of the facility as a part of outbreak testing. During an interview on 02/19/20 at 2:28 PM, the DON confirmed the facility initiated outbreak testing of residents on 02/01/21 On 02/01/21, the facility tested residents located on the Lexington Unit of the facility as a part of outbreak testing because R6 tested positive for COVID-19 on 01/29/21. On 01/30/21, R8, who resided on the Lexington Unit, tested positive for COVID-19 on 01/30/21. On 02/08/21, the facility tested residents on the Fairmont Unit of the facility because of R7 tested positive for COVID-19 on 02/08/21. The DON further confirmed the outbreak testing on 02/01/21 was only performed on the residents located on the Lexington Unit of the facility. The outbreak testing on the Fairmont Unit of the facility began on 02/08/21 after R7 tested positive for COVID-19 on 02/08/21. The DON stated the facility was provided guidance from the county public health officials that they would only need to test residents on the units where the COVID-19 positive residents were located. In addition, the DON stated she was aware of the regulatory requirement to test all residents during outbreak testing and the facility's mitigation plan requiring testing of all residents. The DON provided email correspondence from the county department of public health providing guidance for outbreak testing in the facility. Review of the facility's email correspondence, from the county department of health, dated 02/19/21, stated it does seem reasonable to continue response testing with the current strategy as long as weekly surveillance testing on staff is done for the whole building and staff continue to be cohorted to each unit. In addition, the email correspondence indicated the facility would have to outline their testing strategy in the facility's mitigation plan before it was approved by state officials. Further review revealed the facility made no changes to the policy based on guidance from the county. The policy still indicated all residents needed to be tested following the outbreak. A review of the facility's testing documentation revealed that on 02/01/21, the facility began outbreak testing on the Lexington Unit and tested 56 residents with no new positive cases of COVID-19 identified. On 02/08/21, the facility began testing 40 residents located on the Fairmont Unit as a part of the facility's outbreak testing. The review of the testing documentation revealed the facility failed to test 156 residents located on the other four units of the facility.

Based on observations, staff interviews, resident record review, and facility policy review, the facility: 1. Failed to ensure two of 46 secure unit residents (Resident (R) 1 and R2), who were placed in contact and droplet isolation and quarantined for 14 days due to potential exposure of COVID-19, were kept isolated from the other residents in the unit which placed the remaining 44 residents at risk for possible exposure to COVID-19. Additionally, the facility failed to ensure residents in the secure unit, including R1 and R2, maintained adequate social distancing and used source control measures to prevent the potential spread of COVID-19 during communal group activities and dining in the unit dining room. These failures created the likelihood for the all 46 residents residing in the facility's secure unit to contract and spread COVID-19 and experience symptoms such as decreased oxygen saturations, fever, cough, [MEDICAL CONDITION], and death. On 02/18/21 at 6:30 PM, the facility's Assistant Administrator, Director of Nursing (DON), Assistant Director of Nursing (ADON), Infection Preventionist (IP)1, and IP2 were notified that immediate jeopardy existed at F880: Infection Control related to the failures to ensure residents under isolation precautions were quarantined to their rooms and adequate social distancing source control measures were practiced in the secure unit. The facility presented an acceptable removal plan for the immediate jeopardy at F880 on 02/19/21 at 6:00 PM. The removal plan indicated 100% of activity staff would be educated on suspension of communal dining and activities; 100% of secure unit staff would be re-educated on residents who were on quarantine, contact and droplet precautions, resident masking, and redirecting residents on isolation; newly admitted residents would be quarantined in single rooms or the yellow zone for 14 days; if the facility was unable to safely place a prospective resident in a single room on contact and droplet precautions, the facility would not accept the new admission; and the IPs, DON, or a designee would complete daily monitoring rounds on the secure unit for the suspension of communal dining and activities, and to verify appropriate quarantine of residents. Implementation of the removal plan was verified through observations, staff interviews, and record reviews. Observations verified R1 and R2 were quarantined to their room with one-to-one supervision to ensure they remained in their room. Additionally, all secure unit residents were in their rooms and the dining room was closed and furniture removed. Record reviews and staff interviews revealed activity staff were trained that communal activities were suspended, and secure unit staff were trained on the residents who were quarantined, contact and droplet isolation precautions, resident redirection, and resident mask use. Additionally, review of the daily monitoring rounds revealed they were conducted with no concerns noted. The Assistant Administrator, DON, ADON, IP1, and IP2 were notified that the immediate jeopardy was removed on 02/19/21 at 6:15 PM. Per an email from the Assistant Administrator on 02/21/21 at 3:31 PM, the facility-wide COVID-19 testing performed on 02/19/21 yielded no positive results. Thus, the remaining deficient practice was lowered to an E (pattern of deficient practice with the potential for more than minimal harm) following the removal of the immediate jeopardy. 2. Failed to effectively cohort a new facility admission which resulted in R2 being unnecessarily placed in quarantine when the new admission was placed into the room where R2 resided, and potentially exposing R2 to COVID-19. This failure had the potential to spread COVID-19 infection to R2 and negatively affect R2's psychosocial well-being. 3. Failed to ensure one staff member in the yellow zone donned appropriate personal protective equipment (PPE) when caring for one resident. This failure had the potential to increase the spread of COVID-19 in the yellow zone. Findings include: 1. On 02/18/21 at 10:04 AM, the DON stated newly admitted residents were placed in the yellow zone of the facility and were considered persons under investigation (PUI) for potential COVID-19 infection. The DON stated in the yellow zone, the newly admitted residents were quarantined to their room and cared for under contact and droplet precautions for 14 days after admission. The DON and both facility Infection Preventionists (IPs) stated the secure dementia unit of the facility was a green zone, meaning it housed COVID-19 - negative or recovered residents. Per the facility's undated list of secure unit residents who received the COVID-19 vaccine, there were two residents on the secure unit who had received only the first dose of the vaccination, and eight residents who declined the vaccine, out of 46 total residents. The remaining 36 residents had received both doses of the COVID-19 vaccine. A. Per the 02/11/21 Admission Record in the paper chart, R1 was admitted to the facility on [DATE]. R1's Result Details report from a COVID-19 test done on 02/09/21 documented R1 tested negative for COVID-19. An 02/11/21 Nurse's Note, located in the paper chart, documented R1 was admitted from the hospital into his current room in the secure unit. Review of the February 2021 Order Recap Report, located in the paper record, revealed an order, which originated on 02/11/21, for Contact and Droplet based isolation precautions. Review of the February 2021 Medication Administration Record, [REDACTED]. He did not exhibit any symptoms, shortness of breath, or fever. The undated Licensed Nurses' Daily Skilled Charting Guidelines form, found in the paper record, documented, Potential COVID-19 exposure. Monitor/document any SOB (shortness of breath), congestion, fever, headache, loss of taste or smell, nausea, vomiting, diarrhea. R1's 02/12/21 Care Plan, located in the paper record, documented, Resident is constantly taking off facial mask. Refusing facial mask. Does not want to wear facial mask. The approaches included: monitor for signs and symptoms of COVID-19, continue to offer the facial mask when out of the room, ensure six feet of social distancing, and assist to wash the resident's hands as needed. An undated Resident Care Plan for R1 in the paper chart documented, Risk of getting Coronavirus due to advance age and multiple medical comorbidities. The approaches included: Encourage resident to stay in room, encourage residents to cover face and mouth when a staff member is in the room, assist or remind to wash hands, explain the policies and procedures, monitor for signs and symptoms of COVID-19, and All new admits put on contact isolation for 14 days. Review of R1's Nurses' Notes, found in the paper record, revealed instances of R1 outside of his room in the common areas: -An 02/12/21 Nurse's Note documented, Resident (with) episodes of wandering room to room, redirected PRN (as needed). Stayed in the DR (dining room) most of this shift . -An 02/14/21 Nurse's Note documented, . is noted to be impulsive, aeb (as evidenced by) suddenly [MEDICATION NAME] karte (sic) in the dining room. Redirected (without) difficulty . B. Per the 10/26/20 Admission Record, found in the paper record, R2 was admitted to the facility on [DATE]. Upon admission R1 was placed in the room with R2. R2's 12/11/20 physician's Telephone Order, located in the paper record, documented, Contact/Droplet isolation indefinitely. Review of R2's medical record revealed there was no order to discontinue contract and droplet isolation. Review of R2's undated Resident Care Plan revealed he had a risk of getting Coronavirus due to advanced age and multiple medical comorbidities. The approaches included, Encourage resident to stay in room, encourage residents to cover face and mouth when a staff member is in the room. Additional approaches included assisting the resident to wash his hands, explaining the policy and procedures, monitoring for COVID-19 signs and symptoms, performing labs as ordered, and following current COVID-19 management guidelines. C. On 02/18/21 at 10:55 AM, 15 residents were seated in the activity room, participating in activities. The residents were seated at square tables together. Each table measured 3.5 feet across. R1 was seated at a table in the far left corner of the dining room with another resident seated less than a foot away from him. There was another resident seated across the table with him, less than six 6 feet away. There were six additional tables where two or three residents were seated, less than 6 feet apart from each other. None of the residents were wearing masks. Though Certified Nurse Aide (CNA) 13, CNA14, an activity aide, and Licensed Vocational Nurse (LVN) 11 were in the dining room, there was no redirection of the residents to move at least six feet apart or to wear masks. On 02/18/21 at 10:57 AM, R1's room in the secure unit was observed with a sign and PPE for contact and droplet precautions outside of the door. The name plate outside the door listed R1 and R2 lived in the room, but the room was empty upon observation. On 02/18/21 at 10:58 AM, LVN11 was asked to point out R1 and R2. LVN11 walked over and pointed out R1 seated in the dining room in the far left corner. LVN11 did attempt to redirect R1 back to his room at this time. LVN11 then walked over and pointed out R2, who was walking through the hallway walking past the nurses' station without wearing a mask. Though there were two staff members at the nurses' station, R2 was not redirected to go back to his room. LVN11 stated R1 was recently admitted to the secure unit from the hospital, so R1 was placed on quarantine with contact and droplet precautions for 14 days monitoring. The nurse stated staff donned a mask, performed hand hygiene, and donned a gown and gloves when entering his room. She stated R1 should be quarantined to his room, along with R2, but stated the residents was ambulatory and they go everywhere. I can't keep them from moving. This is a memory care unit so it is harder. We try to keep them separated but they keep moving closer to each other. LVN11 stated R2 was placed on quarantine with contact and droplet precautions because R1 was newly admitted and placed in the room. On 02/18/21 at 11:20 AM and 11:50 AM, R1 was observed still seated in the dining room participating in the activity without a mask. Though CNA1 and CNA2 were observed in the dining room, they were not observed to redirect R1 back to his room. The residents in the dining room seated two and three to a table remained there, participating in activities. On 02/18/21 at 12:00 PM, the DON stated when a resident who needed secure unit placement because of wandering or elopement concerns, they were admitted to the secure unit and placed on 14-day quarantine with contact and droplet precautions. She added they were not placed in the yellow zones where other new admissions were housed because of the wandering/elopement risk. The DON stated the residents in the secure unit were special in that it was difficult to keep them in their rooms and to get them to wear a mask. The DON stated there was a hallway monitor who was stationed near the nurses' station to provided continuous redirection when they saw a resident out of their room. The DON stated, That's the best we can do for them. The DON stated she would have to ask the staff why the resident was in the dining room for an extended period of time. They have to stay as much as possible in the room. She stated therapy, restorative, etc. was all provided in the room. The DON stated R1's roommate was also on contact and droplet precautions because of his contact with R1. The DON stated, We are trying our best to keep in his room. She stated he does not exhibit any symptoms of COVID and is monitored every shift for signs and symptoms. The DON stated, With a new admit, we don't know if someone has COVID or not . there is a potential risk for transmission. The resident will be tested again after ten days, on 02/21/21. On 02/18/21 at 12:27 PM, the DON stated the facility weighed the risks and benefits and placed R1 in the secure unit because of his elopement risk. She stated the facility had a plan in place to address this, but the plan was not followed by staff. On 02/18/21 at 1:47 PM, there were 18 residents in the secure unit dining room finishing up their lunch meals. There were six tables with two residents to the table and one table with four residents to the table. These 16 residents were not seated at least 6 feet apart from one another. None of the residents were wearing masks. On 02/18/21 at 1:50 PM, CNA14 stated he was currently serving as hall monitor, and the secure unit staff rotated responsibility for the monitoring every 30 minutes. He stated he monitored if there were residents who wandered to make sure they stayed away from the doors and stayed safe, and monitored for residents who need to be redirected back to their room for isolation. CNA14 stated he did not see R1 or R2 out of their room earlier in the day, as he was on break right before 11:00 AM. He stated there were monitors stationed in the dining room to monitor the activity in there, and the dining room monitor should have redirected R1 and R2 back to their rooms. On 02/18/21 at 1:52 PM, CNA13 stated she was the monitor in the dining room at 11:00 AM. She stated she was assigned to make sure residents stayed at least 6 feet apart and help with taking residents to bathroom, doing activities, or putting on the TV or music. She stated part of her duty was to redirect residents on quarantine back to their rooms. She stated when R1 was redirected to his room, he usually only stayed there for a few minutes and then came out again. She stated she had redirected R1 prior to the observations made beginning at 10:55 AM and was aware that he came back into the dining room and stayed there for about an hour. She stated she had not redirected him back to his room between 10:55 AM and 11:50 AM while he was in the dining room. On 02/18/21 at 2:00 PM, IP2 stated the facility had cancelled communal dining and activities throughout the building, including in the secure unit. IP1 and IP2 stated they were unaware communal activities and dining were taking place in the secure unit, and IP2 added the staff had been educated not to gather residents in the dining room for meals or activities. IP2 stated she counted on the charge nurse and unit manager to monitor and take responsibility for enforcing facility policies. IP2 stated there was no formal plan or system for monitoring the secure unit for adherence to policies. IP2 stated she did not know why communal dining and activities were taking place, as the staff had been trained that these things were cancelled. IP2 stated staff were supposed to provide one-to-one activities in the resident rooms. IP2 stated it was harder to redirect and control the distance between residents when they are all gathered in one room, and staff should not allow the residents to gather in the dining room. IP2 stated the facility did not routinely test residents for COVID-19, and the residents in the green zone had not been recently tested for COVID-19. Cross-reference F886: COVID-19 Testing - the facility failed to ensure testing of all residents was completed after an identified COVID-19 outbreak in the facility. On 02/18/21 at 3:25 PM, LVN11 stated she was unsure when communal dining and activities were started back up in the secure unit, as before they were only doing small activities with three to four residents outside of the dining room and resident room visits. When asked what had been tried to keep residents from congregating in the dining room, she stated handing out books and putting on the TV in resident rooms were done. She stated staff were to redirect the residents to their rooms, but no other interventions, such as removing tables and chairs or placing physical barriers at the entrance, were attempted. On 02/18/21 at 3:40 PM, the Activity Director (AD) stated she was not aware there was communal activity going on in the secure unit. She stated staff were not supposed to provide group activities but they could do one-to-one visits in the hallway or resident's room, and no activities were to take place in the dining room. She stated the activity staff provided supplies for independent activity when residents were out of their rooms or seated in the dining room, but they were not supposed to be gathering the residents for activities. The AD stated she had not provided training to the activity staff on the need to redirect residents from common areas back their rooms. On 02/19/21 at 12:25 PM, the Medical Director (MD) stated the community's medical system was in dire need of the beds on the secured unit for admissions from the hospital. He stated it was a tough call on the decision to admit residents directly to the secure unit, because the residents did wander and it was nearly impossible to quarantine them to their rooms; however, they need the security of a locked unit because of their wandering behaviors. The MD stated residents were tested at the hospital prior to their admission, and with most of the residents being vaccinated, he was pretty comfortable with allowing new admissions to the secure unit. The MD expressed concern for the emotional well-being of secure unit residents forced to stay in their rooms, stating it can cause anxiety, [MEDICAL CONDITION], lead to more [MEDICAL CONDITION] drug use with unwanted side effects, and really impact social well-being. On 02/19/21 at 12:45 PM, the secure unit manager, LVN12, stated when a resident was newly admitted , staff were expected to keep the resident quarantined to their room and use the correct contact and droplet precautions when providing care in the room. He stated if a quarantined resident wandered out of their room, they should be redirected back to the room immediately. LVN12 stated the residents on the secure unit wandered back and forth into the dining room frequently, and the staff tried to maintain social distancing of at least 6 feet between them. He also stated they tried using masks on the residents, but most would take them off right away. LVN12 stated meals should be served in the residents' rooms, unless there was a situation where a resident was refusing to go back to their room or refusing to eat in their room. LVN12 stated he had provided training to the secure unit staff on redirecting residents, social distancing, and isolation precautions. He stated there were no formal monitoring systems for compliance in place, but stated he conducted informal monitoring while working at the nurses' station and watching what happens in the milieu. Per the facility's undated Infection Control Manual - Coronavirus (COVID-19) policy, Residents newly admitted from the hospital should be quarantined in single rooms if available or a separate observation area (yellow zone) for 14 days from the date of last potential exposure and then retested . If negative, the resident can be released from quarantine . Testing and quarantine are not required for residents readmitted after hospitalization , or who leave the SNF for ambulatory care (e.g., emergency department of clinic) visits unless there is suspected or confirmed COVID-19 transmission at the outside facility as verified with their LHD (local health department) . The facility will limit transport and movement of the resident outside of the room to medically essential purposes (e.g., diagnostics) . When residents come into the facility, they will be educated to wear face covering in public areas and during care when possible . No group activities (internal or external) or communal dining will occur in the facility at this time. Residents will be reminded to practice social distancing and perform frequent hand hygiene . Group activities may also be facilitated (for residents who have fully recovered from COVID-19, and for those not in isolation or quarantine) with social distancing among residents, appropriate hand hygiene, and use of a face covering. 2. Per the 10/26/20 Admission Record, found in the paper record, R2 was admitted to the facility on [DATE]. R2's 10/27/20 Resident Care Plan documented, Risk for mood or behavior changes because of COVID-19 (Coronavirus) restrictions. The approaches included educating the resident on current policies, facilitating phone visits, provide telehealth as needed, encourage individual in-room activities, and monitor for mood or behavior changes. R2's 10/30/20 COVID-19 Activity Care Plan documented, Due to regulatory Infection Control Precautions, the resident is remaining in their room. This creates a potential for decreased social contact (and) need for additional opportunities for interaction with staff and/or family member in an adapted setting. Review of R2's paper record revealed his most recent test for COVID-19 was completed on 11/10/20. R2's 12/11/20 physician's Telephone Order, located in the paper record, documented, Contact/Droplet isolation indefinitely. Review of R2's medical record revealed there was no order to discontinue contract and droplet isolation. On 02/18/21 at 10:57 AM, R2's room in the secure unit was observed with a sign and PPE for contact and droplet precautions outside of the door. The name plate outside the door listed R1 and R2 lived in the room. On 02/18/21 at 10:58 AM, LVN11 stated R2 was placed on quarantine with contact and droplet precautions because a newly admitted resident, R1, was placed in R2's room. LVN11 stated R2 had no other reason to be quarantined. On 02/18/21 at 3:46 PM, IP2 stated R2 was originally placed on quarantine when two staff tested positive for COVID-19 on 12/11/20, and the whole secure unit was placed on quarantine for 14 days because of this. IP2 stated R2's order for contact and droplet isolation was never discontinued, and on 01/11/21, a new resident was placed in the room, so R2 continued on isolation because of rooming with a new admission. IP2 stated the contact and droplet isolation should have been discontinued after 14 days, but the staff failed to get the order to discontinue, so he remained on isolation through 02/11/21, when R1 was admitted to his room and R2 continued on contact and droplet precautions for an additional 14 days. IP2 stated, ideally, a new admission would be placed in a private room, but that was not always possible because of space and roommate compatibility. IP2 stated a team of facility staff had considered moving residents to place R1 in a private room, but decided against it because of the space and compatibility issues. On 02/19/21 at 12:25 PM, the Medical Director (MD) stated the community's medical system was in dire need of the beds on the secured unit for admissions from the hospital. The MD stated the facility had weighed benefits of offering the secure unit beds with being unable to effectively quarantine the newly admitted residents to their rooms or admit them in private rooms. The MD expressed concern for the emotional well-being of secure unit residents forced to stay in their rooms, stating it can cause anxiety, [MEDICAL CONDITION], lead to more [MEDICAL CONDITION] drug use with unwanted side effects, and really impact social well-being. Per the facility's undated Infection Control Manual - Coronavirus (COVID-19) policy, Residents newly admitted from the hospital should be quarantined in single rooms if available or a separate observation area (yellow zone) for 14 days from the date of last potential exposure and then retested . If negative, the resident can be released from quarantine. 3. On 02/18/21 at 10:55 AM, observations were conducted on the Wellington 2 Unit of the facility during the initial tour. Certified Occupational Therapy Assistant (COTA) was observed inside the room of R5 without a gown. Further observations revealed signs outside the doorway indicated the residents were on contact and droplet transmission-based precautions and required staff to wear personal protective equipment (PPE) that included a gown. Additional observations of the unit hallway revealed the PPE cart outside R5's doorway did not have any gowns. However, 7 additional PPE carts with gowns were located on the unit outside the doorways of other rooms on the unit. On 02/18/21 at 10:57 AM, an interview was conducted with COTA. COTA stated she was aware of the signs on the door for contact and droplet precautions and had been trained on the proper use of PPE. COTA further stated she should be wearing a gown but there were no gowns in the PPE cart outside the room. On 02/18/21 at 11:00 AM, an interview was conducted with Registered Nurse (RN)1. RN1 stated she was the Unit Manager on the Wellington 2 Unit. RN1 stated the unit was a yellow zone of the facility and required staff to wear PPE when entering a room to provide care to residents. RN1 further stated all staff have been trained on wearing PPE on the unit and all staff have been instructed to get a gown from any of the other PPE carts in the hallway when a PPE cart is found empty. In addition, RN1 stated there was no shortage of gowns in the facility. On 02/18/21 at 11:05 AM, an interview was conducted with RN2. RN2 stated she was assigned as the nurse working on the Wellington 2 Unit. RN2 stated has been trained on proper use of PPE and stated Wellington 2 Unit is a Yellow Zone and requires staff to wear gowns in the rooms on the unit. RN2 further stated there was no shortages of gowns and staff have been trained to get a gown from a PPE cart before going into a room. On 02/19/21 at 10:10 AM, an interview was conducted with the Director of Therapy Services (DTS). The DTS stated he was made aware that COTA entered the room of R5 without wearing a gown. The DTS stated he immediately in-serviced the Therapy Services staff on the use of PPE in Yellow Zones in the facility. The DTS further stated COTA should have worn a gown into the room of R5.

Based on observation, interview and record review, the facility failed to follow the prescribed diet orders to ensure 1 of 1 sampled residents (1) received a chopped diet. As a result, Resident 1 choked and died after consuming 2 whole sausages and 2 pancakes. Findings: Resident 1, a [AGE] year old male resident, was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. According to the physician's orders [REDACTED]. Resident 1's clinical record was reviewed on 10/31/12. The resident was unable to make medical decisions for himself per the Advanced Healthcare Directive, signed and dated by the physician on 9/28/12. According to the Minimum Data Set (MDS) assessment, dated 10/3/12, the facility assessed Resident 1 with unclear speech, unable to understand others or be understood by staff, and unable to make daily decisions due to severe cognitive impairment. Per the same document, the facility assessed Resident 1 as requiring limited assistance with feeding himself and the assistance of one staff member for supervision. According to the Social Services assessment dated [DATE], Resident 1, "Speaks with few words: yes, no, eat, hungry...Can become aggressive especially when eating." Resident 1 was prescribed a mechanical soft, chopped diet, according to the physician's orders [REDACTED]." An Interdisciplinary Team (IDT) review was completed on 10/5/12. According to the IDT notes, staff were instructed to watch the food trays and the food cart, as Resident 1 was, "Always looking for more food," and needed to be redirected frequently. The resident was placed on 1:1 (one staff member to one resident) during meals due to his behaviors. On 10/30/12 at 1 P.M., the Cook was interviewed by phone. The Cook said he worked the breakfast meal on 10/28/12. He said it was his responsibility to match the food ticket (diet order) and plate the food on the kitchen line. The cook said he prepared a chopped diet of sausage and pancakes for Resident 1. He said he would usually cut the sausage patty into 9 pieces. The pancakes were not cut, as they were soft. The Food Line Checker, a second person that reviewed the diet for correctness, said on 10/30/12 at 1:15 P.M., she was quite busy on 10/28/12. She said since it was a Sunday, she was responsible for answering the phone and responding to requested food changes. She said she was also responsible for checking the trays before the trays were loaded onto the service cart and taken to the nursing station. The Food Checker said the phone rang frequently on 10/28/12. She was uncertain if she reviewed all of the trays on the line that morning. Licensed Nurse (LN) 1 said on 10/31/12 at 1:30 P.M., she was the Charge Nurse on the day shift on 10/28/12. She said she was aware that Resident 1 was a compulsive food seeker. She said Resident 1 grabbed and ate the applesauce when it was left unsupervised on the top of the medication cart. She said she was responsible for checking each tray on the cart before the Certified Nursing Assistants (CNAs) delivered the trays. LN 1 said at about 8 A.M. on 10/28/12, "I was in a hurry." Resident 1, "Stood in front of the food cart. I wanted to make sure he did not grab any other resident's food. I made a mistake. I was not careful to match the diet card with the food on the plate, when I checked the tray," for Resident 1. LN 1 said she handed Resident 1's tray to CNA 1 to move Resident 1 away from the other food trays. CNA 1 said on 10/31/12 at 12:30 P.M., she was assigned to care for Resident 1 on the day shift on 10/28/12. CNA 1 said she was aware Resident 1 wandered throughout the facility and grabbed food from others. She said she was aware Resident 1 was only to have chopped food. CNA said she knew Resident 1 was on 1:1 supervision for meals. CNA 1 said LN 1 handed her Resident 1's breakfast tray from the cart on 10/28/12 at about 8:05 A.M. She told Resident 1 she had his food and he immediately followed her to his room. CNA 1 said she usually checked the trays when she got into the rooms. She said as she lifted the plate cover, Resident 1 grabbed 2 pancakes and 2 uncut sausage patties and stuffed them into his mouth. CNA 1 said Resident 1 walked out of his room and into the hallway. CNA 1 followed behind him with some milk, intending to encourage Resident 1 to drink the milk. CNA 1 said she immediately told LN 1 that Resident 1 grabbed his food and put it into his mouth. Within a minute or two, Resident 1 collapsed on the floor in the hallway, in front of his room. CNA 1 said she called for help. LN 1 said on 10/31/12 at 1:35 P.M., she was in the hallway on 10/28/12 at about 8:10 A.M. and saw Resident 1 fall to the floor. She rushed to Resident 1. He was foaming at the mouth and he looked pale. LN 1 she said she put on gloves and swept the resident's mouth. Some food was removed. LN 1 said she tried to do the [MEDICATION NAME] maneuver (emergency technique to unblock the airway) on the floor, but it was not successful. Resident 1 was not breathing and his skin color was blue. LN 1 said she started CPR (cardiopulmonary resuscitation - mouth to mouth breathing and chest compressions). Another staff member called a "code blue" (resident not breathing and CPR initiated). Other staff members arrived and Resident 1 was carried from the hallway, outside of his room, to his bed. The physician was notified and 9-1-1- was called, while the CPR continued. According to the facility records, the Emergency Medical Technicians (EMTs) arrived at 8:20 A.M. and took over the care of Resident 1. The EMTs transported Resident 1 to the acute care hospital. According to the hospital records, the emergency room (ER) physician removed food from the throat of Resident 1, to establish an airway. Resident 1 was unable to be resuscitated and was pronounced dead, due to airway obstruction. On 10/31/12 at 12:30 P.M. the Registered Dietician and Food Services Manager cooked a sausage patty, the same sausage as prepared on 10/28/12 for Resident 1. The patty was circular and measured 3 inches by 3 inches. According to the facility undated policy titled, Choking Prevention, "Prior to serving the trays to the Residents have the license nurse assigned to the dining room to check that all the meal matches the diet slip...Certified Nursing Assistants (CNAs), are to double check meals after the nurse has checked the tray for any missed items or wrong diet in the tray that the nurse may have over looked." According to the facility diet manual, Healthcare services Group I, Diet Manual Third Edition 2011, a Mechanical Chopped Diet consists of: Meats chopped to the consistency of small dice (1/2 inch). According to the Medical Examiner's report dated 12/24/12, Resident 1 expired due to airway obstruction and aspiration (inhalation) of food. The facility failed to follow the physician's orders [REDACTED]. Resident 1 was known to have behaviors, in which he immediately grabbed for food and stuffed the food into his mouth. As a result, Resident 1 grabbed 2 pancakes and 2 uncut whole sausage patties from his breakfast tray and put all 4 items into his mouth. The resident choked on the food and died .