Every finding on record at Vista Real Post Acute

Based on interview and record review, the facility failed to develop and implement a person-centered comprehensive care plan, including appropriate interventions for one of three residents reviewed for quality of care (Resident 1) who repeatedly refused showering.This failure resulted in the lack of individualized interventions to address the resident's hygiene needs and preferences and had the potential to result in poor hygiene, skin integrity issues, and ineffective communication with the responsible party. Findings: A review of the admission Record indicated that Resident 1 was admitted to the facility on [DATE], with diagnoses that included immunodeficiency (body's defense system is weak) and depression (mental health condition). Resident 1's Brief Interview for Mental Status (BIMS) score was 9 (moderate cognitive impairment). A review of Resident 1's record titled Task: Bathing indicated that Resident 1 refused showering on multiple occasions including March 4 and March 6, 2026. Further review of Resident 1's record indicated no documented evidence that the facility identified the repeated refusals of showering as an identified need, established measurable goals, or developed implemented individualized, person-centered interventions. Further review of Resident 1's progress notes, dated March 18, 2026, indicated, .RP verbalized she is disappointed regarding showers.RP requesting to call her if her mother refuses showers. There was no documented evidence the facility incorporated the responsible party's request for notification into the resident's care plan as an intervention. A review of Resident 1's comprehensive care plan indicated no identified problem, goal, or interventions addressing the resident's repeated refusals of showering. On March 24, 2026, at 3:43 p.m., during a concurrent interview and record review with the Director of Nursing (DON.) The DON stated Resident 1 had prior refusals of showers and the facility did not develop an individualized, person-centered care plan including interventions, to address the resident's refusals. The DON further stated there should have been an individualized care plan to ensure Resident 1's needs and preferences were identified and addressed. The facility policy and procedure, titled, Care Plans, Comprehensive Person- Centered, dated March 2022, indicated, .a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.

Based on interview and record review, the facility failed to ensure effective supervision and implement individualized interventions for one of three residents reviewed for elopement risk (Resident 1), who was assessed as high risk for wandering/elopement. This failure resulted in Resident 1 climbing over the facility fence and leaving the facility grounds, placing the resident at risk for serious injury or death.Findings:Resident 1's record was reviewed. Resident 1 was admitted to the facility on [DATE], with diagnoses including dementia (memory loss). A review of Resident 1's Care Plan, dated September 6, 2025, indicated .Elopement/Wandering: Resident is at risk for elopement/exit seeking/wandering related to agitation, altered cognitive status.voices desired to leave.Interventions.Allow wandering in safe areas within the facility. Further review of the care plan indicated there were no specific interventions implemented to prevent Resident 1 from exiting the facility grounds. A review of Resident 1's Minimum Data Set (an assessment tool) dated December 19, 2025, indicated the resident had moderate cognitive impairment. A review of Resident 1's ELOPEMENT AND WANDERING RISK OBSERVATION/ASSESSMENT, dated December 19, 2025, indicated the resident has a score of 10 (considered at risk for wandering or elopement). A review of Resident 1's eINTERACT SBAR (Situation, Background, Assessment, Recommendations) Summary, dated January 15, 2026, indicated, .Staff saw the resident jumped over the fence; available staff followed resident & (and) redirected the resident to back inside the facility grounds but refused and kept on walking along the side of 8th street heading east. On February 3, 2026, at 11:58 a.m., Certified Nursing Assistant (CNA) 1 was interviewed. CNA 1 stated she was assigned to Resident 1 at the time of the incident. CNA 1 stated she was informed by CNA 2 that Resident 1 had jumped over the fence. CNA 1 stated staff attempted to redirect the resident back to the facility, the resident refused to return. CNA 1 stated law enforcement was contacted. On February 3, 2026, at 12:22 p.m., CNA 2 was interviewed. CNA 2 stated, she was familiar with Resident 1. CNA 2 stated the resident had verbalized wanting to go home with his brother and had refused meals. CNA 2 stated approximately one week prior to the elopement incident, Resident 1 was observed walking near the exit doors and appearing to look for ways to leave the facility. On February 3, 2026, at 12:56 p.m., Activity Assistant (AA) 1 was interviewed. AA 1 stated she was aware Resident 1 was at risk for elopement and required close supervision. AA 1 stated, residents identified as at risk for elopement required close supervision. AA 1 stated that when Resident 1 was outside, staff should have been present with the resident at all times to prevent elopement. AA 1 stated she observed Resident 1 sitting in the garden while she had remained in the lobby and then saw the resident climb over the fence. AA 1 stated she should have been outside supervising the resident instead of remaining in the lobby. On February 26, 2026, at 3:40 p.m., during a concurrent interview and record review of Resident 1's care plan, the Registered Nurse Supervisor (RNS) stated the facility practice was to complete an elopement risk assessment on admission and revise the assessment and care plan if exit-seeking was observed. The RNS stated Resident 1 had exit-seeking behavior, the care plan was not revised to provide new interventions such as 1:1 while outside. On February 26, 2026, at 4:20 p.m., the Director of Nursing was interviewed. The DON stated when staff observed exit-seeking behavior, staff were expected to report the behavior to the nurse so the assessment and care plan can be revised, and the resident may be placed on one-to-one monitoring as needed. The DON stated, Resident 1's care plan should be revised and placed on 1:1 supervision. A review of the facility policy and procedure titled Wandering and Elopements, dated March 2019, indicated, .The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents.If identified at risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety.

Based on observation, interview, and record review, the facility failed to ensure proper disposal of garbage when multiple cardboard boxes were found on the ground outside of the designated container and not stored appropriately. This failure had the potential to attract pests and cause infection control issues. Findings: On June 23, 2025, at 10:55 a.m., during an observation of the garbage and refuse storage area, multiple cardboard boxes were found on the ground near the recycling container and not stored inside the container. On June 23, 2025, at 11:03 a.m., during a concurrent observation and interview with the Dietary Supervisor (DS), in front of the containers, the DS stated there should not be any debris or cardboard boxes on the ground around the containers. The DS further stated the boxes left outside of the container could attract pests and potentially lead to infection control issues. On June 26, 2025, at 1:55 p.m., during an interview with the Registered Dietitian (RD), the RD stated the garbage containers should be kept clean and inspected daily to ensure that no garbage or cardboard boxes were left on the ground in the surrounding area. The RD further stated, not adhering to the policy could result in potential pest infestation and infection control issues. A review of the facility policy and procedure titled Miscellaneous Areas: Garbage and Trash Procedure, dated 2023, indicated, .Garbage and trash cans must be inspected daily that no debris is on the ground or surrounding area, and that the lids are closed .The trash collection area is a potential feeding ground for vermin and rodents and must be kept clean .

Based on interview and record review, the facility failed to ensure, seven of 14 residents reviewed for Advance Directive (AD - written statement of a person's wishes regarding medical treatment) (Residents 1, 6, 10, 21, 23, 32, 42) the resident or their resident representative (RP) had been provided follow up information regarding the formulation of an AD. This failure had the potential to result in the ADs for Residents 1, 6, 10, 21, 23, 32, and 42 not being readily accessible to staff and physicians, which could lead to the residents' wishes regarding medical treatment being unknown and ultimately not honored. Findings 1. On June 24, 2025, at 11:16 a.m., an interview was conducted with Resident 6. Resident 6 stated that he was unsure of having an AD and unsure if asked if he would like to formulate one. Resident 6's record was reviewed. Resident 6 was admitted to the facility on [DATE]. A review of Resident 6's Physician Orders for Life-Sustaining Treatment (POLST), dated October 29, 2024, did not indicate Resident 6 had an AD. A review of Resident 6's Social History Assessment, dated October 30, 2024, indicated, .No advance directive per resident . A review of Resident 6's History and Physical, dated November 2, 2024, indicated Resident 6 had the capacity to understand and make decisions. A review of Resident 6's Interdisciplinary Care Conference, (IDT) dated November 4, 2024, indicated, .resident POLST .discussed . A review of Resident 6's IDT Care Conference, dated February 6, 2025, indicated, .POLST .discussed . A review of Resident 6's Social History Review, dated April 29, 2025, indicated, .Advance Directive .none of the above .self-responsible . There was no documented evidence the resident or RP was provided information about the right to formulate an AD. On June 26, 2025, at 10:24 a.m. a concurrent interview and record review was conducted with the Social Service Director (SSD). A review of the IDT care conference dated November 4, 2024, and the Social History assessment dated [DATE] was reviewed. The SSD stated Resident 6 indicated they did not have an AD during the social history assessment. The SSD stated the protocols were for the SSD to determine if a resident had an AD upon admission, they would attempt to obtain it directly from the resident or from the RP. The SSD indicated if an AD was not present then they would offer the resident resources to formulate one. The SSD indicated if an AD was not determined upon admission, then a follow up would be done during the IDT care conference and then quarterly during the social history assessments conducted by the SSD. The SSD stated she did not follow up with Resident 6 or the RP to determine if they wished to formulate an AD after determining one was not formulated upon admission. The SSD stated she should have followed up with Resident 6 during the IDT care conference to provide him with the right to formulate an AD. The SSD further stated there was a risk for Resident 6's care preferences to not be honored if an AD was not present and available for review in the resident's medical record. 2. A review of Resident 1's admission Record, indicated Resident 1 was admitted to the facility on [DATE]. A review of the Social Service Assessment, dated January 15, 2020, indicated that Resident 1 did not have an AD. A review of Resident 1's History and Physical dated February 23, 2025, indicated Resident 1 had the capacity to understand and make decisions. On June 24, 2025, at 9:14 a.m., during an interview with Resident 1, he stated he was not sure if he had an AD. On June 26, 2025, at 10:30 a.m., during a concurrent interview and review of Resident 1's Social History Assessment with the SSD, she stated if a resident did not have an AD, she would offer resources and education to the resident or the RP. The SSD stated Resident 1 had no AD, was not provided education, and was not reviewed for AD. The SSD further stated she should have followed up and provided AD education to Resident 1 or the RP in order to honor their care preferences. 3. A review of Resident 32's admission Record, indicated Resident 32 was admitted to the facility on [DATE]. A review of Resident 32's Social Service Assessment, dated October 19, 2023, indicated that Resident 32 did not have an AD. A review of Resident 32's History and Physical dated October 22, 2023, indicated Resident 32 does not have the capacity to understand and make decisions. On June 24, 2025, at 11:34 a.m., during an interview with Resident 32, he was not able to verbalize if he had an AD. On June 26, 2025, at 10:30 a.m., during a concurrent interview and review of Resident 32's Social History Assessment with the SSD, she stated if a resident did not have an AD, she would offer resources and education to the resident or the RP. The SSD stated Resident 32 had no AD, was not provided education, and was not reviewed for AD. The SSD further stated she should have followed up and provided AD education to Resident 32 or the RP in order to honor their care preferences. 4. A review of Resident 42's admission Record, indicated Resident 42 was admitted to the facility on [DATE]. A review of Resident 42's Social Service Assessment, dated September 25, 2024, indicated that Resident 42 did not have an AD. A review of Resident 42's History and Physical dated September 30, 2024, indicated Resident 42 has fluctuating capacity to understand and make decisions. On June 24, 2025, at 8:46 a.m., during an interview with Resident 42, he stated he did not know if he has an AD or what is an AD. On June 26, 2025, at 10:30 a.m., during a concurrent interview and review of Resident 42's Social History Assessment with the SSD, she stated if a resident did not have an AD, she would offer resources and education to the resident or the RP. The SSD stated Resident 42 had no AD, was not provided education, and was not reviewed for AD. The SSD further stated she should have followed up and provided AD education to Resident 42 or the RP in order to honor their care preferences. 5. A review of Resident 21's admission Record, indicated Resident 21 was admitted to the facility on [DATE]. A review of the Social Service Assessment, dated September 19, 2024, indicated that Resident 21 did not have an AD. A review of Resident 21's History and Physical dated September 20, 2024, indicated Resident 21 has fluctuating capacity to understand and make decisions. On June 24, 2025, at 8:35 a.m., during an interview with Resident 21, he stated he did not know if he has an AD. On June 26, 2025, at 10:30 a.m., during a concurrent interview and review of Resident 21's Social History Assessment with the SSD, she stated if a resident did not have an AD, she would offer resources and education to the resident or the RP. The SSD stated Resident 21 had no AD, was not provided education, and was not reviewed for AD. The SSD further stated she should have followed up and provided AD education to Resident 21 or the RP in order to honor their care preferences. 6. On June 23, 2025, at 10:21 a.m., an interview was conducted with Resident 10. Resident 10 stated he could not recall if he was offered information about an AD. A review of Resident 10's admission Record, indicated Resident 10 was admitted to the facility on [DATE]. A review of Resident 10's POLST, dated February 20, 2025, did not indicate Resident 10 had an AD. A review of Resident 10's History and Physical, dated February 21, 2025, indicated Resident 10 had the capacity to understand and make decisions. A review of Resident 10's Social History Review, dated May 20, 2025, indicated, .Self responsible .Advance directives .none of the above . A review of Resident 10's IDT Care Summary, dated May 27, 2025, indicated, .POLST discussed . There was no documented evidence that Resident 10 or RP were provided with follow up information or education about the right to formulate an AD. On June 26, 2025, at 10:40 a.m., a concurrent interview and record review of Resident 10's Social History Review and IDT Care Summary was conducted with the SSD. The SSD stated upon admission, she would check with residents or RP if they had an AD, and if they had one, she would request a copy to be available in the facility. The SSD stated if they did not have one, she would provide residents or RP with information and education on how to formulate one. The SSD stated if the resident did not wish to have an AD, a follow up with the resident or RP about AD would be conducted quarterly during a resident's IDT care conference. The SSD stated there was no documentation which indicated Resident 10 was provided with follow up information during the IDT care conference on May 27, 2025. The SSD stated if there was no AD on file there was potential for the facility to not be able to honor their preferences for care. 7. On June 23, 2025, at 11:10 a.m., an interview was conducted with Resident 23. Resident 23 stated he was not sure if he had an AD and could not recall if he or his RP were offered information about an AD. A review of Resident 23's admission Record, indicated Resident 23 was admitted to the facility on [DATE]. A review of Resident 23's POLST, dated January 15, 2025, did not indicate Resident 23 had an AD. A review of Resident 23's History and Physical, dated January 16, 2025, indicated Resident 23 had the capacity to understand and make decisions. A review of Resident 23's Social History Review, dated April 15, 2025, indicated, .Family member responsible .Advance directives .none of the above . A review of Resident 23's IDT Care Summary, dated April 29, 2025, indicated the IDT team met with resident's RP and discussed current plan of care and POLST. There was no documented evidence that Resident 23 or RP were provided with follow up information or education about the right to formulate an AD. On June 26, 2025, at 10:40 a.m., a concurrent interview and record review of Resident 23's Social History Review and IDT Care Summary was conducted with the SSD. The SSD stated upon admission, she would check with residents or RP if they had an AD, and if they had one, she would request a copy to be available in the facility. The SSD stated if they did not have one, she would provide residents or RP with information and education on how to formulate one. The SSD stated if the resident did not wish to have an AD, a follow up with the resident or RP about AD would be conducted quarterly during a resident's IDT care conference. The SSD stated there was no documentation which indicated Resident 23 or RP was provided with follow up information during the IDT care conference on May 27, 2025. The SSD stated if there was no AD on file there was potential for the facility to not be able to honor their preferences for care. A review of the facility's policy and procedure titled, Advance Directives, revised September 2022, indicated, .the resident has the right to formulate an advance directive, including the right to accept or refuse medical or surgical treatment .prior to or upon admission of a resident, the social services director or designee inquires of the resident, his/her family members and/or his or her legal representative, about the existence of any written advance directives .if the resident .indicates that he or she has not established advance directives, the facility staff will offer assistance .information whether or not the resident has executed an advance directive is displayed prominently in the medical record in a section of the record that is retrievable by any staff .

Based on observation, interview, and record review, the facility failed to ensure dietary staff were able to carry out the functions of food and nutrition services safely and effectively when three dietary staff members did not follow the manufacturer's instructions for testing the red bucket (sanitizing solution) sanitizer. This failure had the potential to create unsafe and unsanitary kitchen conditions and could result in foodborne illness (stomach illness acquired from ingesting contaminated food). Findings: A review of the Quaternary Ammonium sanitizer (Quat - sanitizing solution used to sanitize food contact surfaces and equipment) test strip bottle's instructions indicated, Dip test strip into the solution for 1-2 seconds . On June 24, 2025, at 8:46 a.m., a concurrent observation and interview were conducted with the Dietary Aide (DA). The DA demonstrated how to check the Quat sanitizer in the red bucket and was observed placing the test strip in the solution for 10 seconds. The DA stated she should have dipped the test strip for only one to two seconds per the manufacturer's instructions. The DA further stated it was important to follow the manufacturer's instructions to ensure the sanitizer solution was at the proper concentration to prevent any cross contamination or foodborne illness for residents. On June 24, 2025, at 8:52 a.m., a concurrent observation and interview were conducted with the [NAME] (CK). The CK was observed placing the test strip in the Quat sanitizer solution for eight seconds. The CK stated he should have dipped the test strip for one to two seconds to ensure the solution was tested properly. On June 24, 2025, at 8:58 a.m., a concurrent observation and interview was conducted with the Dietary Supervisor (DS). The DS was observed placing the test strip in the solution for five seconds. The DS stated, she did not follow the manufacturer's instructions. The DS stated, she should have followed the manufacturer's guide on the bottle to avoid potential cross contamination and food borne illness. On June 26, 2025, at 1:55 p.m., an interview was conducted with the Registered Dietitian (RD). The RD stated the Quat sanitizer test strips should be dipped for one to two seconds, per the manufacturer's instructions to ensure proper sanitation. The RD further stated, not following the instructions could compromise disinfection and could result in cross contamination and food borne illness to the residents. A review of the professional reference USDA Food Code 2022, Section 3-304.14 Wiping Cloths, Use Limitation .Proper sanitizer concentration should be ensured by checking the solution periodically with an appropriate chemical test kit. A review of the professional reference Food Code 2022, Section 4-501.114 Manual and Mechanical Ware washing Equipment, Chemical Sanitization - Temperature, pH, Concentration, and Hardness, (C) A quaternary ammonium compound solution shall (2) Have a concentration as specified under § 7-204.11 and as indicated by the manufacturer's use directions included in the labeling.

Based on observation, interview and record review, the facility failed to treat one of three residents (Resident 28) with dignity when an Activities Assistant (AA) stood over the resident while providing assistance with liquid nourishment during designated snack period. This failure had the potential to negatively impact the safety, dignity, and respect of Resident 28. Findings: On June 23, 2025, at 10:40 a.m., during an observation in the activities room, Resident 28 was observed to be seated in a Geri chair with the head tilted at a 45-degree angle, positioned at the corner of the room. The AA was observed standing directly over Resident 28, while assisting with liquid nourishment. The AA was not seated at eye level with the resident during assistance. A review of Resident 28's admission Record, indicated, Resident 28 was admitted to the facility on [DATE], with diagnoses of dementia without behavioral disturbance (mental disorder when a person loses the ability to think, remember, learn, make decisions, and solve problems). A review of Resident 28's Care Plan Report, indicated, .Requires assistance with ADL (Activities of Daily Living) functions .the resident will maintain current level of function through the review date .Geri chair while up out of bed for positioning .provided total assistance during meals . On June 23, 2025, at 10:45 a.m., during an interview with the AA, the AA stated he could either sit or stand while assisting Resident 28 with liquid nourishment. On June 25, 2025, at 8:20 a.m., during an interview with the Director of Nursing (DON), the DON stated, it was the facility's expectation that all staff should sit at the resident's eye level when assisting with nourishment to promote safety, dignity, and respect. A review of the facility's Policy and Procedure titled, Assistance with Meals, with revised date of March 2022, indicated, .Residents shall receive assistance with meals in a manner that meets the individual needs of each resident. Under Section titled, Dining Room Residents, .3. Residents who cannot feed themselves will be fed with attention to safety, comfort, and dignity, for example: a. not standing over residents while assisting them with meals; b. keeping interactions with other staff to a minimum while assisting residents with meals; c. avoiding the use of labels when referring to residents (e.g., feeders). Under the Section titled, Residents Requiring Full Assistance, .2. Residents who cannot feed themselves will be fed with attention to safety, comfort and dignity, for example: a. not standing over residents while assisting them with meals; b. keeping interactions with other staff to a minimum while assisting resident with meals .

Based on observation, interview, and record review, the facility failed to ensure proper infection control measures were implemented when: 1. The Licensed Vocational Nurse (LVN) did not clean and disinfect a blood pressure machine between resident uses. 2. The LVN used gloves that had been stored inside her scrub pocket before administering medication. These failures had the potential to result in cross-contamination, increasing the risk of infection spread among an already vulnerable population of residents. Findings: 1. On June 25, 2025, from 9:25 a.m. to 9:55 a.m., an observation was conducted of the LVN checking the blood pressure of Residents 11, 20, and 33 in the residents' room. The LVN did not disinfect the blood pressure machine before or after use between residents. On June 25, 2025, at 10:10 a.m., during an interview with the LVN, the LVN stated, she should have cleaned and disinfected the blood pressure machine between resident uses. On June 26, 2025, at 8:51 a.m., during an interview with the Infection Preventionist (IP), the IP stated, medical devices used on residents should be disinfected after each use to reduce the risk of cross-contamination. A review of the facility policy and procedure titled, Blood Pressure Measuring, dated 2001, indicated, .clean and wipe the sphygmomanometer and cuff with antiseptic then roll up the blood pressure cuff . 2. On June 25, 2025, at 9:40 a.m., inside Resident 33's room, the LVN was observed donning (putting on) gloves that had been stored in her scrub pocket prior to administering medication. On June 25, 2025, at 10:10 a.m., during an interview with the LVN, the LVN stated she used gloves stored in her scrub pocket before administering medication and stated it was acceptable. On June 26, 2025, at 8:51 a.m., during an interview with the IP. The IP stated the facility protocol required staff to obtain gloves from the wall-mounted glove box. The IP stated, storing gloves in scrub pockets was not permitted as it posed a risk of contamination. A review of the facility policy and procedure titled, Personal Protective Equipment-Using Gloves, dated 2001, indicated, .to guide the use of gloves .to prevent the spread of infection, to protect wounds from contamination, to protect hands from potentially infectious materials .when to use gloves .when touching excretions, secretions, blood, body fluids, mucous membranes or non-intact skin .

Based on observation, interview, and record review, the facility failed for one of three residents reviewed (Resident 2) when reports of food intake below 50% on multiple occasions were not properly communicated to nursing staff, physician (MD), and registered dietitian (RD). This failure had the potential to negatively affect Resident 2 ' s nutritional status and overall medical status. Findings: On April 2, 2025, at 11:10 a.m. an interview was conducted with Resident 2. Resident 2 was alert and lying in bed. Resident 2 stated he did not like his diet, was not provided alternate food, and was losing weight. On April 2, 2025, at 11:40 a.m. a lunch observation was conducted with Resident 2. Resident 2 was observed sitting up to the side of the bed with full plate of food. Lunch observation showed uneaten meat, potatoes, and peas. Resident 2 stated, the meat was too salty and the vegetables were not good. Resident 2 stated, the staff were aware he would not eat it. On April 2, 2025, at 11:55 a.m. observed Certified Nursing Assistant (CNA) 1 enter the room of Resident 2, collected the tray without offering an alternative. On April 2, 2025, at 11:58 a.m. a follow up interview was conducted with Resident 2. Resident 2 stated he informed CNA 1 that he did not want to eat his meal and CNA 1 did not offer him an alternative. On April 2, 2025, at 12:01 p.m. an interview was conducted with CNA 1. CNA 1 stated if a resident refused to eat a meal, an alternative should be offered and that refusals should be reported to the charge nurse. On April 2, 2025, at 12:40 p.m. an interview was conducted with Licensed Vocational Nurse (LVN 1). LVN 1 stated she was assigned to Resident 2 today. She stated she was informed at approximately 12:35 p.m. today that Resident 2 refused his lunch meal. She stated she would document the refusal in the medical record, record the intake, and offer a supplement alternative such as a protein shake. LVN 1 stated she should be informed of refused meals no later then one hour after the refusal so alternatives could be offered but that there was no specific policy that she was aware of regarding the time frame. LVN 1 stated a progress note should be written to reflect any meals with less than 50% consumption, an alternative should be offered and the physician and kitchen made aware. On April 2, 2025, Resident 2 ' s record was reviewed. Resident 2 was admitted to the facility on [DATE], with diagnosis which included Schizophrenia (mental health disorder). A review of Resident 2 ' s History and Physical Examination , dated January 17, 2025, indicated has the capacity to understand and make decisions. A review of Resident 2's Minimum Data Set (an assessment tool), dated January 27, 2025, indicated Resident 2 had a Brief Interview of Mental Status (a cognitive screening tool used to assess the mental state of residents) Score of 12 (moderately impaired). A review of the document titled, special diets undated, indicated .special diets .regular .notes .resident likes grilled cheese if he refuses meal .alerts (blank) .dislikes (blank). A review of the documents titled Activity/Residents Requests indicated, there was no documented evidence Resident 2 received an alternative menu item during the breakfast and lunch meal percentage intake found to be less then 50%. A review of the IDT weekly weight nutrition note dated February 19, 2025 indicated, .current weight: 134 lbs (pounds-a unit of measurement) .IBWR (ideal body weight) 139 -166 lbs . A review of Resident 2 ' s intake and output for the month of March 2025 indicated the following: - March 1, 2025, amount eaten 25%-50% lunch. - March 4, 2025, amount eaten 25%-50% lunch. - March 10, 2025, amount eaten 25%-50% lunch. - March 17, 2025, amount eaten 25%-50% breakfast. - March 18, 2025, amount eaten 0-25% breakfast and lunch - March 25, 2025, amount eaten 0-25% lunch. - March 28, 2025, amount eaten 25%-50% lunch. - March 29, 2025, amount eaten 25%-50% lunch . A further review of Resident 2's medical record, indicated, there was no documentation the meal percentage below 50% was reported to the nurse, the medical doctor (MD), or the Registered Dietitian (RD). In addition, there was no documented evidence a care plan was developed to provide interventions regarding Resident 2's meal refusals. On April 2, 2025, at 4:17 p.m., an interview and record review were conducted with the Director of Nursing (DON). The DON stated, she was not aware that Resident 2 consumed less than 50% on March 1, 4, 6, 10, 17, 18, 25, 28, and 29, 2025, and the nurses should have documented the refusals, offered alternatives, and alerted her. The DON stated, she should have been made aware by the nurses and a meeting should have been conducted to provide interventions to prevent weight loss. The DON stated, the RD was present in the facility every Wednesday and during the monthly IDT meetings. On April 7, 2025, at 10:39 a.m. an interview and record review was conducted with the Registered Dietitian (RD). The RD stated she was not made aware of Resident 2's inadequate intakes on March 1, 4, 6, 10, 17, 18, 25, 28, and 29, 2025. The RD stated she was present in the facility every Wednesday of the week and during the IDT monthly weight variance meetings. The RD stated she was not made aware of any preference changes or refusals prior to April 2, 2025. The RD further stated she could have provided prevention interventions earlier if informed. A review of the facility policy and procedure titled, Food and Nutrition Services dated 2001, indicated, Each resident is provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident .Nursing personnel .will evaluate (and document as indicated) food and fluid intake of residents with, or at risk for, significant nutritional problems .variations from usual eating or intake patterns will be recorded in the resident ' s medical record and brought to the attention of the nurse . a nurse will evaluate the significance of such information and report it, as indicated, to the attending physician and dietitian .

Based on interview and record review, the facility failed to ensure that one of four sampled residents (Resident 2) received continuous supervision and assistance, when the staff assigned to monitor Resident 2 left the resident unattended while he was sitting in a chair and had fallen asleep. This failure had the potential to result in harm to Resident 2, including injury from an unassisted fall. Findings: A review of Resident 2's Admission Record, indicated Resident 2 was admitted to the facility on [DATE], with diagnoses which included muscle wasting and atrophy (a disease that causes loss and weakening of muscles). A review of Resident 2's Minimum Data Set (an assessment tool), dated January 26, 2025, indicated Resident 2 had a Brief Interview for Mental Status (tool used to assess a resident's cognitive function) score of 6 (severe cognitive impairment). A review of Resident 2's Nurse's Notes, dated February 7, 2025, at 5:42 p.m., indicated, .(Certified Nurse Assistant [CNA] 4's name) assigned 1 on 1 to resident .Resident was found on the floor .Per (CNA 4) she went to grab resident dinner from the food cart in the hallways .upon arriving to resident room she found resident .in the floor .Resident stated that he fell asleep sitting on the chair in his room and fell .Resident sustained a 3 cm (centimeter - unit of measurement) cut and bump to left forehead .complained of .pain on the stated site .Send to ER (emergency room ) for further eval (evaluation) and treatment . On March 18, 2025, at 3:46 p.m., during an interview with the Director of Nursing (DON), she stated residents on one-on-one monitoring require the assigned staff to continuously monitor them to ensure their safety. The DON further stated Resident 2 was on one-on-one monitoring due to elopement behavior and had a fall on February 7, 2025, at 5:42 p.m., sustaining a 3 cm laceration and bump on the left forehead. The DON stated Resident 2 was sitting on a chair inside his room when CNA 4 stepped out to grab Resident 2's dinner from the food cart located in the hallway in front of Resident 2's door. The DON further stated when CNA 4 returned to the room, she found Resident 2 on the floor. The DON stated Resident 2 had fallen asleep, slid out of the chair, and fell . The DON stated CNA 4 should not have left Resident 2 unattended and could have intervened immediately to prevent Resident 2 from sliding out of the chair, which could have prevented the fall and injury. The DON further stated the fall was preventable. On March 18, 2025, at 4:12 p.m., during an interview with License Vocational Nurse (LVN) 1, she stated she assessed Resident 2 after his fall on February 7, 2025, at around 5 p.m. LVN 1 further stated CNA 4 informed her that while Resident 2 was sitting in his chair, she (CNA 4) stepped out of the room to grab his dinner tray from the food cart in the hallway. LVN 1 stated, when CNA 4 returned to the room, Resident 2 was on the floor. LVN 1 stated Resident 2 had fallen asleep while sitting in his chair in his room, slid sideways and fell to the floor, causing a laceration and bump to his left forehead. LVN 1 stated Resident 2 was placed on one-on-one monitoring, where the assigned staff needed to stay close and maintain a constant visual on the resident for safety. LVN 1 further stated CNA 4 should not have left Resident 2 unattended in his chair and could have intervened sooner which might have prevented the fall and injury. On March 20, 2025, at 10:11 a.m., during an interview with CNA 4, she stated residents on one-on-one monitoring were to be continuously observed, and the assigned staff had to stay close and within arms reach of the resident to intervene if needed for safety. CNA 4 stated, she was assigned to provide one-on-one monitoring for Resident 2 on February 7, 2025, around 5 p.m., when Resident 2 fell and sustained laceration on his left forehead CNA 4 stated she and Resident 2 were sitting inside his room watching TV when she heard the food cart rolling in the hallway. CNA 4 further stated she left Resident 2 to grab his dinner tray from the hallway, and when she returned to the room, she found Resident 2 on the floor. CNA 4 stated she should not have left Resident 2 unattended in the chair, and further stated if she had stayed close by and not left, she could have intervened right away and prevented Resident 2 from falling. A review of the facility document titled, Responsibilities of a Sitter, undated, indicated, .Patients at high risk for falls, confusion, impaired mobility, or other safety concerns may require a 1:1 sitter .The sitter will provide continuous bedside observation .maintain patient safety .to prevent falls or injuries . A review of the facility policy and procedure titled, Safety and Supervision of Residents, dated July 2017, indicated, .Our facility strives to make the environment as free from accident hazards as possible .Resident safety and supervision and assistance to prevent accidents are facility-wide priorities .Our individualized, resident-centered approach to safety addresses safety .for individual residents .The care team shall target interventions to reduce individual risk .including adequate supervision .Ensuring the interventions are implemented correctly and constantly .

Based on interview and record review, the facility failed for one of three residents (Resident 1) to notify the resident's representative (RP) of a decline in the resident's health status/condition. This failure had the potential to result in the RP not being informed in a timely manner, delaying their opportunity to be present regarding Resident's care at the end of life. Findings: A review of Resident 1's Admission Record, indicated Resident 1 was admitted to the facility on [DATE]. A review of Resident 1's Minimum Data Set (an assessment tool), dated [DATE], indicated Resident 1 had a Brief Interview for Mental Status (tool used to assess a resident's cognitive function) score of 2 (severe cognitive impairment). A review of Resident 1's Nurse's Notes, dated [DATE] at 12:50 a.m., indicated, .Resident was unresponsive to verbal, tactile and painful stimuli .No response to sternal rub .No heart and breath sounds noted by auscultation .No chest rise and fall noted .Skin was pale, slightly cool and clammy .No vital signs noted .Assessed by two charge nurses .(name of facility physician) notified .Hospice nurse notified and came .(name of hospice physician) pronounced resident dead . A review of Resident 1's Nurse's Notes, dated [DATE], at 3:34 a.m., indicated, .May release body to family mortuary of choice .RP made aware . On [DATE], at 10:41 a.m. during an interview with Licensed Vocational Nurse (LVN) 2, she stated when a hospice resident passed away in the facility, two licensed nurses conduct an assessment to determine whether the resident had a heartbeat, was breathing, or was responsive. LVN 2 further stated after this assessment, the facility physician and the resident's representative were to be notified immediately. LVN 2 stated hospice was contacted for further instructions and to pronounce the time of death. LVN 2 stated on [DATE], at 12:50 a.m., Resident 1 was found unresponsive, not breathing and without a heartbeat. LVN 2 further stated she had notified the facility physician and hospice but had not contacted Resident 1's RP. LVN 2 stated she had waited for hospice to arrive in the facility to call Resident 1's time of death before notifying the RP. She further stated she notified Resident 1's RP at 3:34 a.m. (approximately 2.5 hours) after Resident 1 had passed. LVN 2 stated she should have contacted the RP immediately after confirming Resident 1 was no longer alive as it was important to inform and update the RP promptly so the family could come and say goodbye. On [DATE] at 11:15 a.m. during a concurrent interview and review of Resident 1's nurse's notes with the Director of Nursing (DON), she stated, when a resident was on hospice and died , licensed nurses were expected to assess the resident, and if the resident no longer had a heartbeat and was no longer breathing, the facility physician and the resident's family or representative were to be notified immediately. The DON further stated, hospice was contacted to officially pronounce the death. The DON stated, a resident's death was considered a change in the resident's health status or condition. The DON stated on [DATE], at 12:50 a.m., LVN 2 assessed Resident 1 as unresponsive, with no heartbeat and not breathing. The DON stated, the facility physician and hospice were notified. The DON further stated LVN 2 did not notify Resident 1's RP of the assessment immediately, and the RP was not contacted until 3:34 a.m. The DON stated, LVN 2 should have called and notified Resident 1's RP immediately to ensure timely communication with Resident 1's family, allowing them the opportunity to see Resident 1 and say goodbye before the remains were released to the mortuary. A review of the facility policy and procedure titled, Death of a Resident, Documenting, dated [DATE], indicated, .The Nurse Supervisor/Charge Nurse will inform the resident's family of the resident's death . A review of the facility policy and procedure titled, Change in a Resident's Condition or Status, dated 2001, indicated, .Our facility promptly notifies the resident .and the resident representative of changed in the resident's medical/mental condition and/or status .A significant change .is a major decline .in the resident's status .Unless otherwise instructed by the resident, a nurse will notify the resident's representative when .there is a significant change in the resident's physical, mental .status .

Based on interview and record review the facility failed to provide an environment free of physical abuse for one of five residents (Resident 2) when staff did not intervene and redirect Resident 2 away from Resident 3, who had previously alleged that Resident 2 had taken his belongings. This failure resulted in Resident 3 punching Resident 2 on the right side of the face, causing Resident 2 to fall and sustain a laceration (broken skin) and swelling on the right side of the face. Findings: On December 23, 2024, Resident 2' s admission record was reviewed. Resident 2 was admitted to the facility on [DATE] with diagnoses which included dementia (memory loss). A review of Resident 2's Minimum data Set (an assessment tool), dated September 24, 2024, indicated a Brief Interview for Mental Status (used to identify the cognitive condition of a resident) score of 12 (moderate cognitive impairment). A review of Resident 2's IDT (Interdisciplinary Team) Note, dated December 18, 2024, indicated, .At 6:15am resident (Resident 3) was accusing this resident (Resident 2) of taking some of his belongings .At 10:55am other resident (Resident 3) swung his right hand towards this resident (Resident 2) and hit him in the face . A review of Resident 2's Progress Notes, dated December 18, 2024, indicated: - .At around 10:55am at the hallway in front of the dining room, (Resident 3) was with activity director .(Resident 2) was walking towards the dining room .(Resident 3) just suddenly swung his right hand towards (Resident 2) .(Resident 2) was hit on the right side of his face and sustained a small cut and swelling. - .Addendum to the incident: resident loss balance and fell on the floor when he was hit by (Resident 3) . On December 23, 2024, Resident 3' s admission record was reviewed. Resident 3 was admitted to facility on November 11, 2024 with diagnoses which included schizophrenia (a severe mental disorder affecting a person's emotions and perception of reality). A review of Resident 3's History and Physical, dated November 17, 2024, indicated Resident 3 has the capacity to understand and make decisions. A review of Resident 3's eINTERACT Change of Condition Form, indicated the following: - On December 18, 2024, indicated, .At 0615H (6:15 a.m.), (Resident 3) approached (Resident 2) who was sitting on the chair across nursing station .(Resident 3) asked (Resident 2) about his missing item/thing .with angry voice .(Resident 2) ignored him and went towards his room .(Resident 3) get upset and punched the wall along the nurse station . - On December 18, 2024 at 10:55 a.m., indicated, .Physical aggression towards another resident (Resident 2) . A review of Resident 3's Progress Notes, dated December 18, 2024, indicated, .At around 10:55am at the hallway in front of the dining room, (Resident 3) was with activity director .(Resident 2) was walking towards the dining room .(Resident 3) suddenly swung his right hand towards (Resident 2) .(Resident 2) was hit on the right side of his face . A review of Resident 3's Care Plan, dated December 18, 2024, indicated, .Focus: Accused other resident of taking belongings and punched the wall .Interventions: Observe whether the behavior endangers .other resident .Intervene if necessary .removing others from the surrounding area. On December 23, 2024 at 10:12 a.m., during a concurrent interview and review of the progress notes for Residents' 2 and 3 with Registered Nurse (RN) 1, she stated on December 18, 2024, at 6:15 a.m., Resident 3 was agitated and accused Resident 2 of taking his belongings. RN 1 further stated Resident 3 became upset and punched a wall. RN 1 stated at 10:55 a.m. on December 18, 2024, (four hours after the allegation), Resident 3 was in the hallway in front of the dining room with the Activity Director (AD) when Resident 2 walked down the hallway toward them. RN 1 further stated when Resident 3 saw Resident 2, he swung his hand and hit Resident 2 on the right side of the face, causing a laceration. RN 1 stated activity and nursing staff were aware Residents 2 and 3 had an interaction at 6:15 a.m., and were instructed to keep the two residents apart at all times to prevent an altercation. RN 1 further stated staff should have redirected Resident 2 away from Resident 3 to avoid any interaction which could have prevented the incident. On December 23, 2024 at 10:55 a.m., during an interview with Resident 2, he stated on the morning of December 18, 2024, Resident 3 accused him of taking his belongings and became upset. Resident 2 further stated later that morning, at around 10 a.m., he was walking down the hallway in front of the dining room when Resident 3 suddenly punched him on the right side of the face, causing a laceration. On December 23, 2024 at 11:12 a.m., during an interview with the AD, she stated she was aware Residents 2 and 3 had an interaction on December 18, 2024 at 6:15 a.m., during which Resident 3 was agitated, accused Resident 2 of taking his belongings, and punched a wall. The AD further stated on December 18, 2024, at 10:55 a.m., she was with Resident 3 at the hallway outside the dining room when she saw Resident 2 walking down the hallway towards them. The AD stated she redirected Resident 3, but the resident refused. The AD further stated no facility staff redirected Resident 2 away from the hallway where Resident 3 was located. The AD stated when Resident 3 saw Resident 2, Resident 3 stood up and punched Resident 2 on the right side of the face, causing a laceration. On December 23, 2024 at 11:30 a.m., during an interview with the Director of Nursing (DON), she stated Residents 2 and 3 had an interaction on December 18, 2024 at 6:15 a.m., and activity and nursing staff were aware that both residents should be kept apart to prevent an altercation. The DON further stated Residents 2 and 3 had an altercation at 10:55 a.m. on December 18, 2024, in the hallway in front of the dining room, where Resident 3 punched Resident 2 on the right side of the face causing a laceration. The DON stated the altercation was preventable and the facility staff should have intervened, redirected, and removed Resident 2 from the hallway where Resident 3 was located, preventing the residents from seeing each other and avoiding the altercation. A review of the facility policy and procedure titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, dated April 2021, indicated, .Residents have the right to be free from abuse .This includes but is not limited to freedom from .Physical abuse .by anyone including .Other residents . A review of the facility policy and procedure titled, Resident-to-Resident Abuse, undated, indicated, .If a resident-to-resident incident occurs, staff should immediately intervene .Separate the residents and take them to areas away from each other until the situation subsided .

Based on observations, interviews, and record review, the facility failed to provide effective supervision for one of five sampled residents (Resident 2), who had history of exhibiting unprovoked aggressive behavior towards staff members and had history of altercation with another resident. This failure resulted in Resident 2 to be able to hit a resident (Resident 1) on the left side of her face with a plastic plate cover. Resident 1 sustained a black bruise and swelling above the corner of the left upper lip. Findings: On November 19, 2024, at 11:13 am., an unannounced visit to the facility was conducted to investigate a complaint and facility Reported Incident on an allegation of abuse. A review of Resident 2's Admission Record, indicated, Resident 2 was admitted to the facility on [DATE], with diagnoses which included dementia (memory loss) and schizoaffective disorder (a mental health condition with symptoms of delusions [believing things that are not real], hallucinations [seeing things or hearing voices] and mood disorder [affects the emotional state]). A review of Resident 2's History and Physical, dated August 28, 2024, indicated he had fluctuating capacity to make decisions. On November 19, 2024, at 1:29 p.m., Resident 2 was observed sitting in the hallway adjacent to the nurse's station, sitting in his wheelchair. In a concurrent interview with Resident 2, he stated that he hit a lady (Resident 1) with a plate cover because the resident stabbed him with a pen. However, Resident 2 was unable to recall the date of the incident nor the name of the resident he allegedly hit. On November 19, 2024, at 2:02 p.m., observed Resident 1 in the Activity room, sitting in a wheelchair at a table sipping on coffee. Resident 1 had a purple to black bruise above the corner of her left upper lip. A review of Resident 2's Progress Notes, dated October 12, 2024, at 1:40 p.m., indicated At around 12:15 p.m., this resident barged into room [ROOM NUMBER] and started arguing with a CNA . Resident argues that room [ROOM NUMBER] is his room and that he needs to be assisted back to his bed immediately. CNA redirected resident (sic) by stating that he has been moved to another room and that he will be assisted right away after she is done feeding 32 B. This agitated the resident instantly. Resident then started to scream profanity; grabbed a stainless steel (sic) fork from his pants and physically assaulted the CNA towards the left side of her abdomen. CNA sustained fork- related superficial abrasions to said area . Resident then wheeled himself towards the activity area and started making verbal threats to other facility staff who are trying to stop him from grabbing more forks from the dining tables. Incident happened past noon time where other residents are still eating. Close supervision provided to ensure everyone's safety. A review of Resident 2's Care Plan, dated October 21, 2024, indicated Focus . Psychosocial- Behavior: Exhibits or is at risk for behavioral symptoms (i.e., striking out, grabbing others, combative, verbally, or physically abusive) due to: Schizoaffective disorder, impulse disorder >Another Resident claims he hit her on the left side of her face and head .Interventions . Observe whether the behavior endangers the resident and/or others. (Intervene if necessary: removing others from the surrounding area) . A review of Resident 2's progress notes titled Nurse Practitioner Note, dated October 24, 2024, indicated, . (Resident 2) was involved in an incident with a female peer (Resident 3) . the patient (Resident 2) entered a female peer's room, causing her to yell and scream .The female peer initially accused the patient of hitting her but later recanted upon police arrival. However, she (Resident 3) maintained that the patient (Resident 2) had grabbed her and made threats .Assessment and Plan Aggressive Behavior and Safety Concerns .Patient's impulsive and aggressive behavior poses a risk to himself and others in the facility .Plan .Implement increased supervision and safety measures .Consider 1:1 observation if aggressive behaviors escalate .Follow-up and monitoring .instruct staff to maintain detailed logs and r report any significant changes or incidents immediately .the overall goal is to stabilize the patient's mental state, reduce aggressive behaviors, and ensure the safety of both the patient and others in the facility. Close monitoring and frequent reassessment will be crucial in managing this complex case . A review of Resident 2's progress notes titled, Behavior Note, dated October 28, 2024, indicated, .At 6:30 pm CNA (name) called me (RN Supervisor) .I immediately went to the room and found the resident (Resident 2) inside the bathroom .which is not his room. Resident was agitated, combative, and always cursing/yelling disturbing other residents inside the room .the resident insistently stayed inside the bathroom .The resident was holding a shaving cream bottle, he removed the cap, threw it at the CNA and when the CNA tried to get the cap he punched the CNA in the face .Resident won't listen to the any staff and he continued yelling inside .Reported to MD (physician) with no new order .Assigned another CNA and will do buddy system when providing care to the resident . A review of Resident 2's progress notes titled, Nurses Notes, indicated the following: - November 2, 2024, .At about 8 PM, resident became aggressive, yelling and trying to open the exit door in hallway 2. CN and other staffs redirected him unsuccessful, due to resident swung his arms to hit staffs. Resident stood up, exit door opened, the alarm sounded, resident startled and dropped him down back to w/c, at that time the door closed and somehow caused an abrasion (scrape against a rough surface) on his left knee and s/t (skin tear) on his left forearm . - November 3, 2024, .Approx. (approximately) 8:30 am I was made aware that the resident stuck her in the wrist with the call light while trying to provide patient care. I attempted to communicate with the resident, and he continued to tell me ' they are trying to kill me, and I will slice their throats' I continued to keep my distance and trying to calm the resident down, he continues to yell and make aggressive statements such as ' If they come towards me I will kill them all' . A review of Resident 2's Progress Notes dated November 16, 2024, at 5 p.m., indicated At about 3 pm, CN heard loud noise in dining room, CN went there, saw Activity staff trying to separate [Resident 1] from [Resident 2], [Resident 1] was crying at this time. Activity staff said [Resident 2] used the cover of plate to hit [Resident 1]'s left side of face. CN saw a little bruise on her left upper mouth. CN asked her if she was in pain, she said yes . A review of Resident 1's medical records indicated she was admitted on [DATE], with diagnoses of type 2 diabetes mellitus, (a chronic condition that affects the way the body uses sugar), dementia, (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning), and depression, (a mood disorder that causes a persistent feeling of sadness and loss of interest). A review of Resident 1's History and Physical dated January 24, 2024, indicated she did not have the capacity to make decisions. A record review of Resident 1's Progress Notes, dated November 16, 2024, at 5 p.m., indicated At about 3 pm, CN [charge nurse] heard loud noise in dining room, CN went there, saw activity staff trying to separate [Resident 1] from [Resident 2] (sic) [Resident 1] was crying at this time. Activity staff said [Resident 2] used the cover of plate to hit [Resident 1's] left side of face. CN saw a little bruise on her left upper mouth. CN asked her if she was in pain, she said yes . A review of Resident 1's Wound Evaluation dated November 17, 2024, at 7:53 a.m., indicated .Bruise Body Location: - Upper - Left - Lip New - 1 day old . Dimensions Area 3.22 cm Length 2.8 cm Width 1.71 cm . A review of Resident 3's admission records indicated she was admitted on [DATE], with diagnoses including dementia. A review of Resident 3's History and Physical dated August 28, 2024, indicated she did not have the capacity to understand and make decisions due to dementia. On November 19, 2024, at 2:12 p.m., an interview was conducted with Certified Nursing Assistant, (CNA) 1. CNA 1 stated she was familiar with Resident 2. CNA 1 stated Resident 2's behavior had been getting worse. CNA 1 stated that she had been stabbed in the abdomen with a fork by Resident 2. CNA 1 stated that Resident 2's behavior was unpredictable and had gotten worse. CNA 1 stated Resident 2 required close supervision by CNA and Activity staff. She stated someone should be supervising the resident (Resident 2) and keeping him away from other residents. On November 19, 2024, at 2:47 p.m., an interview was conducted with a Licensed Vocational Nurse (LVN). The LVN stated she was assigned to Resident 2, and she stated Resident 2 had been more aggressive and the resident needed constant supervision. The LVN stated, Resident 2 was a danger to other residents during his episodes of aggressive behavior. The LVN stated that a one on one (1:1) supervision would require one staff member to be supervising one resident, and Resident 2 was not on 1:1 supervision. On November 19, 2024, at 3:11 p.m., an interview was conducted with a Registered Nurse (RN). The RN stated when Resident 2 had aggressive behavior, Resident 2 was a danger to other residents. The RN stated Resident 2 was previously accused of hitting a female resident (a resident different from Resident 1). The RN stated the resident should have been on close supervision. On November 19, 2024, at 4:49 p.m., an interview was conducted with CNA 3. CNA 3 stated, she was assigned to Resident 2 on November 16, 2024, and she was to supervise Resident 2 due to the resident's violent behavior. CNA 3 stated on November 16, 2024; she left Resident 2 in the dining room to provide care to another resident. CNA 3 stated Resident 2 was sitting in his wheelchair one table away from Resident 1. CNA 3 stated she returned to the activity room when she heard Resident 2 in his wheelchair, yelling, and holding a plastic cover, near a crying Resident 1. CNA 3 stated she did not feel safe caring for Resident 2, as his behavior had been becoming increasingly violent. On November 19, 2024, at 5:47 p.m., an interview was conducted with the Director of Nursing (DON). The DON stated on November 16, 2024, the Activity Assistant (AA) was not within arm's length of Resident 2 and was unable to prevent Resident 2 from hitting Resident 1 with the plate cover. On November 27, 2024, at 12:38 p.m., a telephone interview was conducted with the AA. The AA stated on November 16, 2024, at approximately 3 p.m., he was in the dining room. However, he stated he left the dining area to return empty dinner trays, and as he came back to the dining area, he witnessed Resident 2 wheel himself over to Resident 1 and hit her in the face with a plastic plate cover. The AA stated he was not close enough to physically intervene, so he shouted at Resident 2 to stop. On December 9, 2024, at 3:46 p.m., a telephone interview was conducted with the DON. The DON stated that if the resident could not be re-directed, the staff should have notified the physician. The DON stated that supervision for Resident 2 should be for a staff to be close enough to intervene. A review of the facility policy and procedure titled, Behavioral Assessment, Intervention and Monitoring, revised March 2019, indicated, .The interdisciplinary team will evaluate behavioral symptoms in residents to determine the degree of severity, distress, and potential safety risk to the resident, and develop a plan of care accordingly. Safety strategies will be implemented immediately if necessary to protect the resident and other from harm .Atypical behavior will be differentiated from behavior that is dangerous or problematic for the resident(s) or staff, or behavior that signals underlying distress .Interventions and approached will be based on a detailed assessment of physical, psychological, and behavioral symptoms and their underlying causes .

Based on observation and interview, the facility failed to contain waste in a closed container, and provide a comfortable homelike environment for three of six residents reviewed (Residents 30, 42, and 43) when: 1. Multiple discarded medical equipment and non-medical materials surrounding the outside disposal bins. This failure had the potential to attract insects and rodents, presenting a health risks to the vulnerable population in the facility. 2. The window blinds in resident rooms were damaged. This failure had the potential to cause disruption of sleep, inability to properly control sunlight leading to increased heat. Findings: 1. On July 8, 2024, at 1:15 p.m. the outside waste disposal bins were observed to have multiple scattered debris of discarded and broken medical equipment and waste. On July 10, 2024, at 09:13 a.m., a concurrent observation and interview were conducted with Maintenance Supervisor (MS). The MS was made aware of the buildup of scattered debris and discarded medical equipment outside near the large garbage bins. There were several broken medial equipment items, metal file cabinets, aluminum cans, worn wood planks, and spider webs. The MS stated he had know about the debris for nine months. The MS further stated all waste should be discarded and not left outside of disposal bins. The MS stated there was a potential to harbor pests in the areas with debris. On July 10, 2024, at 09:41 a.m. a concurrent observation and interview was conducted with Facility Administrator (FA) outside the facility near the waste disposal bins. The FA stated there should not be waste and debris build up around the disposal bins. The FA futher stated there was a potential for pests to harbor in the areas in and around the debris among the waste disponal bins. On July 11, 2024, at 09:24 a.m., an interview was conducted with the Infection Preventionist (IP) The IP stated all waste should be disposed of in the designated waste disposal bins and not left outside of the bins. The IP stated any large debris materials piled up around waste disposal areas had the potential to harbor pests and insects. A review of the facility policy and procedure titled, Waste disposal, dated January 2012, indicated, .All infectious and regulated waste shall be handled and disposed of in a safe and appropriate manner .The Infection Preventionist and Environmental Services Director will ensure that wast is properly disposed of . A review of the facility policy and procedure titled, Pest Control, dated May 2008, indicated, .Garbage and trash are not permitted to accumulate and are removed from the facility daily. 50204 2a.On July 8, 2024, at 9:51 a.m., during concurrent observation in Resident 30's room and interview, multiple damaged blinds were observed. Resident 30 stated he had to cover his eyes with towel and that he could not sleep due to the bright light coming through the damaged blinds. 2b. On July 8, 2024, at 10:10 a.m., Resident 42, was observed sitting in his wheelchair in his room. The room's horizontal window blinds were observed to be damaged. Resident 42 stated .it is getting warm again. Resident 42 stated the heat comes through the damaged spot, making the room warm in the afternoon. 2c. On July 8, 2024, at 11:00 a.m., a concurrent observation and interview were conducted inside Resident 43's room.The room was observed to have damaged window blinds. Resident 43 stated .the heat from window pass through the broken blind that makes my room warm . On July 10, 2024, at 9 a.m., an interview was conducted with the MS. The MS stated he was aware of the condition of the window blinds. The MS stated, .the blinds needed to be replaced . On July 10, 2024, at 9:13 a.m., an interview was conducted with the FA. The FA was aware of the damaged window blinds and stated the blinds needed to be repaired. A review of facility policy and procedure titled, The Maintenance Service, undated, indicated, .The Maintenance Department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times .Maintaining the building in good repair .

Based on observation, interview, and record review the facility failed to ensure Dietary staff were able to carry out the functions of food and nutrition services safely and effectively when: 1. The [NAME] used a slotted spoon to scoop out meatloaf without measuring the portion when preparing pureed meat during the lunch service on July 8, 2024. (Cross referred F 803) This failure had the potential for four out of four residents who received pureed meat prepared in the kitchen to not meet their nutritional needs, which could lead to nutrition-related health complications. 2. Diet Aide 2 served ice cream instead of diet cookies to Resident 7, who had a physician-ordered renal controlled carbohydrate during the lunch service on July 8, 2024. (Cross referred F 808) This failure had the potential for Resident 7, to receive a dessert prepared in the kitchen that did not meet their nutritional needs which may lead to nutrition-related health complications. Findings: On July 8, 2024, at 9:54 a.m., a concurrent observation and interview were conducted with [NAME] 1 (CK) in the kitchen. CK 1 was observed preparing pureed meat. CK 1 was observed preparing pureed meat and using a slotted spoon to scoop the meat loaf portion instead of using a measuring cup. CK 1 did not refer to the pureed meat recipe. On July 9, 2024, at 2:06 p.m., an interview was conducted with the Registered Dietitian (RD). The RD stated Cooks should follow recipes and use a measuring spoon for serving portions when preparing meals. The RD explained that not measuring the meatloaf portion would affect the nutiritonal values of the prepared pureed meat. A review of the facility recipe titled, PUREED MEATS, undated, indicated, DIRECTIONS: 1 Measure out the total number of portions (based on the portion size indicated on the cook's spreadsheet) needed for puree diets . A review of the facility Policy and Procedure titled, MENU PLANNING, dated 2015, indicated, .PROCEDURES: .4 .Standardized recipes .shall be .used in food preparation . A review of the facility Job Description, titled Cook, dated 2023, indicated, .Duties and Responsibilities: 1. Responsible for the preparation of food ., 2. Attend menu conferences .to meet serving needs of the residents. 2. On July 8, 2024, at 11:30 a.m., an observation of the lunch meal plating service was conducted with Diet Aide 2 (DA) in front of the trayline (a system of food preparation in which trays move along an assembly line). DA 2 was observed serving ice cream on the meal tray for Resident 7 instead of diet cookies. A review of the facility document titled, Cooks spreadsheet (the menu document used to guide dietary staff on food items, portions, texture of foods and therapeutic diet), dated July 8, 2024, indicated, .Diet Cookies was to be served to Renal Controlled Carbohydrate diet (CCHO) [a meal plan for Renal Diabetic residents] . On July 8, 2024, at 12:15 p.m., a concurrent interview and record review was conducted with the Dietary Supervisor (DS) in the dining room. A review of Resident 7's Meal tray ticket (menu based on the resident's diet physician order), indicated Renal CCHO. Resident 7 was served ice cream. The DS reviewed the Cooks spreadsheet and stated Resident 7 should have received diet cookies instead of ice cream. A review of Resident 7's physician diet ordered, dated July 8, 2024, indicated, .Dietary - Diet .CCHO, Renal diet (a meal plan for kidney failure residents) .Dietary to give .120 milliliter (ml- a unit of measurement) at lunch . On July 9, 2024, at 2:06 p.m., a concurrent interview and record review were conducted with the Registered Dietitian (RD). The RD stated according to the Cooks spreadsheet, Resident 7 should have received diet cookies instead of ice cream. The RD stated Resident 7's physician-ordered diet indicated Resident 7 fluid intake provided should be 120 ml equivalent to 4 oz during lunch meal. The RD stated if Dietary Aide 2 served 4 oz of ice cream to Resident 7, Resident 7 would receive an extra 120 ml fluid from the ice cream. The RD stated if Resident 7 consumed the extra fluid, there was a potential risk for fluid overload. The RD further stated residents with renal failure should limit their intake of dairy products (including ice cream) due to high levels of phosphorus (natural mineral find in dairy products) and potassium (natural mineral) found in these products. The RD stated serving ice cream to a renal failure resident like Resident 7 could negatively affect their electrolyte levels and overall health. A review of the facility provided document, titled VERIFICATION OF JOB COMPETENCY DEMOSTRATION -DIETARY AIDE, dated 2024, the job competency indicated, Name: Diet Aide 2, . Competency Demostrated knowledge of : .Diet Manual, .by Demostrate or verbal had a check mark (mean competent), verified by the DS . But from the observation showed the Diet Aide 2 was not competent to follow the Cooks spreadsheet (the menu document used to guide dietary staff on food items and therapeutic diet).

Based on observation, interview, and record review, the facility failed to ensure the menus were followed and resident nutritional needs were met when: 1. The [NAME] did not follow puree recipes when preparing pureed diet during the lunch service on July 8, 2024; (Cross referred F 802) This failure had the potential for 4 out of 4 residents who had physician ordered pureed diets, as the pureed food prepared in the kitchen did not meet their nutritional needs which may lead to nutrition-related health complications. 2. The [NAME] served biscuit instead of wheat roll for Carbohydrate Control diet Residents during the lunch service on July 8, 2024; This failure had the potential for 12 out of 12 residents who had physician-ordered Carbohydrate Control diets, as the food prepared in the kitchen did not meet their nutritional needs which may lead to nutrition-related health complications. 3. The [NAME] was not supposed to serve biscuits to Mechanical Soft diet residents during the lunch service on July 8, 2024. This failure had the potential for 14 out of 14 residents who had physician-ordered Mechanical Soft diets, as the food prepared in the kitchen did not meet their nutritional needs which may lead to chewing and swallowing difficulties. Findings: 1. On July 8, 2024, at 9:54 a.m., a concurrent observation and interview were conducted with [NAME] 1 (CK) in the kitchen. The CK 1 was observed preparing pureed meat. CK 1 used a slotted spoon to scoop out three servings of meatloaf without measuring the portion and then put the meatloaf into the blender. CK 1 stated he added 2 cups of beef broth into the blender with meatloaf and blended them together. After blending, the pureed meatloaf became watery. CK 1 stated to achieve a pudding-like consistency, he needed to add 1/2 cup of thickener. During the entire process of preparing pureed meat, CK 1 did not refer to the pureed meat recipe. On July 8, 2024, at 10:05 a.m., a concurrent observation and interview were conducted with CK 1 in the kitchen. CK 1 was observed preparing pureed biscuits. CK 1 stated he put 3 pieces of biscuits, 2 cups of chicken broth, and 1/2 cup thickener into the blender. Then CK 1 blended the biscuit, chicken broth and thickener together to make pureed biscuits. During the entire process of preparing the pureed biscuits, CK 1 did not refer to the pureed biscuit recipe. On July 8, 2024, at 10:17 a.m., a concurrent observation and interview were conducted with CK 1 in the kitchen. CK 1 was observed preparing pureed vegetables. CK 1 used a 1/2 cup scoop to place 3 servings of vegetables into the blender. He then added 2 cups of chicken broth and 1/2 cup thickener into the blender with the vegetables. Afterwards CK 1 blended the vegetables, chicken broth, and thickener together to make pureed vegetables. During the entire process of preparing pureed vegetable, CK 1 did not refer to the pureed vegetable recipe. On July 9, 2024, at 2:06 p.m., an interview was conducted with the Registered Dietitian (RD). The RD stated Cooks should follow recipes when preparing meals, as deviating from the recipe could affect the nutritional value of the meals. The RD stated since CK 1 did not follow recipe by adding extra fluid and thickener, the volume of the pureed foods was increased, but the concentration of nutrients per serving was diluted. The RD further stated residents on pureed diets who received this diluted concentration of pureed foods would not receive the correct amount of calories and protein which could result in weight loss. A review of Resident 11, 33, 40, and 50 's physician diet order, dated July 9, 2024, indicated, .Resident 11, 33, 40, and 50 were on .pureed diet . A review of the facility recipe titled, PUREED MEATS, undated, indicated, DIRECTIONS: 1 .Measure out the total number of portions (based on the portion size indicated on the cook's spreadsheet) needed for puree diets. 2. Puree on low speed to a paste consistency before adding any liquid. 3. Gradually add warm liquid (low sodium broth or gravy) .starting with the smaller amount and adding in more as needed to achieve the desired consistency .5. Add stabilizer (food thickener) to increase the density of the pureed food if needed . A review of the facility recipe titled, PUREED BREAD PRODUCTS, undated, indicated, DIRECTIONS: .2. Puree on low speed adding milk gradually .starting with the smaller amount and adding in more as needed to achieve the desired consistency .4. Add stabilizer to increase the density of the pureed food if needed . A review of the facility recipe titled, PUREED VEGETABLES, undated, indicated, DIRECTIONS: .2 .Puree on low speed to a paste consistency before adding any liquid. 3. Gradually add warm liquid (low sodium broth or milk) if needed .starting with the smaller amount and adding in more as needed to achieve the desired consistency . 4. Puree on low speed, adding stabilizer where needed . A review of the facility Policy and Procedure titled, MENU PLANNING, dated 2023, indicated, .PROCEDURES: .4 .Standardized recipes .shall be .used in food preparation . 2. On July 8, 2024, at 11:15 a.m., an observation of the lunch meal plating service was conducted with the CK 1 at the Trayline (a system of food preparation in which trays move along an assembly line). There was no wheat roll available in Trayline. The CK 1 was observed serve biscuit to all residents including Controlled Carbohydrate diet [(CCHO) a meal plan for diabetic residents] residents. A review of the facility document titled, Cooks spreadsheet (the menu document used to guide dietary staff on food items, portions, texture of foods and therapeutic diet), dated July 8, 2024, indicated, .Wheat roll was to be served to CCHO diet . On July 8, 2024, at 12:10 p.m., an interview was conducted with CK 1. CK 1 stated he only prepared and served biscuits to all residents. On July 9, 2024, at 2:06 p.m., a concurrent interview and Cooks July 8, 2024 spreadsheet review was conducted with the Registered Dietitian (RD). The RD stated according to Cooks spreadsheet, residents on CCHO diet should receive a wheat roll instead of a biscuit. The RD stated the plan menu for the CCHO diet as indicated on the Cooks' spreadsheet is to serve wheat roll to evenly distribute carbohydrates throughout the meals which helps control blood sugar levels for diabetic residents. The RD stated cooks should follow the Cooks spreadsheet. A review of Resident 2, 7, 12, 13, 33, 34, 40, 42, 43, 45, 49, and 110 's physician diet order, dated July 9, 2024, the physician diet order indicated, .CCHO diet . A review of the facility document titled, Diet Menu - Controlled Carbohydrate Diet, dated 2023, indicated, A controlled carbohydrate diet, is a meal plan .used for diabetic residents and those with other metabolic concerns . Instead of counting calories, the carbohydrate are evenly, systematically, and consistently distributing through three meals and evening snack in an effort to maintain a stable blood sugar level throughout the day . A review of the facility Policy and Procedure titled, Menu Planning, dated 2023, indicated, .Policy: .The menu are planned to meet nutritional needs of residents in accordance with .Physician's orders and, to extent medically possible . A review of the facility Policy and Procedure titled, Menu Service, dated 2023, indicated, .Policy: Meals that meet the nutritional needs of the resident will be served in an accurate and efficient manner . 3. On July 8, 2024, at 11:15 a.m., an observation of the lunch meal plating service was conducted with CK 1 at the Trayline. CK 1 served biscuits to all residents including residents on Mechanical soft diets. A review of the facility document titled Cooks spreadsheet, dated 7/8/24, indicated, .Mechanical soft diet residents not supposed served biscuit . On July 8, 2024, at 12:10 p.m., an interview was conducted with CK 1. CK 1 stated he had only prepared and served biscuits to all residents. On July 9, 2024, at 2:06 p.m., a concurrent interview and Cooks' July 8, 2024 spreadsheet review were conducted with the Registered Dietitian (RD). The RD stated according to the Cook's spreadsheet, residents on Mechanical Soft diet should not receive biscuits. The RD further stated a biscuit was hard and residents on Mechanical soft diets residents could have difficulty to chew and swallow the biscuit. A review of Resident 3, 9, 7, 13, 32, 35, 43, 44, 46, 48, 47, 49, 55, and 56's physician diet order, dated July 9, 2024, indicated, .Mechanical Soft diet . A review of the facility document titled, Diet Menu - Mechanical Soft Diet dated 2023, indicated, .Description: The mechanical soft diet is designed for residents who experience chewing or swallowing limitations .Grains: .Avoid: Breads with hard crusts . A review of the facility Policy and Procedure titled, Menu Planning, dated 2023, indicated, Policy: .The menu are planned to meet nutritional needs of residents in accordance with .Physician's orders and, to extent medically possible . A review of the facility Policy and Procedure titled, Menu Service, dated 2023, indicated, Policy: Meals that meet the 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 food preparation and storage practices in the kitchen when: 1. There was buildup found on the ice maker; 2. Wear and tear were observed on the mixer in the kitchen; 3. The milk refrigerator's gasket was found to have black grime; 4. [NAME] grime was found on equipment; 5. Open food items were found on exposed to the air; 6. Three serving scoops were stored wet with other dry scoops, and one plastic container was stacked wet with other dry containers; 7. The vent hoods were covered with grease and dust; 8. The ceiling above the steam table was covered with dust. These failures had the potential to cause foodborne illness (stomach illness acquired from ingesting contaminated food) in a medically vulnerable population of 51 out of 52 residents who received food prepared in the kitchen. Findings: 1. On July 8, 2024, at 2:19 p.m., a concurrent observation and interview were conducted with the Dietary Supervisor (DS) and Maintenance Assistant (MA) in the kitchen in front of the ice machine. The Surveyor used a white paper towel to wipe the inside of the ice maker. The white paper towel turned black. The DS and MA stated the ice maker was not clean. On July 9, 2024, at 2:06 p.m., an interview was conducted with the Registered Dietitian (RD). The RD stated, the ice maker should not be soiled and should be kept clean. The RD stated a soiled ice maker could potentially contaminate the ice. A review of the facility policy and procedure titled, SANITATION, dated 2018, indicated, .9. All .equipment shall be kept clean .14. Ice which is used in connection with food and drink shall be from a sanitary source . 2. On July 8, 2024, at 9:29 a.m., a concurrent observation and interview were conducted with the DS in the kitchen. The stationary mixer was observed to be missing a coating of paint with exposed brown grime. The DS stated the mixer was super old and had wear and tear. On July 9, 2024, at 2:06 p.m., an interview was conducted with the RD. The RD stated the wear and tear mixer did not have smooth surface, which made it difficult to clean and needed to be replaced. A review of the facility policy and procedure titled, SANITATION, dated 2018,indicated, .9. All .equipment shall be kept clean .and shall be free from breaks, corrosions, open seam, cracks and chipped areas . 3. On July 8, 2024, at 10:43 a.m., a concurrent observation and interview were conducted with the DS in front of milk refrigerator in the kitchen. Black grime buildup was found on the milk refrigerator's gasket (the rubber piece that lines along refrigerator door to prevent cool air from sipping out). The DS stated dietary staff missed cleaning the milk refrigerator's gasket. On July 9, 2024, at 2:06 p.m., an interview was conducted with the RD. The RD stated the milk refrigerator's gasket needed to be cleaned thoroughly to prevent cross-contamination. A review of the facility's policy and procedure titled, SANITATION, dated 2018, the indicated, .9.All .equipment shall be kept clean . 4. During kitchen initial tour on July 8, 2024, at 9:14 a.m., a concurrent observation and interview were conducted with the DS. Several pieces of equipment in the kitchen were found to have brown grime. The equipment listed below were affected: i) Silver storage shelves used to store cans in the storage room; ii) The base of the can opener; iii) The storage shelves used to store clean domes (a piece of kitchen equipment used as a cover to keep food hot); iv) The silver storage shelves used to store spices. The DS stated brown grime was found on the observed equipments. On July 9, 2024, at 2:06 p.m., an interview was conducted with the RD. The RD stated equipment with brown grime did not have smooth surfaces making it difficult to sanitize. A review of the facility's policy and procedure titled, SANITATION, dated 2018, indicated, .9. All .equipment shall be kept clean .and shall be free from breaks, corrosions, open seam, cracks and chipped areas . 5. On July 8, 2024, at 9:14 a.m., a concurrent observation and interview were conducted with the DS in front of the reach-in freezer in the kitchen. There were two opened food items ([NAME] fish and beef patties) exposed to the air. The DS stated opened food items should be wrapped or sealed to prevent freezer burn. On July 9, 2024, at 2:06 p.m., an interview was conducted with the RD. The RD stated opened food items stored in the freezer should be sealed or closed, otherwise there was a potential for freezer burn and contamination. A review of the facility's procedure titled, FREEZER STORAGE, dated 2023, indicated, .5. Store frozen foods in an airtight moisture wrapper such as a plastic bag or freezer paper to prevent freezer burn . 6. On July 8, 2024, at 10:07 a.m., a concurrent observation and interview were conducted with the DS in the kitchen. One wet plastic container was stacked with other dried containers on the shelf. The DS stated the wet plastic container should not be stacked with other dried containers because moisture could create bacteria. On July 8, 2024, at 10:20 a.m., a concurrent observation and interview were conducted with the DS in the kitchen. Three wet scoops with water droplets were stored with other dried scoops in the drawer. The DS stated, the wet scoops should not be stored with other dry scoops because moisture could create bacteria. On July 9, 2024, at 2:06 p.m., an interview was conducted with the RD. The RD stated plastic containers and scoops should completely air-dried before being stored otherwise, moisture could lead to organism growth. A review of the facility's policy and procedure titled, DISHWASHING, dated 2023, indicated, .5 .Dishes are to be air dried in racks before stacking and storing . A review of the facility's policy and procedure titled, 3-COMPARTMENT PROCEDURE FOR MANUAL DISHWASHING, dated 2023, indicated, .All items are air-dried, which means no water droplets are present . 7. On July 8, 2024, at 10:24 a.m., a concurrent observation and interview were conducted with the DS in the kitchen. The hood vent above the stove was observed covered with grease and black grime. The DS referred to the grease and black grime as dust located on the hood vent above the stove. On July 9, 2024, at 2:06 p.m., an interview was conducted with the RD. The RD stated the hood vent above the stove should be keep clean. A review of the facility's policy and procedure titled, SANITATION, dated 2018, indicated, .9. All .equipment shall be kept clean . 8. A review of the U.S Food and Drug Administration's (FDA) Food Code 2022, indicated, Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. On July 8, 2024, at 10:51 a.m., a concurrent observation and interview were conducted with the DS in the kitchen. The ceiling above the steam table was found to be covered with black debris. The DS referred to the black debris as dust. The DS stated that dust could possibly fall down. On July 9, 2024, at 2:06 p.m., an interview was conducted with the RD. The RD stated the kitchen needed to be keep clean and dust-free to prevent cross-contamination.

Based on observation, interview, and record review, the facility failed to ensure infection control practices were implemented, when: 1. Resident (55) was observed to have a pair of black shoes and blue pants on top of a commode (chair with a built-in toilet seat). 2. The Activity Director (AD) was observed to have long artificial nails when providing direct care to residents. These failures had the potential to increase the risk of transmission of infectious disease (disorders caused by organisms) to vurnerable residents in the facility. Findings: 1. On July 8, 2024, at 10:10 a.m., a concurrent observation and interview were conducted inside Resident 55's room. Resident 55's pair of black shoes and blue pants were on top of a commode. Resident 55 stated he asked the staff to placed it in his big closet this morning. On July 8, 2024, at 10:20 a.m., a concurrent observation and interview was conducted with Certified Nursing Assistant (CNA) 1 inside Resident 55's room. CNA 1 stated, Resident 55's shoes and pants should not be on top of a commode. CNA 1 stated all clean clothes should be kept in the cabinet. On July 8, 2024, at 10:30 a.m., an interview was conducted with the Registered Nurse (RN) 1. The RN 1 stated resident's clothing should be placed in a designated cabinet or drawer. RN 1 stated clothing placed on top of a commode could become contaminated and spread infection. On July 9, 2024, at 2:30 p.m., an interview was conducted with the Infection Preventionist (IP) in Resident 55's room. The IP stated any clean clothes should not be placed on top of a commode. The IP further stated clothes placed top of a commode will become contaminated and could lead to infection. On July 9, 2024, at 3 p.m., the Director of Nursing (DON) was interviewed. The DON stated, CNAs should always make rounds and check for potential infection control issues. The DON stated any garment found in a dirty area should be removed, washed, and kept in a clean place. A review of the facility policy and procedure titled, Infection Prevention and Control, dated December 2023, indicated, .The objectives of the infection prevention and control policies and procedures are to monitor, prevent, detect, investigate, and control infections in the facility . 2. On July 9, 2024, at 11:00 a.m., an observation was conducted with the Activity Director (AD) during a Resident Council Meeting. The AD was observed to have long artificial nails, 11 millimeters long from the edge of the nail bed, while providing care to residents in the dining hall. On July 9, 2024, at 2:30 p.m., an interview was conducted with the AD. The AD stated she provided direct care to residents in the facility. The AD further stated she had artificial nails and was not aware of the facility policy regarding artificial nails. On July 9, 2024, at 3:57 p.m., an interview was conducted with the IP. The IP stated according to the facility's policy, nails must be of appropriate length and should not be too long for direct care staff. The IP further stated long nails could potentially damage the skin of residents, lead to skin breakdown, and cause infection. On July 10,2024, at 8:04 a.m., an interview was conducted with the DON. The DON stated direct care staff should not have artificial nails and should follow the facility's policy. A review of the facility policy and procedure titled, Handwashing/Hand Hygiene, dated October 2023, indicated, .Personnel with direct-care resident responsibilities should maintain short, natural fingernails .Fingernails should not extend past fingertips .Wearing artificial fingernails is strongly discouraged with direct-care responsibilities, and is prohibited among those caring severely ill or immunocompromised residents .the infection preventionist may request the removal of artificial fingernails and/or nail polish at any time if it is determined that they present an infection control risk .

Based on interview and record review, the facility failed to notify the resident representatives (RP) and Office of the State Long-Term Care Ombudsman (LTC Ombudsman) of a transfer for one of three residents (Resident 57) reviewed for closed records. This failure had the potential to result in the RP and LTC Ombudsman not to be informed about Resident 57's plan of care and condition. Findings: On July 10, 2024, at 12:00 p.m., Resident 57's record was reviewed. Resident 57 was admitted to the facility on [DATE], with a diagnosis which included anxiety disorder (excessive worry and feelings of fear, dread, and uneasiness). A review of the document titled, Physicians Discharge Summary, dated April 16, 2024, indicated, .Sent to Hospital from Appointment . There was no documented evidence that the facility mailed or faxed a letter of transfer/discharge notice to Resident 57's RP and to the LTC Ombudsman. On July 10, 2024, at 2:04 p.m., a concurrent interview and record review was conducted with the Director of Medical Records (DMR). The DMR stated, residents who discharged from the facility should be sent a letter to indicate a discharge was initiated and that the Ombudsman should be notified in writing. The DMR stated there was no documentation that indicated a letter was sent to the resident RP and to the LTC Ombudsman to indicate a discharge/transfer from the facility. On July 11, 2024, at 8:19 a.m., an interview was conducted with the Director of Nursing (DON). The DON stated the process for transfer/discharge is the nurse in charge will process and send a letter of notification to the RP and Ombudsman. The DON stated Resident 57 was transferred to the hospital from a scheduled clinic appointment and did not return. The DON further stated there was no letter of notification sent and one should have been sent to Resident 57's RP and to the LTC Ombudsman after Resident 57 was discharged from the facility. On July 11, 2024 at 2:36 p.m. a concurrent interview and record review was conducted with the Licensed Vocational Nurse (LVN 1). LVN 1 stated Resident 57 was sent to the Veterans Administration (VA) clinic on April 16, 2024 and was transferred to the hospital from the clinic. LVN 1 stated there was no letter of notification sent to Resident 57's RP and to the Ombudsman. LVN 1 further stated a letter of notification should have been sent. A review of the facility policy and procedure titled, Transfer or Discharge, dated October 2022, indicated, .Facility transfers and discharges, when necessary, must meet specific criteria and require resident/representatives notification and orientation, and documentation as specified in this policy .Notice to Transfer is provided to the resident and representative as soon as practicable before the transfer and to the long-term care (LTC) ombudsman when practicable (e.g., in a monthly list of residents that includes all notice content requirements) .The facility will send a copy of the discharge notice to a representative of the Office of the State LTC Ombudsman .

Based on interview, and record review, the facility failed for two of six residents reviewed for Advance Directive (AD - written statement of a person's wishes regarding medical treatment) (Residents 4 and 5) to: 1. Ensure a copy of the Advance Directive (AD - written statement of a person's wishes regarding medical treatment) was available in the resident's record; and 2. Verify if the resident did have an advance directive or if the resident representative was provided information regarding formulation of the advance directive. These failures had the potential for Residents 4 and 5's AD to not be readily retrievable by the staff and the physician, making them unaware of, and unable to honor the residents wishes regarding their medical treatment. Findings: 1. On July 8, 2024, at 3:50 p.m., Resident 5's record was reviewed. Resident 5 was admitted to the facility on [DATE]. A review of Resident 5's History and Physical dated December 29, 2023, indicated Resident 5 does not have the capacity to understand and make decisions. A review of Resident 5's Minimum Data Set (an assessment tool), dated February 29, 2024, indicated Resident 5 had Brief Interview of Mental Status (BIMS - a tool to assess cognitive function of an individual) score of 4 (severe cognitive impairment). A review of Resident 5's Advance Directive Acknowledgement Form, dated December 9, 2022, indicated Resident 5 had executed an Advance Directive. There was no documented evidence a copy of the AD was provided in Residents 5's medical record. On July 10, 2024, at 2:17 p.m., during a concurrent interview and review of Resident 5's medical record with the Social Service Director (SSD), the SSD stated if the resident has an AD, a copy of the AD is obtained and placed in the resident's record. The SSD stated Resident 5 had an AD but was not available in the resident's record. The SSD further stated Resident 5's AD should have been available and accessible to the staff and physician. 44270 2. On July 9, 2024, at 12:03 p.m. Resident 4's record was reviewed. Resident 4 was admitted to the facility on [DATE]. A review of Resident 15's History and Physical dated December 29, 2023, indicated, .does not have the capacity to understand and make decisions . A review of Resident 4's MDS dated [DATE], indicated Resident 4 had a BIMS Score of 3 (severe impairment in cognition). A review of Resident 4's Advance Directive Acknowledgement Form, dated December 16, 2022, indicated, .I have executed an Advance Directive . A review of Resident 4's Physician Orders for Life-Sustaining Treatment (POLST), dated December 16, 2022, indicated, .Advance Directive not available. A review of Resident 4's Social History Review, dated June 11, 2024, indicated, .Advance Directive .daughter is the responsible party. There was no documented evidence a copy of Residents 4's AD had been provided in medical record, or that Resident 4 and/or resident representative (RR) were given information about formulation of the AD. On July 10, 2024, at 2:27 p.m., during a concurrent interview and review of Resident 4's record with the SSD, the SSD stated it is her responsibility to ensure residents have an AD. The SSD stated, if the resident has an AD, a copy should be obtained and placed in the resident's record. The SSD further stated, the AD should be available and accessible to the staff and physician. The SSD stated Resident 4's AD was not in her medical record and it was unclear whether Resident 4 had an AD. The SSD stated during a quarterly meeting on May 30, 2024, with Resident 4's RR, Resident 4's representative was unclear if Resident 4 had an AD. The SSD stated the representative should be offered assistance with the AD during the quarterly review. She stated she did not offer it during the last SSD assessment and that it should have been offered. During a review of the facility Policy and Procedure titled, Advance Directives, dated December 2016, indicated, .Prior to or upon admission of a resident, the Social Service Director or designee will inquire of the resident, his/her family members and/or his or her legal representative, about the existence of any written advance directives .Information about .an advance directive shall be displayed prominently in the medical record .

Based on observation, interview, and record review, the facility failed to ensure the physician recommendation for wound treatment was transcribed to an actual physician order for one of two residents (Resident 23) reviewed. This failure resulted in a gap in the communication regarding the physician's recommendation which affected the implementation of the recommended care or treatment. Findings: On July 11, 2024, Resident 23's record was reviewed. Resident 23 was admitted to the facility on [DATE], with diagnoses that included wheelchair dependent and severe debility (state of being weak). A review of the facility document titled, COC (Change of Condition) Progress Notes, dated June 4, 2024, indicated, . resident has skin tear on the right hand .Primary Provider Feedback: Primary Care Provider responded with the following feedback. A.Recommendations: Cleanse area with NS (normal saline - a sterile souliton of salt in water); pat dry; apply Triple Antibiotic (a topical medication that inhibits the growth of bacteria on the skin) . Further review of Resident 23's Physician Order, for the month of June 2024 and July 2024, indicated, the physician's recommendation was not transcribed to an actual physician order for Resident 23. On July 11, 2024, at 1:02 p.m., a concurrent interview and record review of Resident 23's COC was conducted with the Infection Preventionist. The IP stated the physician recommendation during the resident's change of condition was not transcribed to an actual physician order. The IP stated there was no order from the physician to cleanse the area with NS, pat dry, and apply triple antibiotic. The IP stated the physician recommendation was not recorded in the treatment administration record and was not followed. On July 11, 2024, at 2:15 pm., a concurrent intererview and record review was conducted with the Director of Nursing (DON). The DON stated physician's recommendation in the COC was not followed. The DON further stated the physician's recommendation should have been followed to prevent wound infection. The facility policy and procedure titled, Physician Orders, dated July 2016, indicated, .Verbal orders must be recorded immediately in the resident's chart by the person receiving the order and must include prescriber's last name, credentials, the date and the time of the order . The facility policy and procedure titled, Physician Orders, Accepting, Transcribing and Implementing (noting) . undated, indicated, .Licensed nursing personnel will ensure that written (noting), telephone, and verbal orders will be recorded and implemented .Telephone and Verbal orders .Record the actual order received from the physician .

Based on observation, interview, and record review, the facility failed to provide adequate supervision for one of three sampled residents (Resident A), when the resident was left in another resident's room (Resident B) to use the bathroom unattended. This failure caused Resident A to fall and sustained a hip fracture. Findings: On (MONTH) 2, (YEAR), at 12:20 p.m., an unannounced visit to the facility was conducted to investigate Resident A's fall incident. On (MONTH) 2, (YEAR), Resident A's record was reviewed. Resident A was admitted at the facility on (MONTH) 10, 2008, with [DIAGNOSES REDACTED]. Resident A's MDS (minimum data set- an assessment tool) dated (MONTH) 19, (YEAR), indicated the following: 1. Section C- Cognitive Patterns- BIMS (brief interview of mental status) score was 9 (moderately impaired); and 2. Section G- Functional Status- toilet use (how resident uses the toilet room, transfer on/off toilet). Resident A needed supervision and a set up help. Resident A's fall risk assessment dated (MONTH) 20, (YEAR), indicated Resident A had a score of 13, and was categorized as high risk. Resident A's nurses notes dated (MONTH) 20, (YEAR), indicated, At around 12:30 pm cna (certified nursing assistant) called cn (charge nurse) to room 11, cn went there and saw resident 14 d (Resident A) laying (sic) on the floor in between the 4 beds. 3 cnas were assisting, resident was screaming and yelling let me get up cna and cn trying to convince him to stay where he was and not move, but he kept yelling and screaming getting agitated, moving and reaching for his w/c (wheelchair). Cn asked him (Resident A) what happened and he said he pushed me pointing to 11 a (Resident B), when 11 a (Resident B) was asked he said he pushed him because he was in his room . Resident A's SBAR (situation background assessment recommendation- communication form of change of condition) dated (MONTH) 20, (YEAR), indicated, Resident was pushed by another. Resident can't moved (sic) left lower leg, refused to be touched . possible fracture .transfer to the hospital . The facility physician order [REDACTED]. Resident A's acute hospital notes dated (MONTH) 20, (YEAR), indicated Resident A had a left hip displaced fracture (bone breaks into two or more parts and the bones get displaced from their original position). Resident A's acute hospital operative report dated (MONTH) 21, (YEAR), indicated Resident A undergone ORIF (open reduction internal fixation- surgical procedure to fix a severe bone fracture, or break) of the left hip. Resident A's admission nursing assessment dated (MONTH) 26, (YEAR), indicated Resident A was readmitted to the facility with three surgical sites (left hip, left midlateral thigh, and left lateral thigh). Resident A's nurses' skilled notes dated (MONTH) 27, (YEAR), indicated Resident A was evaluated by PT (physical therapy) and OT (occupational therapy). The notes further indicated Resident A would benefit from rehabilitation due to muscle weakness, difficulty in walking due to the surgery (ORIF). On (MONTH) 2, (YEAR), at 12:20 p.m., the Director of Nursing (DON) was interviewed. She stated Resident A wanted to use the bathroom on (MONTH) 20, (YEAR), at approximately 12:30 p.m. The DON stated Resident A's bathroom was occupied by another resident. The DON stated Certified Nursing Assistant (CNA) 1 wheeled Resident A at the entry door of Room 11 and left Resident A to use the bathroom unattended. She stated CNA 1 left Resident A at Room 11 and assisted another resident. The DON stated CNA 1 saw Resident A lying on the floor near Resident B's bed, and heard Resident A saying, He pushed me, pointing his finger at Resident B. On (MONTH) 2, (YEAR), at 1:20 p.m., Resident B was interviewed. Resident B stated the resident (Resident A) entered his (Resident B) curtain and space and felt threatened. Resident B stated the resident (Resident A) just kept on approaching, so he placed his hand out to keep him off his space. Resident B stated Resident A tripped on the ground. On (MONTH) 2, (YEAR), at 1:45 p.m., the Registered Nurse Supervisor (RNS) was interviewed. She stated Resident A's body assessment was done after the incident of fall on (MONTH) 20, (YEAR). The RNS stated Resident A was very guarded with his left hip and verbalized pain. She stated she could tell there was something wrong with Resident A. On (MONTH) 2, (YEAR), at 2 p.m., The DON was re-interviewed. She stated Resident A should have not been left unattended in Room 11. The DON stated Resident A needed supervision. On (MONTH) 6, (YEAR), at 2:45 p.m., CNA 1 was interviewed. CNA 1 stated she was helping a resident at Room 14's bathroom when Resident A verbalized wanting to use the bathroom. CNA 1 stated she instructed Resident A to use the bathroom in Room 11. She stated she walked Resident A to the door of Room 11 and left. On (MONTH) 9, (YEAR), at 10:10 a.m., CNA 2 was interviewed, and stated she saw CNA 1 wheel Resident A inside Room 11. CNA 2 stated, I would not have left Resident A inside Room 11 unattended. She stated the resident (Resident B) occupying Room 11 was very territorial. CNA 2 further stated Resident A could not ambulate as he used to after the incident of fall on (MONTH) 20, (YEAR). Resident A's MDS dated (MONTH) 3, (YEAR) (13 days after the incident of fall), Section G (Functional Status) indicated Resident A needed an extensive assistance with a two person physical assist. On (MONTH) 9, (YEAR), at 10:15 a.m., Resident A was observed sitting on his wheelchair being propelled by the DON to his room. During a concurrent interview with Resident A, he stated he could not walk anymore and his hip hurts. On (MONTH) 9, (YEAR), at 11:10 a.m., Licensed Vocational Nurse (LVN)1 was interviewed. She stated Resident A should have not been left in Room 11 unattended. LVN 1 stated the resident occupying the room (Room 11) was not friendly to both staff and residents. On (MONTH) 28, (YEAR), at 4 p.m., the DON was interviewed regarding the facility's investigation of the fall incident involving Resident A. She stated Resident A should have been taken by the staff to an unoccupied room to use the bathroom. The DON stated Resident B did push Resident A. She further stated Resident A sustained a fracture due to the incident. A review of the facility's undated policy and procedure titled Fall Prevention Program, indicated, .Purpose: 1. To improve the quality of life and quality of care for residents .The goal of this program is to prevent falls, reduce both the incidence of fall, and or injuries that may accompany falls. Process .Identify specific patterns, situations and behaviors associated with the fall incidence. Establish a common method of communication to remind staff to monitor these residents for fall prevention .Staff will be alerted to those residents at risk, trained on the care plan interventions designed to prevent or reduce repeated falls .