Every finding on record at We Care Skilled Nursing - Fremont

Based on observation, interviews, and record review, the facility failed to ensure a safe environment by not monitoring visitors entering and exiting the facility. This failure potentially compromised the safety of the residents. During a phone interview with Resident 1's Family Member (FM) 1 on 3/20/26 at 2:35 p.m., FM1 stated that she had observed visitors entering and leaving the facility without checking in or out at the front lobby desk. FM 1 stated she was concerned about her mother's safety. During a review of Resident 1's admission record indicated the resident was admitted on [DATE] with diagnoses that included anxiety disorder. During a concurrent observation and interview on 3/23/26, at 9:30 a.m., with the Director of Nursing (DON), in the facility lobby, visitors were observed entering and exiting the facility without signing in or out at the front reception desk. DON stated that the visitors were not required to check in or out. Upon further observation, there was no designated visitor sign-in log at the front desk. During an interview with the Front Lobby Receptionist (FLR) on 3/23/26 at 11:15 a.m., the FLR confirmed that there was no requirement for visitors to check in or check out at the front lobby desk. During another interview with the DON on 3/23/26 at 2:30 p.m., DON acknowledged that the facility visitors should be signing in and out in the front desk to ensure the residents' safety. During a review of the facility's policy and procedure (P&P) titled, Visitation, dated 2001,the P&P indicated, Policy Statement: Our facility permits residents to receive visitors subject to the resident's wishes and the protection of the rights of other residents in the facility. Reasonable Clinical and Safety Restrictions: Some visitation may be subject to reasonable clinical and safety restrictions that protect the health, safety, security and/or rights of the facility's residents .

Based on observation, interview and records review the facility failed to ensure to keep one of three sample selected residents (Resident 1) privacy when, resident was taking shower, and the bathroom door was opened by staff multiple times.This deficient practice could result in causing Resident 1 to experience emotional distress, a loss of dignity, and a breakdown of trust in caregivers, potentially leading to anxiety, depression, or withdrawal from necessary medical care.A review of Resident 1's admission Record, printed on 1/15/2026, the admission record indicated Resident 1 was admitted to the facility in September 20205 with multiple diagnosis including Subacute Osteomyelitis (a serious infection and inflammation of the bone) right ankle and foot.During an interview on 1/15/26 At 9: 35 a.m. with Resident 1, Resident 1 stated, he was taking shower and asked the care givers to leave him alone in the bathroom. Resident 1 stated while Resident 1 was taking shower the staff opened the shower door multiple times and he was very upset and distressed at that time.During an interview on 1/15/26 at 10:15 a.m. with the Certified Nurse Assistant (CNA) 1, CNA 1, stated, she was walking on the hallway and noticed the shower wheelchair was outside the room and the sign on the door showed in use, CNA 1 opened the door and immediately Resident 1 started yelling and CNA 1 closed the door quickly. CNA 1 stated the staff should not open the shower door if the sign on the door shows in use for the resident's privacy and she made a mistake.During an interview on 1/15/26 at 10:05 a.m. with the Licensed Vocational Nurse (LVN) 1, LVN 1 stated, she was walking on the hallway and noticed the shower's wheelchair was on the hallway and she thought nobody was in the shower room and opened the door, Resident 1started to yell and LVN 1 changed the sign to in use and left. LVN 1 stated when they leave the residents inside the shower, they must change the sign on the door and make sure to watch for the residents' privacy.A review of the facility's policy and procedure Dignity revised February 2021, indicated . Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem.Residents' private space and property are respected at all times.

Based on interview, record review and observation, facility failed to be comply with Federal, State, and Local Laws and Professional Standards for one of three sample selected residents (Resident 1) when resident 1 had unusual occurrence (Fall), skin laceration and hospitalization and the facility did not follow the state regulation (22 CCR S 72541) to report the incident to the California Department of Public Health (CDPH).This deficient practice has the potential to result in negative outcomes for residents including actual harm, serious injury, a decline in quality of life, and putting residents at high risk of similar, potentially more severe, future incidents.A review of Resident 1's admission Record indicated Resident 1 was admitted to the facility with multiple diagnosis including muscle weakness.A review of SBAR (a structured communication framework widely used in healthcare to provide a clear, concise, and organized method for conveying critical information between professionals) dated 11/5/25, indicated .At 03:16 pm resident had unwitnessed fall. LN (Licensed Nurse) was near the resident's room during shift change, both nurses heard loud noise and rushed to room. Resident found flat lying on her back on floor next to table. upon assessment resident alert and oriented x1. active bleeding noted to back of head. laceration approximately 2 cm with moderate bleeding. called 911 3:32 pm. paramedics arrived- 3:34 pm .During an interview on 12/9/25 at 9:30 a.m., with the Director of Nursing (DON), DON stated Resident 1 fell and had a skin laceration on her head, was sent to the hospital for evaluation and hospital sent Resident 1 back to the facility the next day. Furthermore, DON stated the facility did not report this incident to the CDPH because it was not a significant injury involved with the incident.A review of the facility's policy and procedure Unusual Occurrence Reporting revised December 2007, indicated .As required by federal or state regulations, our facility reports unusual occurrences or other reportable events which affect the health, safety, or welfare of our residents, employees or visitors.

Based on observation, interview and record review, the facility failed to provide treatment and care in accordance with professional standards of practice in four of four sampled residents (Residents 58, 44, 66 and 274) when: 1.PRAFO boot (Pressure Relief Ankle Foot Orthosis - a device worn on the ankle and foot to help manage foot and ankle issues) was not applied to Resident 58 as ordered by a physician. 2.Resident 44's lips were dry, cracked, peeling and tongue had thick build-up of whitish matter. 3.Resident 274 did not receive preferred as needed and scheduled pain medication in a timely manner. These failures had the potential to cause physical discomfort and emotional distress to Residents 58, 44, and 274. Findings: 1.A review of Resident 58's admission Record printed 12/4/24, indicated Resident 58 was admitted to the facility in 2022 with multiple diagnosis including an admitting diagnosis Cerebral Infarction (death of an area of brain tissue when a blocked blood vessel prevents delivery of an adequate blood and oxygen supply to the brain). During a concurrent observation and interview on 12/4/24, at 12:41 p.m., with Certified Nursing Assistant (CNA) 1, Resident 58 was observed without a PRAFO boot. CNA 1 stated they documented they applied the PRAFO boot although they did not. CNA 1 stated they did not know what a PRAFO boot was. During a concurrent interview and record review on 12/4/24, at 2:10 p.m., with Director of Rehab (DOR), Resident 58's Physical Therapy Daily Note, dated 5/29/24 was reviewed. The Daily Note, indicated, Trial continued with PRAFO due to pt's (patient's) tendency to get into L (left) ankle PF (plantar flexion -movement of the foot and ankle that bends the foot downward and away from the body) at rest and increased tightness / resistance noticed during relative dorsiflexion (upward or backward bending of a body part). DOR stated Resident 58 was a stroke patient and the PRAFO boot was important to position the ankle and to prevent further contraction. During a review of Resident 58's Physician's Orders, dated 7/12/24, the orders indicated: CNA to apply PRAFO to left ankle 4 hours per day, check skin for redness or irritation before and after application, and report to charge nurse for change in skin condition. LN (licensed nurse) to monitor task completion: apply at 9am and off at 1pm. During a review of Resident 58's Care Plan Self Care Deficit, dated 7/2/24, the Care Plan indicated, CNA to apply ankle/ foot orthosis to left ankle 4 hours daily . During a review of the facility's policy and procedure (P&P) titled, Use of Orthopedic (a medical tool that prevents, treats, or restores the function of the human skeletal system and related structures) Support Devices/ Equipment, undated, the P&P indicated, Orthotics (devices or supports that help to prevent, correct, or align the function of the body's movable parts) will be utilized based on medical necessity and individualized care plans, as prescribed by a qualified healthcare provider. The P&P indicated Staff responsible for applying orthotics will receive training to ensure appropriate handling and usage. The P&P indicated Orthotics should be applied and removed according to the resident's care plan . 3. During a record review of Resident 44's admission Record (AR) printed on 12/4/24, the admission Record indicated Resident 44 was admitted in the facility in March 2023 with multiple diagnoses that included cerebral infarction (death of an area of brain tissue when a blocked blood vessel prevents delivery of an adequate blood and oxygen supply to the brain), dysphagia (difficulty of swallowing), and encounter for attention to gastrostomy (GT, an opening into the stomach from the abdominal wall, made surgically for nutritional support). During a record review of Resident 44's Care Plan dated 5/18/23, the Care Plan indicated Resident 44 had self-care deficit total dependent with Activities of daily living (ADLs, are those needed for self-care and mobility and include activities such as bathing, dressing, grooming, oral care, ambulation, toileting, eating, transferring, and communicating). During a concurent observation and interview on 12/2/24 at 10:36 a.m. with Resident 44, Resident 44 was lying in bed and was observed to have left arm contracture (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints). Resident 44 also had dry, cracked, and peeling lips. Resident 44 did not have upper and lower teeth. Resident 44 stated no when asked if he received routine oral care from the nursing staff. During a follow up observation and interview on 12/4/24 at 8:32 a.m. with Resident 44, Resident 44 stated he still did not receive oral care from the nursing staff. Resident 44's tongue was observed to have a thick build-up of whitish matter covering more than half of Resident 44's tongue. Resident 44 stated he wanted his mouth cleaned. During a concurrent observation and interview on 12/4/24 at 8:38 a.m. with Certified Nurse Assistant (CNA) 2, CNA 2 stated the CNAs were responsible in providing oral care to Resident 44. Resident 44 was observed showing CNA 2 his tongue. CNA 2 stated Resident 44's tongue was covered in whitish matter. CNA 2 stated the oral care should have been provided every shift. CNA 2 stated the risk of not providing proper oral care to Resident 44 could have caused build-up of mucus and could have affected Resident 44's general health. During an observation and interview on 12/4/24 at 8:48 with Licensed Vocational (LVN) 1, LVN 1 stated Resident 44 was NPO (nil per os, or nothing by mouth which a person should not consume food, beverages, or oral medications). LVN 1 was observed assessing Resident 44's tongue. LVN 1 stated Resident 44's thick build-up of whitish matter on his tongue could have been from the accumulation of mucus. LVN 1 stated Resident 44's tongue looked like milk curds. LVN 1 further stated providing oral care to Resident 44 should have been consistent through out the shifts to prevent infection. During an interview on 12/4/24 at 12:07 p.m. with the Director of Nursing (DON), the DON stated the CNAs and the licensed nurses were responsible in maintaining the oral health for Resident 44. The DON further stated oral care should have been provided at least twice a day on a daily basis. The DON stated not providing oral care could have resulted mouth infection to Resident 44. During a record review of the facility's P&P, titled, Mouth Care dated 2001, the P&P indicated The purpose of this procedure are to keep the resident's lips and oral tissues moist, to cleanse and freshens resident's mouth, and to prevent oral infection. During a record review of the facility's P&P, titled, ADL, Supporting, dated 2001, the P&P indicated, Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with .a. hygiene (bathing, dressing, grooming, and oral care) 4. During a record review of Resident 274's History and Physical (H&P), dated 11/28/24, the H&P indicated, Resident 274 had diagnoses of right femur closed fracture (break or crack in bone) status post ORIF (open reduction and internal fixation, a surgical procedure that treats broken bones by realigning and stabilizing them with hardware) with rod placement and staph haemolyticus bacteremia (bacterial infection). During a record review of Resident 274's Order Summary Report printed on 12/4/24, the Order Summary Report indicated an order to administer Norco oral tablet 5-325 milligrams(mg) (a controlled substance used to help relieve moderate to severe pain) 1 tablet by mouth every 4 hours for routine pain management for 3 days until 12/6/24. The Order Summary Report also indicated an order to administer Norco oral tablet 5-325 mg 2 tablets by mouth every 4 hours as needed for moderate pain. During a record review of Resident 274's Medication Administration Record (MAR) for December 2024, the MAR indicated Resident 274 last received his as needed Norco on 12/3/24 at 9:15 a.m. The MAR also indicated Resident 274 did not receive his routine Norco at 4:00 p.m. and 8:00 p.m. on 12/3/24 and at 12:00 p.m. and 4:00 a.m. on 12/4/24. During a record review of Resident 274's Progress Notes dated 12/3/24, electronically signed by a licensed nurse at 4:11 p.m. and 7:33 p.m., the progress note indicated Resident 274's routine Norco was on order. . During a record review of Resident 274's Progress Notes dated 12/4/24, electronically signed by LVN 3 at 1:36 a.m. and 7:04 a.m., the progress note indicated Resident 274's routine Norco as drug not available. During a record review of Resident 274's Care Plan dated 11/28/24, the Care Plan indicated Resident 274 had a potential/risk for pain/discomfort .related to closed fracture right femur status post ORIF, muscle spasm. The document indicated to Administer pain medication as ordered. During an interview on 12/3/24 at 9:38 a.m. with Resident 274, Resident 274 stated he just had a surgery on his right femur and his pain was not well managed. Resident 274 stated he was not getting his Norco pain medication in a timely manner. Resident 274 stated he wanted to go home so he would not have to wait for his pain medications. During a follow up interview on 12/4/24 at 9:04 a.m. with Resident 274, Resident 274 stated he was in a lot of pain from the previous night because he did not receive his Norco. Resident 274 stated the nurses kept telling him that his Norco was not available because the pharmacy did not deliver it. Resident 274 he preferred to receive two tablets of Norco for pain because it was more effective in treating his pain but it was not available when he needed it. Resident 274 stated he was very uncomfortable and did not sleep until 2:00 a.m. because of pain. During an interview on 12/4/24 at 9:08 a.m. with LVN 1, LVN 1 stated Resident 274's Norco ran out on 12/3/24. LVN 1 stated they have followed up and faxed the refill to the pharmacy, but the facility did not receive Resident 274's Norco until 12/4/24. During an interview on 12/4/23 at 9:15 a.m. with LVN 3, LVN 3 stated she did not administer Resident 274's Norco because the medication was not available. LVN 3 stated she and the PM nurse did not use the emergency kit supply (or e-kit, a limited supply of medication for urgent use in a sealed box) for Resident 274's Norco. LVN 3 stated she could have used the e-kit, but she did not. LVN 3 stated without the supply of Norco 5-325 mg, Resident 274 could have been in a lot of pain. During an observation and interview on 12/4/23 at 9:23 a.m. with LVN 1, LVN 1 was observed checking the e-kit supply in the medication room. LVN 1 stated the e-kit supply container had not been opened, therefore, the emergency supply of Norco 5-325 mg was available for use. The e-kit's label indicated there were 6 tabs available for emergency use. During an interview on 12/4/24 at 12:13 p.m. with the Director of Nursing (DON), the DON stated she did not know that Resident 274 ran out of his pain medication. The DON stated the licensed nurses should have called her or the MD if a medication was not available. The DON added the e-kit should have been utilized as an emergency supply. The DON stated because Resident 274 did not receive his Norco, Resident 274 had the potential for being uncomfortable because of pain. The DON stated it could also have affected Resident 274's moods and ADLs performance. During a record review of the facility's policy and procedure (P&P), titled, Pain - Clinical Protocol dated 2001, the P&P indicated, Treatment/Management .With input from the resident to the extent possible, the physician and staff will establish goals of pain treatment; for example, freedom from pain .improved functioning, mood, and sleep. During a record review of the facility's undated P&P, titled, Physician Orders, the P&P indicated Orders must be implemented promptly, within timeframes based on the urgency of the medical need.

Based on observation, interview and record review, for one of one sampled resident (Resident 51) reviewed for dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) care, the facility failed to ensure phosphate binder (medication that binds/attaches to some of the phosphates in food, reducing one's blood phosphorus levels) was administered as ordered by the physician. This failure had the potential to result in increased blood phosphorus (mineral) levels. Findings: During a review of Resident 51's admission Record, the admission Record indicated Resident 51 was admitted to the facility in September 2024 with diagnoses that included diabetes (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing), end stage renal disease (a permanent condition that occurs when the kidneys are no longer able to function properly), and dependence on renal dialysis. During a review of Resident 51's Order Summary Report dated 11/30/24, the Order Summary Report indicated a physician's order for Resident 51 to receive dialysis three times weekly every Tuesday, Thursday and Saturday from 5:00 a.m. until treatment is completed. The report also indicated an order for Phoslo (a phosphate binder) 667 milligrams (mg) three capsules by mouth three times daily to be given with meals. During a review of Resident 51's Medication Administration Record (MAR) for October 2024, the MAR indicated Resident 51 received Phoslo three times daily at 8:00 a.m., 12:00 noon, and 5:00 p.m., except 8:00 a.m. dose on 10/5/24, 10/8/24, 10/12/24 and 10/19/24; and went to dialysis three times weekly, on Tuesdays, Thursdays, and Saturdays, as scheduled. During a review of Resident 51's MAR for November 2024, the MAR indicated Resident 51 left for dialysis early morning every Tuesdays, Thursdays, and Saturdays and received 8:00 a.m. doses of Phoslo daily. During an interview on 12/3/24 at 1:10 p.m. with Registered Nurse (RN) 1, RN 1 stated Resident 51 would leave between 4:00- 5:00 a.m. with a breakfast bag, and ate breakfast at the dialysis center. RN 1 stated, upon returning to the facility around 10:00-11:00 a.m., Resident 51 would be given scheduled morning medications that included Phoslo. During an observation and concurrent interview on 12/3/24 at 1:14 p.m. with Licensed Vocational Nurse (LVN) 5, LVN 5 stated Resident 51 left for dialysis and was not at the facility around the time the first dose of Phoslo was due for administration. LVN 5 stated, before lunch, LVN 5 checked Resident 51's blood sugar and administered insulin as ordered. LVN 5 then prepared the Phoslo and administered it to Resident 5 even without the lunch tray by the bedside. During an interview and concurrent review of Resident 51's Order Summary Report and MAR on 12/5/24 at 10:06 a.m. with Infection Preventionist (IP), IP stated Phoslo's administration time should have been adjusted so that Resident 51 took the medication with meals. IP stated, taking Phoslo when Resident 51 was not eating would render the medication ineffective, because it was supposed to be taken with meals. During a review of Resident 51's dialysis care plan last revised on 10/4/24, the care plan indicated for Resident 51's medications to be administered as ordered, and for facility to coordinate care with dialysis center staff. During a review of the facility's policy and procedure (P&P) titled End-Stage Renal Disease, Care of a Resident with last revised September 2010, the P&P indicated Residents with end-stage renal disease will be cared for according to currently recognized standards of care. The P&P indicated for staff to be educated and trained on the timing and administration of medications.

During a review of Resident 51's admission Record, the admission Record indicated Resident 51 was admitted to the facility in September 2024 with diagnoses that included diabetes (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing), end stage renal disease (a permanent condition that occurs when the kidneys are no longer able to function properly), and dependence on renal dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) . During a review of Resident 51's Order Summary Report dated 11/30/24, the Order Summary Report indicated a physician's order dated 10/3/24, for Resident 51 to receive dialysis three times weekly every Tuesday, Thursday and Saturday from 5:00 a.m. until treatment is completed. The report also indicated a physician's order dated 10/3/24 for Phoslo (a phosphate binder) milligrams (mg) three capsules by mouth three times daily to be given with meals. During a review of Resident 51's Medication Administration Record (MAR) for October 2024, the MAR indicated Resident 51 received Phoslo three times daily at 8:00 a.m., 12:00 noon, and 5:00 p.m., except 8:00 a.m. dose on 10/5/24, 10/8/24, 10/12/24 and 10/19/24; and went to dialysis three times weekly, on Tuesdays, Thursdays, and Saturdays, as scheduled. During a review of Resident 51's MAR for November 2024, the MAR indicated Resident 51 left for dialysis early morning every Tuesdays, Thursdays, and Saturdays and received 8:00 a.m. doses of Phoslo daily. During an interview on 12/3/24 at 1:10 p.m. with Registered Nurse (RN) 1, RN 1 stated Resident 51 would leave between 4:00- 5:00 a.m. with a breakfast bag, eat breakfast at the dialysis center. RN 1 stated, upon returning to the facility around 10:00-11:00 a.m., Resident 51 would be given 8:00 a.m. dose of Phoslo. During an interview and concurrent review of Resident 51's Order Summary Report and MAR on 12/5/24 at 10:06 a.m. with Infection Preventionist (IP), IP stated Phoslo's administration time should have been adjusted so that Resident 51 took the medication with meals. IP stated, taking Phoslo when Resident 51 was not eating would render the medication useless, because it was supposed to be taken with meals. IP stated not knowing if the Consultant Pharmacist (CP) had identified this issue during Drug Regimen Review. During a review of Resident 51's Clinically Significant Medication Regimen Review Communication Form dated and signed 10/7/24 by CP 2, the form indicated a drug regimen review was conducted and there were no issues found. During a telephone interview on 12/5/24 at 10:13 a.m. with CP 1, CP 1 stated, when conducting drug regimen review, the following records are reviewed; medication orders, gradual dose reduction and drug interactions, MAR to review whether directions of administration and diagnoses are appropriate, or whether medications are given appropriately, with or without food. During a review of the facility's policy and procedure (P&P) titled Consultant Pharmacist Services Provider Requirement last revised January 2018, the P&P indicated Consultant Pharmacist (CP) provides consultation on all aspects of of the provision of pharmacy services that included, assisting facility in defining schedules of administration of medications to maximize the effectiveness and reviewing MARs to ensure proper administration of medications. Based on observation, interviews, and record review, the facility failed to provide pharmaceutical services and procedures that assure accurate dispensing and administration of medications when: 1. An emergency kit (or e-kit, a limited supply of medication for urgent use in a sealed box) supply was stored in the medication refrigerator with a tampered or broken seal. 2. Resident 43 and Resident 325's hazardous drugs (medications that pose short or long-term harm upon exposure to human via skin or inhalation) were stored in medication carts and used by nursing staff without protective measures during medication administration. 3. Resident 274 did not receive preferred as needed and routine pain medication in a timely manner according to physician's order. 4. Consultant Pharmacist (CP) did not identify irregularity with Resident 51's phosphate binder (used to treat high blood phosphorus levels) administration. These failed practices could contribute to risk of drug diversion, unsafe handling of hazardous medications which could pose health risk to staff and residents, physical discomfort, and ineffective medication use. Findings: 1. During a concurrent observation and interview on 12/2/24 at 1:49 p.m. with Licensed Vocational Nurse (LVN) 2, a container of refrigerated e-kit was stored in the medication refrigerator was observed to have a tampered or broken seal. The e-kit label indicated date filled: 9/17/24. The e-kit container included medications such as three insulin vials (lowers blood sugar), two promethazine suppositories (used to treat allergic reactions), and two vials of lorazepam (decreases anxiety and used to treat serious seizures that do not stop) 2 milligrams (mg)/milliliters (ml). LVN 2 stated green ties indicated the e-kit had not been opened and red ties indicated the e-kit had been used and a medication could have been taken out. LVN 2 stated he did not know why the e-kit container had a broken green tie. LVN 2 stated the e-kit that was stored in the refrigerator should have had intact green ties if it was not used. LVN 2 stated the e-kit should have not been accepted by the receiving nurse and should have been returned to the pharmacy immediately upon receipt if the e-kit container had a broken seal. LVN 2 stated it was important to keep the refrigerated e-kit sealed and secured because it contained lorazepam which was considered a controlled substance. During an interview on 12/4/24 at 12:27 p.m. with the Director of Nursing (DON), the DON stated she was responsible for auditing the medication rooms including the medication refrigerator. The DON stated she did not notice the refrigerated e-kit to have a broken seal because it had green ties. The DON stated the green ties indicated the e-kit had not been opened or used. The DON stated she should have taken the e-kit out from the refrigerator and checked for the integrity of the green ties. The DON stated it was important to secure the e-kit because the medications could have been used inappropriately. During a phone interview on 12/5/24 at 7:50 a.m. with the Consultant Pharmacist (CP), CP stated the nurse consultant of the facility was responsible for auditing the medication rooms, medication refrigerators, and medication carts. CP further stated the e-kit should not have had a tampered or broken seal. The CP stated the e-kit should have been refused by the facility in the first place, and should have been returned to the pharmacy for replacement. During a record review of the facility's policy and procedure (P&P), titled, Emergency Medications, dated April 2021, the P&P indicated, The consultant pharmacist shall inspect the emergency medication kits monthly and record the findings on the record maintained with each kit. During a record review of the facility's P&P, titled, Pharmacy Services Overview, dated April 2019, the P&P indicated, Medications are received, labeled, stored, administered and disposed of according to all applicable state and federal laws and consistent with standards of practice .The consultant pharmacist, in collaboration with the dispensing pharmacy and the facility, oversees the development of procedures related to pharmacy services, including .medication packaging and dispensing system. 2. During a medication pass observation on 12/3/24 at 7:58 a.m. with LVN 1, LVN 1 prepared and administered a medication called Finasteride (treats enlarged prostate) to Resident 43 labeled by pharmacy with a yellow sticker that indicated Antineoplastic (anticancer) hazardous drug .observe special handling, administration, and disposal requirements. LVN 1 did not wear gloves when she removed the hazardous medication from the bubble pack (a card that packaged doses of medication within a plastic bubbles or blisters) into the pill cup for administration to Resident 43. Further observation indicated the bubble pack was not stored in zip lock bag for safer handling by nursing staff. During a medication pass observation on 12/3/24 at 8:44 a.m. with LVN 1, LVN 1 prepared and administered a medication called Paxil (treats depression) to Resident 325 labeled by pharmacy with a red sicker that indicated hazardous drugs. LVN 1 did not wear gloves when she removed the hazardous medication from the bubble pack into a pill cup for administration to Resident 325. Further observation indicated the bubble pack was not stored in zip lock bag for safer handling by nursing staff. During a follow up interview on 12/3/24 at 9:24 a.m. with LVN 1, LVN 1 stated she forgot to wear gloves during the administration of Finasteride to Resident 43. LVN 1 stated she should have worn gloves when preparing and administering the medication to Resident 4 because Finasteride was considered teratogenic (medications that can cause fetal malformations to pregnant women). LVN 1 stated she never wore gloves when she prepared for the other hazardous medication Paxil. LVN 1 stated hazardous medications were always stored together with the non-hazardous medications. LVN 1 stated she did not know what their policy was for storing hazardous medications. During an interview on 12/4/24 at 12:29 p.m. with the DON, the DON stated the hazardous medications should have been handled with care. The DON stated the licensed nurses should have worn gloves when handling any hazardous medications. The DON stated hazardous medications could have caused unwanted side effects especially to licensed nurses who were handling them. The DON added the hazardous medications should have been separated from non-hazardous medications and should have been kept in a zip lock bag provided by the pharmacy for safe storage and handling. During an interview on 12/5/24 at 7:53 a.m. with CP1, CP1 stated the facility had not asked him to provide in-service about hazardous medications to the licensed nurses. CP1 stated when pharmacy sent out hazardous medications, they should have been in a special bag for safe handling. CP1 stated the hazardous medications should have been separated from the non-hazardous medications if that was the facility's policy and procedure. During a record review of the facility's undated P&P, titled, Handling of Hazardous Drugs, the P&P indicated, To establish safe handling, storage, administration, and disposal procedures for hazardous drugs to protect staff, residents, and the environment from potential exposure and adverse effects .Hazardous drugs .medications identified as hazardous by the National Institute for Occupational Safety and Health (NIOSH), including those who pose risks due to carcinogenicity, reproductive toxicity, organ toxicity, or genotoxicity. The P&P further indicated the hazardous drugs should be separated from non-hazardous drugs and staff must wear appropriate personal protective equipment (PPE) including double gloves made of powder-free chemotherapy-tested material. 3. During a record review of Resident 274's History and Physical (H&P), dated 11/28/24, the H&P indicated, Resident 274 had diagnoses of right femur closed fracture (break or crack in bone) status post ORIF (open reduction and internal fixation, a surgical procedure that treats broken bones by realigning and stabilizing them with hardware) with rod placement and staph haemolyticus bacteremia (bacterial infection). During a record review of Resident 274's Order Summary Report printed on 12/4/24, the Order Summary Report indicated an order to administer Norco oral tablet 5-325 mg (a controlled substance used to help relieve moderate to severe pain) 1 tablet by mouth every 4 hours for routine pain management for 3 days. The Order Summary Report also indicated an order to administer Norco oral tablet 5-325 mg 2 tablets by mouth every 4 hours as needed for moderate pain. During a record review of Resident 274's Medication Administration Record (MAR) for December 2024, the MAR indicated Resident 274 last received his as needed Norco on 12/3/24 at 9:15 a.m. The MAR also indicated Resident 274 did not receive his routine Norco at 4:00 p.m. and 8:00 p.m. on 12/3/24 and at 12:00 p.m. and 4:00 a.m. on 12/4/24. During a record review of Resident 274's Progress Notes dated 12/3/24, electronically signed by a licensed nurse at 4:11 p.m. and 7:33 p.m., the progress note indicated Resident 274's routine Norco was on order . During a record review of Resident 274's Progress Notes dated 12/4/24, electronically signed by LVN 3 at 1:36 a.m. and 7:04 a.m., the progress note indicated Resident 274's routine Norco as drug not available. During an interview on 12/4/24 at 9:04 a.m. with Resident 274, Resident 274 stated he was in a lot of pain from the previous night because he did not receive his Norco. Resident 274 stated he preferred to receive two tablets of Norco for pain because it was more effective in treating his pain. Resident 274 stated he requested for his preferred pain medication Norco, but nurses told him multiple times that it was not available because the pharmacy had not delivered it. Resident 274 stated he was very uncomfortable and did not sleep until 2:00 a.m. because of pain. During an interview on 12/4/24 at 9:08 a.m. with LVN 1, LVN 1 stated Resident 274's Norco ran out on 12/3/24. LVN 1 stated they have followed up and faxed the refill to the pharmacy, but the facility did not receive Resident 274's Norco until around 7:00 a.m. on 12/4/24. During an interview on 12/4/23 at 9:15 a.m. with LVN 3, LVN 3 stated she did not administer Resident 274's Norco because the medication was not available. LVN 3 further stated she did not use the e-kit as an emergency supply to provide Resident 274 his preferred pain medication. LVN 3 stated if Resident 274's pain was not managed, Resident 274 could have been in a lot of pain and discomfort. During an interview on 12/4/24 at 12:13 p.m. with the Director of Nursing (DON), the DON stated she did not know that Resident 274 ran out of his pain medication. The DON stated the request for refill was faxed on 12/3/24 as soon as the physician signed the order for refill. The DON stated the licensed nurses should have called her or the physician if a medication was not available. The DON added the e-kit should have been utilized as an emergency supply. The DON stated because Resident 274 did not receive his Norco, Resident 274 could have been uncomfortable because of pain. The DON further stated the pharmacy should have advised the nurses who called and followed up to utilize the e-kit. During an interview on 12/5/24 at 7:58 a.m. with the CP 1, CP 1 stated he did not know why the dispensing pharmacy did not deliver Resident 274's Norco in a timely manner. CP 1 stated e-kits should have been used by the licensed nurses as an emergency supply for Resident 274's Norco. During a record review of the facility's policy and procedure (P&P), titled, Pain - Clinical Protocol dated 2001, the P&P indicated, Treatment/Management .With input from the resident to the extent possible, the physician and staff will establish goals of pain treatment; for example, freedom from pain .improved functioning, mood, and sleep. During a record review of the facility's P&P, titled, Pharmacy Services Overview, dated April 2019, the P&P indicated, Pharmaceutical services consist of .Residents have sufficient supply of their prescribed medications and receive medications (routine, emergency or as needed) in a timely manner .

Based on observation, interview, and record review the facility failed to ensure safe medication storage for hazardous drugs (medications that pose short or long-term harm upon exposure to human via skin or inhalation) of five out five sampled residents (Residents 43, 325, 29, 30 and 28). These failures could contribute unsafe handling of hazardous drugs which could pose health risks to staff and residents. Findings: During a medication pass observation on 12/3/24 at 7:58 a.m. with Licensed Vocational Nurse (LVN)1, LVN1 prepared Resident 43's medications. LVN1 was observed removing a medication called finasteride (treats enlarged prostate) tablet 5 milligrams (mg) from the medication cart that was stored together with Resident 43's non-hazardous drugs. Resident 43's finasteride bubble pack (a card that packaged doses of medication within plastic bubbles or blisters) had a pharmacy labeled yellow sticker that indicated Antineoplastic (anticancer) hazardous drug .observe special handling, administration, and disposal requirements. After LVN1 prepared Resident 43's finasteride, LVN1 returned the hazardous drug back inside the cart with no zip lock for safe storage. During a medication pass observation on 12/3/24 at 8:44 a.m. with LVN1, LVN1 prepared Resident 325's medication. LVN1 was observed removing Resident 325's medication called Paxil (treats depression) 20mg from the medication cart that was stored together with Resident 325's non-hazardous drugs. Resident 325's Paxil bubble pack had a pharmacy labeled red sicker that indicated hazardous drugs. LVN1 returned Resident 325's hazardous drug back inside the cart with no zip lock for safe storage. During an interview on 12/3/24 at 9:24 a.m. with LVN1, LVN1 stated the hazardous drugs had always been stored with non-hazardous drugs. LVN1 stated hazardous drugs should have been handled with care because it could have caused side effects like congenital malformations. During an observation on 12/3/24 at 12:30 p.m. with Registered Nurse (RN)1, multiple hazardous drugs in bubble packs were not in zip lock bags and stored together with the non-hazardous drugs: 1. Resident 29's divalproex tablet 250 mg (antiseizure) had a pharmacy labeled yellow sticker that indicated antineoplastic hazardous drug. 2. Resident 30's methimazole 10 mg (thyroid medication) had a pharmacy labeled yellow sticker which indicated caution: hazardous drug. 3. Resident 28's divalproex tablet 125 mg had a pharmacy labeled red sticker which read hazardous drug. During an interview with on 12/3/24 at 12:43 p.m. with Registered Nurse (RN) 1, RN 1 stated the hazardous drugs were always stored in the medication cart together with the non-hazardous drugs. RN 1 stated she was not sure what the policy was for proper handling of hazardous drugs. During an interview on 12/4/24 at 12:29 p.m. with the DON, the DON stated the hazardous drugs should have been stored separately from non-hazardous drugs and should have been in zip lock bags provided by the pharmacy for safe storage and handling. The DON stated the nurses might not have known the purpose of the zip lock bags when they received the hazardous drugs from the pharmacy. The DON stated hazardous drugs could have caused unwanted side effects especially to licensed nurses who were handling them. During an interview on 12/5/24 at 7:53 a.m. with CP, CP stated the facility had not asked him to provide in-service about hazardous drugs to the licensed nurses. CP stated when pharmacy sent out hazardous drugs to the facility, they should have been in a special zip lock bag for safe handling. CP stated the hazardous drugs should have been separated from the non-hazardous drugs if that was the facility's policy and procedure. During a record review of the facility's undated P&P, titled, Handling of Hazardous Drugs, the P&P indicated, To establish safe handling, storage, administration, and disposal procedures for hazardous drugs to protect staff, residents, and the environment from potential exposure and adverse effects .Hazardous drugs .medications identified as hazardous by the National Institute for Occupational Safety and Health (NIOSH), including those who pose risks due to carcinogenicity, reproductive toxicity, organ toxicity, or genotoxicity. The P&P further indicated the hazardous drugs should be separated from non-hazardous drugs and staff must wear appropriate personal protective equipment (PPE) including double gloves made of powder-free chemotherapy-tested material.

Based on observation, interview and record review, the facility failed to prepare food in accordance with professional standards of food service safety when: - Multiple food items, stored in reach-in refrigerators # 1 and # 2, and walk-in refrigerator, were either not dated or stored beyond their use-by dates. - Previously thawed food items were replaced in the freezer. - A scoop with the handle touching the food item was stored inside the flour bin. These failures had the potential to result in cross-contamination and food-borne illnesses. Findings: During a concurrent observation and interviews on 12/2/24 at 9:39 a.m. with [NAME] 1 and Kitchen Aide (KA) 1, in the kitchen, the following were observed: Inside reach-in refrigerator #1; - An opened gallon of milk did not have a date. - Five cups of assorted colored liquids (amber, red, orange) dated 11/27/24. - A tray of clear yellow-colored dessert in individual serving cups, a tray of several glasses of white-colored liquids and a tray of assorted colored liquids that did not have dates. Cook 1 stated the assorted colored liquids were juices that were extra from previous meals. KA 1 stated the date written on the tray was the day the juices were prepared. Inside the walk-in refrigerator; - An opened gallon of whole milk did not have a date. - A half-full container of egg salad dated 11/27/24, veggie gravy dated 11/29/24, and gelatin with an opened-on date 11/26/24. - An opened container of Buttermilk dressing dated 11/29/24 and Caesar dressing with an opened-on date 11/12/24. - On the bottom shelf of the walk-in refrigerator were open boxes of the following; beef shoulder for pot roast dated 11/25/24, two plastic bags of boneless chicken thighs with pull-out date 11/25/24 and use by date 11/27/24, cut-up chicken in a plastic container dated 12/1/24. Cook 1 stated, the boxes should indicate a pull-out date if taken out of the freezer, otherwise, the dates written on the boxes were delivery dates. [NAME] 1 also stated, sometimes, food items are stored inside the walk-in refrigerator once delivered. Inside the reach-in refrigerator # 2; - An opened carton of Thick and Easy thickened dairy beverage without a lid and not dated. KA 1 stated not knowing when the dairy beverage was opened. Under the counter, a plastic scoop was inside a bin labeled flour, the handle was touching the food item. During a follow-up observation and concurrent interview on 12/2/24 at 11:44 a.m., with [NAME] 1, inside the freezer, the following were observed; a pack of turkey patties, plant based chicken strips, and ham dated 11/9/24. The food items were soft to touch. [NAME] 1 stated KA 2 had arranged the boxes that were inside the walk-in refrigerator and replaced them inside the freezer. [NAME] 1 stated the food items were left in the walk-in refrigerator to thaw and should not have been replaced back in the freezer. [NAME] 1 also stated food items that have already been pulled out of the freezer for thawing should be cooked by their use-by date, or thrown out. During a review of the facility's Refrigerated Storage Guide dated 2020, the guide indicated meats taken from the freezer to thaw that included roasts and poultry (chicken) had maximum refrigeration time of two days once meat has thawed. The guide also indicated; egg salad has a maximum refrigeration time of three days, desserts prepared including pudding and cream pies, opened condensed or evaporated milk have three days, and gelatin dessert has five days maximum refrigeration time. During a review of the facility's policy and procedure (P&P) titled Food Preparation dated 2018, the P&P indicated when thawing meat in a refrigerator, label the meat with pull and use-by date.

Based on observation, interview, and record review, the facility failed to implement infection control practices for four of four sampled residents (Resident 43, 47, 325, 274 and 66) when: 1. Blood pressure (BP) cuff was not cleaned and disinfected after each use with Residents 43, 47 and 325. 2. Hand hygiene was not performed before administering the pre-filled Enoxaparin injection (a medication that uses a syringe and needle that can help reduce the risk of developing blood clots) to Resident 274. 3. Hand hygiene, wear of Personal Protective Equipment (PPE) and maintaining aseptic technique of equipment were not implemented during a medication administration to Resident 66. These deficient practices had the potential spread of infection at the facility. Findings: 1. During a medication pass observation on 12/3/24 at 7:58 a.m. with Licensed Vocational Nurse (LVN)1, LVN1 entered Resident 43's room. LVN1 was observed taking Resident 43's BP on his right arm using a manual BP cuff and a stethoscope (a medical device that allows healthcare providers to listen to sounds inside the body, such as the heart, lungs, and intestines). After the procedure, LVN1 placed the BP cuff on the side of the medication cart. LVN 1 then prepared and administered Resident 43's medications. After LVN 1 administered Resident 43's medications, LVN1 did not clean or sanitize the BP cuff she used with Resident 43. During a subsequent observation on 12/3/24 at 8:14 a.m. with LVN1, LVN1 entered Resident 47's room that had a sign on the wall that indicated Enhanced Barrier Precaution (an infection control intervention designed to reduce transmission of multidrug-resistant organisms). LVN1 was observed taking Resident 47's BP on his right arm using the same BP cuff she previously used for Resident 43 without cleaning or sanitizing. LVN1 returned to the medication cart and placed the BP cuff on the side of the medication cart. LVN1 then prepared and administered Resident 47's medications through gastrostomy tube (GT tube, an opening into the stomach from the abdominal wall, made surgically for nutritional support). After LVN1 administered Resident 47's medications, LVN1 did not clean or sanitize the BP cuff that she previously used with Residents 43 and Resident 47. During a subsequent observation on 12/3/24 at 8:44 a.m. with LVN1, LVN1 entered Resident 325's room. LVN1 was observed taking Resident 325's BP on her left arm using the same BP cuff she previously used for Resident 43 and Resident 47 without cleaning or sanitizing. After LVN1 administered Resident 325's medications, LVN1 still did not clean or sanitize the BP cuff that she used with Residents 43, 47 and 325. 2. During an observation on 12/3/24 at 9:01 a.m. with LVN1, LVN1 prepared Resident 274's medications that included Nicotine Patch (a patch that can help a person quit smoking) 7 milligrams(mg)/24 hours and Enoxaparin Sodium Injection Solution Prefilled Syringe 30 mg/0.3 milliliters(ml). With gloved hands, LVN1 removed Resident 274's old nicotine patch from Resident 274's left arm. LVN1 then applied the new nicotine patch on Resident 274's right arm. After the procedure, LVN1 changed her gloves without performing hand hygiene and proceeded to administer Resident 274's Enoxaparin injection. LVN1 administered the medication on Resident 274's left upper abdomen. During an interview on 12/3/24 at 9:24 a.m. with LVN1, LVN1 stated she forgot to clean or sanitize the BP cuff. LVN1 stated the BP cuff she used for Residents 43, 47, and 325 should have been cleaned and disinfected to prevent infection. LVN1 further stated she also forgot to wash her hands after she applied Resident 274's nicotine patch and before she administered Resident 274's injectable medication. LVN1 stated she thought she did not need to perform hand hygiene since she used new a pair of gloves prior to administer Resident 274's Enoxaparin injection. During an interview on 12/4/24 at 11:58 a.m. with the Director of Nursing (DON), the DON stated the BP cuff should have been cleaned and disinfected after each resident use. The DON stated an example of using the BP cuff to a resident who was in contact precaution or had a skin infection and using it on other residents could lead to the spread infection. The DON further stated, washing or sanitizing hands in between procedures or before and after medication administration should have been the standard of practice for infection control. During a record review of the facility's undated policy and procedure (P&P), titled, Disinfection of Medical Equipment, the P&P indicated, All reusable medical equipment must be cleaned and disinfected according to facility standards and manufacturer guidelines after each use or as specified to maintain a safe and hygienic environment for residents and staff. The P&P indicated blood pressure cuffs must be disinfected after use with each resident. During a record review of the facility's P&P, titled, Handwashing/Hand Hygiene revised in August 2015, the P&P indicated, The facility considers hand hygiene the primary means to prevent the spread of infections .Use an alcohol-based hand rub containing at least 62% alcohol; or alternatively, soap (antimicrobial or non-microbial) and water for the following situations After handling used dressings, contaminated equipment, etc.m. After removing gloves .The use of gloves does not replace handwashing/hand hygiene. Integration of glove used along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections.

Based on observation, interview and record review, for one (Resident 12) of four sampled residents, the facility failed to implement a person-centered intervention that addressed Resident 12's dementia, mental and psychosocial well-being when Resident 12 was not involved in activity programs as indicated in care plan. Dementia is a general term to describe a group of symptoms related to loss of memory, judgment, language, complex motor skills, and other intellectual function, caused by the permanent damage or death of the brain's nerve cells, or neurons. However, dementia is not a specific disease. There are many types and causes of dementia with varying symptoms and rates of progression. (Adapted from: About Dementia. Alzheimer's Foundation of America. 30). This failure had the potential to increase confusion and distress with Resident 12. Finding: During a review of Resident 12's Annual Minimum Data Set (MDS - a standardized assessment tool that measures health status in nursing home residents)), dated 4/17/24 indicated Resident 12 had short-term and long-term memory problem. Resident 12 rarely /never made self understood. Resident 12 rarely never understands others. Resident 12 had no physical, verbal or other behavioral symptoms directed towards others e.g., hitting, kicking, pushing, scratching, grabbing or screaming at others, verbal/vocal symptoms like screaming or disruptive sounds. MDS indicated Resident 12 had no potential indicators of psychosis (a mental disorder characterized by disconnection from reality). Resident 12's activity preferences while at the facility that was very important included doing things with group of people and participation in religious services or practices. Resident 12's diagnoses included Non-Alzheimer's Disease (a group of diseases characterized by progressive deficits in behavior, executive function or language). During a review of Resident 12's Pre-admission Screening Resident Review (PASRR) Level 11 evaluation (a federal requirement to ensure that residents are not inappropriately placed in nursing homes for long term care) dated 4/25/23, the PASRR indicated Resident 12 had no serious mental illness. During a review of Resident 12's Alteration in Activity/Cognitive Problems/Behavioral problems, revised 10/11/24, care plan interventions included encourage involvement in activities of interest . Behavior care plan indicated Resident 12 attended AM (morning) group activities when up . During an observation on 12/02/24 at 9:44 a.m., Resident 12 laid in bed, awake, verbal with incomprehensible sounds. During an observation on 12/03/24 at 8:36 a.m., Resident 12 was in bed awake, alert, verbal with unintelligible words and gibberish sounds. During a concurrent observation and interview on 12/03/24 at 9:36 a.m. with Licensed Vocational Nurse (LVN)1, Resident 12 was in bed in her room. LVN 1 stated Resident 12 had a behavioral manifestation of continuously calling out causing her distress and exhaustion. During a concurrent interview and record review on 12/03/24 at 12:04 p.m. with Director of Nursing (DON), Resident 12's behavioral care plans were reviewed. DON stated Resident 12 had a behavior of continuously calling out and talking loud. DON stated Resident 12's behavioral interventions included increase socialization and involvement in activities of interest. During an interview on 12/05/24 at 10:08 a.m. with Activity Assistant (AA1), AA1 stated Resident 12 has not attended activities for a long time . TV remote was not working so the residents watched one TV channel the whole day. During an interview on 12/05/24 at 10:12 a.m. with Activities Director (AD), AD stated Resident 12 liked to socialize and enjoyed activities. AD stated Resident 12 has not attended activity programs for a long time. AD could not provide Resident 12's activity attendance record. AD stated she had brought it up during the daily staff meeting. AD stated the nursing staff were responsible for dressing residents up in time to attend scheduled activities. During an interview on 12/05/24 at 10:39 a.m. with LVN1, LVN1 stated Resident 12 got out of bed every Tuesday, Friday and Sunday for restorative nursing exercises. LVN1 stated Resident 12 stayed up from from 10 AM to 2 PM . LVN 1 said Resident was not taken to attend programmed activities. LVN1 stated going to activities was a good idea. During a review of the facility's policy and procedure (P&P) titled, Dementia, revised November 2018, the P&P indicated, For the individual with confirmed dementia, the IDT will identify a resident-centered care plan to maximize remaining function and quality of life.

Based on observation, interview and record review, the facility failed to ensure one (Resident 12) of five sampled resident was free from unnecessary drugs when; Resident 12 whose diagnoses included dementia was receiving Zyprexa (antipsychotic medication) for continuously calling out causing distress. Antipsychotic medications are drugs used to treat schizophrenia and bipolar disorder and serious mental health disorders. According to the manufacturer, elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death. Zyprexa is not approved for use in psychotic conditions related to dementia. Although causes of death varied, most of the deaths appeared to be related to cardiovascular (e.g. heart failure, sudden death). [Reference: https://www.[NAME].com/zyprexa]. This failure had the potential for residents to receive unnecessary medications and had the potential for causing the residents to suffer adverse medication side effects. Findings: During a review of Resident 12's Annual Minimum Data Set (MDS), Resident Assessment and care guide tool, dated 4/17/24, indicated Resident 12 had short-term and long-term memory problem. Resident 12 rarely /never made self understood. Resident 12 rarely never understands others. Resident 12 had no physical, verbal or other behavioral symptoms directed towards others e.g., hitting, kicking, pushing, scratching, grabbing or screaming at others, verbal/vocal symptoms like screaming or disruptive sounds. MDS indicated Resident 12 had no potential indicators of psychosis. Resident 27's diagnoses included Non-Alzheimer's Disease (a group of diseases characterized by progressive deficits in behavior, executive function or language). During a review of Resident 12's Order Summary Report dated 9/25/24, indicated the physician prescribed Resident 12, Zyprexa oral tablet 7.5 mg give one tablet by mouth two times a day for psychosis disorder manifested by continuous calling out causing distress. During a review of Resident 12's Medication Administration Record (MAR), dated 12/1/24 to 12/3/24 and 11/12/24 to 11/30/24 indicated Resident 12 was administered zyprexa 7.5 mg give one tablet by mouth two times a day for continuous calling out causing distress. During a review of Resident 12's Pre-admission Screening Resident Review (PASRR) Level 11 evaluation (a federal requirement to ensure that residents are not inappropriately placed in nursing homes for long term care) dated 4/25/23, the PASRR indicated Resident 12 had no serious mental illness. During an observation on 12/02/24 at 9:44 a.m. Resident 12 laid in bed, awake verbal with incomprehensible sounds. During an interview on 12/03/24 at 9:36 a.m. with Licensed Vocational Nurse (LVN 1), LVN1 stated Resident 12 was administered Zyprexa for continues calling out that caused Resident 12 distress. LVN1 said Resident 12's distress was presented by facial grimacing, wanting to say something but unable to verbalize thoughts. LVN 1 stated despite administration of Zyprexa Resident 12 continued to continuously call out for from time to time. LVN 1 stated Resident 12 sometimes had behaviors and sometimes no behaviors. LVN 1 could not provide documentation of episodes of grimacing and the provision of non-drug interventions. During a review of Resident 12's alteration in behavior care plan, initiated 10/11/24, Resident 12's care plan indicated Resident 12 had behaviors: continuously calling out causing distress, refusing care/restlessness, and climbing out of bed . Interventions included: encourage increased socialization and participation in activities as a therapeutic use of distraction. During a concurrent observation and interview on 12/05/24 at 8:30 a.m. with Certified Nursing Assistant (CNA3) in Resident 12's room, Resident 12 laid in bed awake. CNA3 stated he was Resident 12's care giver. CNA3 stated Resident 12 mumbles to her self, was pleasant and had no combative behavior. During a concurrent interview and record review on 12/03/24 at 12:04 p.m. with Director of Nursing (DON), Resident 12's behavioral care plans were reviewed. DON stated Resident 12's behavior manifested by continuously calling out and talking loud non stop caused distress. DON stated Resident 12's distress included sore throat. DON could not provide documentation of episodes of Resident 12's sore throat and interventions provided. DON stated Resident 12's behavioral interventions included encourage increased socialization. During an interview on 12/05/24 at 9:19 a.m. with Activities Director (AD), AD stated Resident 12 liked to socialize and enjoyed activities. AD stated Resident 12 had not attended activity programs for a long time. AD could not provide Resident 12's activity attendance record. During an interview on 12/03/24 at 1:36 p.m. with Social Service Director (SSD), SSD stated Resident 12 mumbles at times . SSD stated Resident 12 was not agitated or combative. SSD stated Resident 12's mumbling did not cause her distress. During a review of the facility's policy and procedure (P&P) titled, Antipsychotic Medication Use, revised July 2022, the P&P indicated, Antipsychotic medications shall generally be used only for the following conditions/diagnosis i.e. psychosis in the absence of dementia. Antipsychotic medications will not be used if the only symptoms are one or more of the followings: a. Wandering b. Poor self care c. Restlessness d. impaired memory e. Mild anxiety f. Insomnia g. Inattention or indifference to surroundings h. sadness or crying alone i. Fidgeting j. Nervousness k. Uncooperativeness

Based on observation, interview and record review, the facility failed to provide nutritious vegetarian meals (foods that do not contain meat, but only fruits, vegetables, and dairy products) to meet nutritional needs for one of seven sampled residents (Resident 16). Facility did not recognize, intervene and/ or evaluate Resident 16's 23 pounds (lbs.), a significant amount of weight loss during a six-month period. This failure resulted in Resident 16 to lose five (5) more lbs. over the following 2 weeks from first six months, leading to 28 lbs. weight loss in over six months, feeling of weakness, consistent hunger and psychological distress, frequently eating snacks such as chips and cookies. Resident 16 remained at high risk for continued weight loss, malnutrition (not getting proper/enough nutrients for the body), a decline in functional status and further psychological distress. Findings: During a review of Resident 16's admission record titled Resident Face Sheet dated 8/31/23, the Face Sheet indicated, Resident 16 was admitted to the facility on ,d+[DATE]. During a review of Resident 16's Minimum Data Set (MDS- an assessment tool to guide care) dated 7/11/23, the MDS assessment indicated, Resident 16's Brief Interview for Mental Status (BIMS- a mental status exam) was 15 out of 15, indicating intact mental status. The MDS assessment indicated, Resident 16 had active diagnoses of Hypertension (high blood pressure), Renal Insufficiency (poor kidney function), Diabetes Mellitus (a disease characterized by elevated levels of blood glucose), Hyperlipidemia (high concentration of fats in the blood) and Depression (mood disorder that causes a persistent feeling of sadness and loss of interest). The MDS assessment also indicated, Resident 16 required supervision with eating. During a record review of Resident 16's Nutrition/Hydration status Care Plan dated 4/7/20, the Care Plan indicated, Resident 16 had an alteration in nutritional status related to therapeutic diet, hypertension, hyperlipidemia, chronic kidney disease, vitamin B12 deficiency . The care plan indicated, the goal for Resident 16 was to not have a significant weight loss/gain .The care plan indicated, to provide following interventions: controlled carbohydrate mechanical soft diet, no red meat, poultry, fish or eggs, to monitor/ assess food preferences, monitor labs as ordered, encourage family to bring in favorite foods/ snack, encourage 75% or more of meals, if intake is less than 75%, offer substitutes . During a review of Resident 16's Order Summary Report dated 9/1/23 indicated Resident 16's Physician ordered diet was Controlled Carbohydrate (CCHO-low carbohydrate) diet. Mechanical Soft texture (foods that break apart without a knife designed for patients who have trouble chewing or swallowing). No red meat, poultry, fish, or eggs. Ground food with plain yogurt. During a review of Resident 16's food preference document titled Food & Nutrition Service Director Nutrition Chart Review and Interview dated 4/28/23, the Dietary Supervisor (DS) documented Resident 16's food preference was vegetarian, without details of options in vegetarian foods. The document also indicated Resident 16 disliked meat, fish and eggs. During an observation and interview on 8/28/23 at 12:09 p.m., with Resident 16, in Resident 16's room, Resident 16 was lying in bed awake. Resident 16 stated, she was a vegetarian and facility served her foods such as mashed potatoes, mashed sweet potatoes, yogurt, ice cream and milk. Resident 16 stated, she sometimes had lentil soup prepared and brought to her by a family member. Resident 16 stated, she would like more variety of Indian style vegetarian foods, if she can. Resident 16 stated, she recently had a few bottom teeth extracted and ate soft foods. Resident 16 stated, the facility stored her uneaten food brought from home, but would not reheat the leftovers. Resident 16 stated, she had lost about 25 lbs. in the last few months. Resident 16 had a clear, plastic, gallon sized ziplock bag with two (2) packs of [NAME] chocolate [NAME] cookies and two (2) packs of [NAME] golden [NAME] cookies in the bed next to her. Resident 16 stated, facility staff brought her these cookies which she would dip in tea or milk and ate often. During a concurrent interview and record review on 8/31/23 at 11:22 a.m. with the Minimum Data Set Coordinator (MDSC), Resident 16's electronic medical record for Weights and Vitals was reviewed. The record indicated, Resident 16's weight on 2/1/23, 8/2/23 and 8/17/23 was 227 lbs., 204 lbs., and 199 lbs. respectively indicating a significant weight loss of 28 lbs. The MDSC stated, Resident 16 was overweight and is happy with the weight loss. The MDSC stated, Resident 16 had a few teeth extracted in 7/2023, and was in process of getting new dentures. The MDSC stated the Assistant Director of Nursing (ADON), Registered Dietician (RD) and Resident 16's Physician (MD 2) were involved in Resident 16's plan of care, especially regarding weight changes. During an interview on 8/31/23 at 11:46 a.m. with the ADON, ADON stated, the Nursing Assistants weighed the residents and notified her about weight variance. The ADON stated, facility then had an Interdisciplinary team (IDT-team members from different departments who work together to resolve patient care problems) meeting to review residents' plan of care. The ADON stated RD and Activities Director (ACT) were part of the weight meeting. The ADON stated, Resident 16 was a strict vegetarian, so the diet options were limited for her at the facility. The ADON stated, she was aware of Resident 16's weight loss and the RD had made recommendations to monitor Resident 16's Hemoglobin A1c (test that shows what a patient's average blood glucose level was over a period of two to three months) on a quarterly basis. The ADON stated, there were no other labs such as Albumin (blood test done to measure absorption of protein levels in the body) ordered or completed to assess nutritional status of Resident 16. During a concurrent observation and interview with Certified Nursing Assistant (CNA) 4 on 8/31/23 at 12:18 p.m., in the hallway outside of Resident 16's room, Resident 16's lunch tray was observed. On Resident 16's tray was 1/3 cup (c) of white rice, 1/3 c. of mashed potatoes with gravy, 1/2 c. of herbed green beans, two (2) wheat rolls, 1/2 c. of chopped watermelon pieces and one 4-oz glass of milk. During a follow up observation and interview with Resident 16 on 9/01/23 at 7:09 a.m., Resident 16's breakfast tray was observed. On Resident 16's breakfast tray was two slices of brown bread, one cup of oatmeal, one 4-oz cup of coffee and one 4-oz cup of cold milk. Resident 16 stated she was going to eat only oatmeal with milk and coffee; because she was not fond of bread and the facility staff knew about that. Resident 16 stated she also did not eat lunch served to her on 8/31/23. Resident 16 stated, she felt weak and had no energy on a consistent basis. Resident 16 stated, it has been going on for months. Resident 16 stated, she would like to eat Indian vegetarian home food however she could not. Resident 16 stated, she was about to fall the other day after her shower because she was feeling so weak. Resident 16 stated, she ate crackers and cookies all day long to keep herself full. Resident 16 stated, she had lost interest in watching TV and checking messages on her phone. Resident 16 stated, she was just lying in the bed for the most part of the day every day. Resident 16 stated, she was not happy about her weight loss. During an observation in Resident 16's room on 9/01/23 at 9:01 a.m. with CNA 4, the following items were observed on Resident 16's beside nightstand and overbed tray: one 8-oz plastic container of [NAME] Biscuits, one 12.3 oz box of Papadi chickpea flour crisps, 12-1/2 oz bags of chips of different varieties [including nacho cheese flavored Doritos, Cheetos crunchy and Lays potato chips], 2 packs of [NAME] chocolate [NAME] flavor cookies, 2 packs of [NAME] golden [NAME] flavor cookies and three 1-oz package of Chips Ahoy miniature chocolate chip cookies. During a telephone interview with the RD on 8/31/23 at 1:16 p.m., RD stated, she had been following Resident 16's weight variance for a long time. RD stated, Resident 16 was not on a physician prescribed weight loss regimen (the process of losing weight with the help and guidance of a healthcare professional). RD stated, Resident 16 preferred an Indian vegetarian diet and it was hard to know if Resident 16 was eating enough protein because Resident 16 had a lot of snacks at the bedside. During a review of Resident 16's nutritional care assessments titled Registered Dietitian assessment dated [DATE], 4/13/23, and 7/19/23, the nutritional assessment indicated, the following: facility provided 1900 Kilocalories (kcal) calories, 96 grams (gm) of protein while she required 1750-2100 kcal and 70-84 gm of protein every day .resident has many containers of food at her bedside from outside sources .nutritional goal was to slow weight loss . continue diet as ordered . perform appropriate labs as ordered without any clear indication of what were the appropriate labs for Resident 16. The assessment dated [DATE] also showed [Resident 16]'s needs weren't always met with current diet and intake, however there was no indication of change in plan of care. During a concurrent interview and record review with the Dietary Supervisor (DS) on 9/01/23 at 10:38 a.m., in facility's kitchen, facility's cooks spreadsheet document titled, Summer Menus for the week of 6/5/23 was reviewed. The DS stated, she and her staff, including Cooks followed the same Summer Menus sheets to prepare and plate the portion size of foods for all residents who consumed food prepared in facility's kitchen even during the week of 8/28/23. The DS stated, the document showed the menu for residents who consumed the following types of diets: 1. Regular, 2. Mechanical soft (foods that break apart without a knife designed for patients who have trouble chewing or swallowing), 3. Pureed (foods have a soft and pudding-like consistency), 4. Dysphagia Mechanical (for people who have trouble swallowing), 4. Two gram Sodium (low salt) 5. Controlled Carbohydrate (CCHO-low carbohydrate) and quantity for Small, Regular, and large portions for above mentioned types of diets. The spreadsheet did not have Menus for Vegetarian dishes and/or their portion sizes. During an interview with the DS on 9/1/23 at 10:45 a.m., in DS office, the DS stated, she was unable to find written vegetarian options available at the facility. The DS stated, the RD was responsible to review and approve each menu each month however, she was unable to provide a copy of any signed and approved menus. The DS stated, the facility substituted meat items for vegetarian residents with veggie nuggets, veggie patties, tofu, yogurt, lentils, and cheese. During an observation and interview on 9/1/23 at 10:55 a.m., in facility's kitchen, with DS, three packs of 14-Ounces (Oz.) Tofu was stored in the Walk-in refrigerator, a large cardboard box with frozen Veggie patties on the kitchen counter and lentils/grains were stored in dry storage area. There was no evidence of availability of Veggie nuggets, and/ or Cheese. The DS stated, we don't cook Paneer (the Indian style Cheese). The DS stated at times, the facility prepared Spinach and Tofu and Lentil Soup for vegetarian residents. The DS was unable to state how frequently did the facility serve Spinach-Tofu and Lentil Soup to Resident 16, and if there were more dishes available to meet her protein, fat and carbohydrate needs. During an interview and record review on 9/1/23 at 11:05 a.m., in facility's kitchen, with DS and Cook 1, two binders titled Recipe Book #1 and Summer Recipe Book were reviewed. The DS stated, she was unable to find a recipe on how to make the lentil soup, tofu and or any vegetarian dish. The DS stated, her staff, including Cook 1 just knew how to make certain Vegetarian foods. Cook 1 confirmed she never followed a recipe to cook Vegetarian meals. During a telephone interview with MD 2 on 9/01/23 at 11:07 a.m., MD 2 stated, he was aware of Resident 16's weight loss however she was not on a physician prescribed weight loss regimen. MD 2 stated, he was under the impression that facility had a vegetarian menu to meet Resident 16's nutritional needs and was unaware the facility actually did not have a vegetarian menu. MD 2 also stated, he relied on the RD to intervene for Resident 16's weight loss and did not know that Resident 16's plan of care from 6 months ago was not change nor updated since Resident 16 began losing weight. During an interview with LVN 14 on 8/31/23 at 12:16 p.m. in the hallway outside of Resident 16's room, LVN 14 stated, facility staff could not reheat food brought from home because the staff did not have a food thermometer available at the facility to check the temperature of the reheated food. During an interview with ACT on 9/01/23 at 9:20 a.m., ACT stated, Resident 16 has not seemed like herself lately, she was more energetic in the past, is now less energetic and has been withdrawn. During an interview with Restorative Nursing Assistant (RNA) 1 on 9/01/23 and 9:28 a.m., RNA 1 stated, she worked with Resident 16 for range of motion exercises. RNA 1 stated, she observed a decline in her health; and stated, she seems different over the past one to two months. During a review of facility's Policy & Procedure (P&P) titled RDs for Healthcare, Inc. Weight Change Protocol dated 2018 indicated, The RD will assess, nutritionally diagnosis, suggest interventions, monitor and evaluate success of the interventions .Assessment: .Determine if the: .meals sent to resident meet their needs and goals .Interventions: .allow for food preferences (cultural, customary) using selections, foods from home .Evaluation: .The evaluation process is done again if there is another significant weight change. Interventions are changed if not effective. During a review of the Facility Assessment (an assessment about facility's residents population and services provided to the residents) document dated 4/14/2023 indicated, 1.6: Our facility provides a variety of activities and psycho-social support to the multicultural population we serve. This includes .food preferences .Resident food preferences are honored based on likes and dislikes, culture, and diet restrictions. Families are encouraged to bring homemade foods .

Based on interview and record review, the facility failed to ensure if safe skilled nursing care was provided to all 62 residents residing at the facility when Licensed Nurses (LNs) including, three of three sampled Registered Nurses (RNs) and 12 of 12 sampled Licensed Vocational Nurses (LVNs) who had been working at the facility for more than one year, did not receive an annual competency assessment (a measure of an employee's knowledge, skills and behaviors used in performing specific job tasks) since their date of hire. This failure had the potential to cause compromised skilled nursing care to all 63 residents residing in the facility. Findings: During a review of facility's untitled, undated, document for current nursing employee list, the employee list indicated, the facility employed 17 direct care LNs including 12 LVNs and three (3) RNs whose hire dates ranged from 4/26/2002 till 8/18/2023. During a concurrent interview and record review on 8/31/23 at 10:30 a.m. with Director of Staff Development (DSD), LVN 2 and LVN 3's personnel files were reviewed. DSD stated, LVN 2 was hired on 8/31/2004 and LVN 3 was hired on 5/29/2009. DSD stated, there were no competency skills check found on both files since their date of hire. During a concurrent interview and record review on 8/31/23 at 10:45 a.m. with DSD, personnel files for sampled three RNs and 12 LVNs were reviewed. The DSD stated, RN 1, RN 2 and IP were hired on 8/16/21, 10/17/15 and 10/16/18 respectively. The DSD stated, LVN 1, LVN 4, LVN 5, LVN 6, LVN 7, LVN 9, LVN 10, LVN 11, LVN 12 and LVN 14 were hired on 11/14/05, 7/1/03, 12/03/13, 2/17/22, 6/16/10, 10/07/15, 6/1/22, 10/21/16, 4/26/02 and 2/27/08 respectively. The personnel files indicated, all 15 sampled nurses were working at the facility for more than a year. The DSD stated, there were no competency skills check found on all the files. The DSD stated, the Director of Nursing (DON) was responsible for LNs annual competency evaluation. During an interview on 8/31/23 at 1:50 p.m., the DON stated, she checked LNs skills during her rounds/observations. The DON stated, most LNs worked in the facility for number of years and were familiar with resident's needs. The DON stated, she did not complete competency assessment/evaluation for any LNs on an annual basis. During an interview on 9/1/23 at 11:15 a.m. with Administrator (Admin), the Admin stated, he expected the DON to conduct the required annual competency assessment for LNs and he was not aware that LNs competency assessments weren't done since their date of hire. During a review of the facility's undated Policy and Procedure (P&P) titled, Knowledge and Skills Competency Evaluation, the P&P indicated, In an effort to provide optimal clinical care, direct care nursing staff are required to meet minimum standards before caring for residents. Knowledge and skill competencies are evaluated upon hire, annually thereafter and as needed, as indicated by job performance, newly introduced procedures, specific techniques required for an individual resident or new products and equipment .Employees will be evaluated as part of their annual performance review. They will also be evaluated on an ongoing basis by senior staff members and/or external consultants to ensure that their skills and knowledge are still sharp.

Based on observation, interviews and record review, the facility failed to ensure food are stored under sanitary conditions when; The following food items in refrigerator were not labeled and no use by date: One bottle of jalapeno peppers opened 8/8/23 with no use by date One container of garlic in water opened, unlabeled with no use by date One container of beef base opened with no use by date Walk in freezer was cluttered with several boxes of food items. These failures had the potential to result in food borne illnesses. Findings: During the initial tour of the kitchen on 8/28/23 at 10:30 a.m., accompanied by Dietary Supervisor (DS) the followings were observed in the walk-in refrigerator; one bottle of jalapeno peppers opened 8/8/23 with no use by date; one container of garlic in water opened and unlabeled with no use by date; one container of beef base opened with no use by date. Walk-in freezer was cluttered with several boxes of food items over each other and tightly packed with no space to check food items. During an interview on 8/28/23 at 10:43 a.m. with DS, DS stated, food items must be labeled and dated when opened and placed in the refrigerator with use by date. DS stated, the walk-in freezer was cluttered since when she was hired 10 months ago. Review of the facility's policy and procedure, titled Labeling and Dating of Foods dated 2020, indicated ; All food items in the storeroom, refrigerator, and freezer need to be labeled and dated.

Based on observation, interview and record review, the facility failed to follow food safety requirements when following was noted: 1. Food items kept in the refrigerator designated for food brought from outside the facility were not labeled and not separated from staff's food. 2. Facility did not allow heating/ reheating cold food leftovers for residents brought from outside. These failures had the potential to cause foodborne illness for residents in the facility. Findings: During a concurrent observation and interview on 8/31/23 at 12:04 p.m. with the Assistant Director of Nursing (ADON), at nursing station one's medication room, the ADON opened a 3.7 cubic foot refrigerator located inside nursing station one's medication room. A small, circular, clear, plastic container that contained small, chopped pieces of yellow food labeled with Resident 16's name, dated 8/29/23; and a small, clear, unlabeled and undated container with a blue lid that contained white pasta was in the refrigerator. The ADON stated, facility policy was to label food with the item and use by date. The ADON stated, she was unable to find who the unlabeled food belonged to. Licensed Vocational Nurse 1 (LVN 1) then walked in the medication room and stated, the unlabeled and undated container with the blue lid belonged to them. LVN 1 stated, staff food should not be stored in the refrigerator designated for residents' food brought from outside the facility. During an interview with LVN 14 on 8/31/23 at 12:16 p.m., LVN 14 stated, she was unable to reheat food for residents because staff did not have food thermometer available to check the temperature of the food. During an interview with Certified Nursing Assistant (CNA) 4 on 8/31/23 at 12:18 p.m., CNA 4 stated she was unaware that staff was to label the date on residents' food/ leftovers brought from outside prior to keeping them in the refrigerator. CNA 4 stated, she labels leftover food items only with residents' name. During an interview with Family Member 1 (FM 1- family of a resident who was identified as eating food from home) on 9/1/23 at 9:42 a.m., FM 1 stated, they never received a copy of the facility's foods brought by family/visitors policy. FM 1 stated, facility staff told them that they would not warm food brought from home and to only bring enough food for that specific mealtime. During a review of the facility's Policy and Procedure (P&P) titled Foods Brought by Family/Visitors revised 10/ 2017, the P&P showed, .Facility staff will strive to balance resident choice and a homelike environment .2. Nursing staff will provide family/visitors who wish to bring foods to the facility with a copy of this policy. Residents will also be provided a copy in a language and format he or she can understand .7b. Perishable foods must be stored in re-sealable containers with tightly fitting lids in a refrigerator. Containers will be labeled with the resident's name, the item and the [use by] date .

Based on observation, interviews and record review the facility failed to maintain ice machine in a safe and proper working condition when ice machine located in the kitchen was not sanitized per manufacturers instructions. This failures had the potential to result in food borne illnesses. Findings: During an observation and concurrent interview on 8/28/23 at 11:12 a.m., the ice machine located in the kitchen was filled with water and small tiny ice floating in the ice bin. DS stated, the ice machine was not harvesting ice properly, freezes from time to time and had to be unplugged to dispense ice. DS said she had complained about the ice machine not making proper ice for several months. During an interview on 8/29/23 at 9:33 a.m., with Cook (CK), CK stated, ice machine freezes up ice and had to be un plug from time to time. Ck stated, the ice from ice machine are used in the kitchen, distributed to ice chest placed outside the nurses station for residents use. CK stated, she had worked in the Kitchen for [AGE] years. During an interview on 8/29/23 at 9:35 a.m., with Dietary Aide (DA 2), D2 stated, ice from ice machine are distributed to ice chest cooler, place at the nurses station and hall ways for residents' use. During an interview on 8/31/23 at 9:52 a.m., with Administrator (Admin), Admin stated, ice machine started having problem with harvesting ice from time to time in June 2023. Admin stated, the ice machine problem progressing got worse. Admin stated, Ice machine was last sanitized in June 2023. Admin stated, routine ice machine sanitation was not included in the preventative maintenance contract. During an interview on 8/31/23 at 1:22 a.m., with Registered Dietician (RD), RD stated, she visited facility weekly on Thursdays. RD stated she checked kitchen for sanitation practices. RD stated, she was aware the ice machine was having trouble making ice from time to time. RD stated, she had not looked for the ice machine sanitation log. During an interview on 9/1/23 at 10:39 a.m., with DS, DS stated, she was told by Maintenance Supervisor (MS) that the ice machine was to be sanitized annually by an outside contractor. DS stated ice machine could incubate bacteria when not sanitized per manufacturer instruction. Review of the Maintenance Manual-Ice Series Cubers date 02/2020, indicated; General Maintenance Procedure; Cleaning Instruction for Ice-O-Matic CIM Series Ice Machines: Note: Proper cleaning of an ice machine requires two parts: descaling and sanitizing. Sanitizing should be performed after each descaling but no more than once per month. Sanitizing disinfects the machine and removes microbial growth including mold and slime. Ice-O-Matic requires anickel-safe sanitizer such as Nu-Calgon ImS-III or equivalent diluted per manufacturer instructions. To insure economical, trouble free operation of your machine, it is recommended that the following maintenance be performed every 6 months. Clean the ice-making section per the instructions below: Routine cleaning with Cleaning should be performed a minimum of every 6 months. Local water conditions may require that cleaning be performed more often. (Reference: www.iceomatic.com)

Based on interview and record review, the facility failed to have a Registered Nurse (RN) on duty for at least eight consecutive hours for nine weekends during the month of June, July and August of 2023. This failure had the potential to place residents residing at the facility at risk to receive limited nursing assessment and compromised health and safety. Findings: During an interview on 8/30/23 at 11:49 a.m. with Licensed Vocational Nurse (LVN 14), LVN 14 stated, there were no RN on duty on some weekends but she was unable to remember the exact dates with no RN coverage. During an interview on 8/30/23 at 12:02 p.m. with Certified Nursing Assistant (CNA 3), CNA 3 stated, facility had only LVNs working during weekends. During a review of Licensed Nurses (LNs) monthly schedule, dated June 2023, July 2023 and August 2023, the schedule indicated, weekends with respective dates of 6/4/23, 6/18/23, 6/25/23, 7/9/23, 7/22/23, 7/23/23, 7/29/23, 7/30/23, 8/5/23, 8/6/23, 8/12/23, 8/13/23 and 8/20/23, no RN who was scheduled to work. During a concurrent interview and record review on 8/30/23, at 1:18 p.m., with Payroll/Human Resource (P/HR), the facility's document titled, Nursing Staffing Assignment and Sign-In Sheet, dated 6/4/23, 6/18/23, 6/25/23, 7/9/23, 7/22/23, 7/23/23, 7/29/23, 7/30/23, 8/5/23, 8/6/23, 8/12/23, 8/13/23 and 8/20/23 were reviewed. The P/HR stated, staff on duty signed the assignment sheet every time they came to work. P/HR stated, there were no RNs who signed the assignment sheet for the dates reviewed. During an interview on 9/1/23 at 7:52 a.m., LVN 2 stated, lack of RN coverage was difficult for the LVNs to handle residents' emergencies such as falls, bleeding, intense pain and difficulty breathing, she had to phone/call an RN for advice on assessment/intervention. LVN 2 also stated, the time spent in calling an RN and the Doctor caused delayed treatment that could further worsen the resident's condition. LVN 2 stated, an RN coverage was essential daily including the weekends, due to their advanced assessment skills and decision-making process. During an interview on 9/1/23 at 8:39 a.m., the DON stated, an absence of RN in the facility would potentially decrease the excellence of care and health of residents living at the facility.

Based on observation, interview, and record review, the facility failed to label according to accepted professional principle and did not safely store drugs and biologicals under proper temperature controls when: 1. Temperature of medication refrigerator on Stations 1 & 2's Medication Room were not within the recommended temperature range. 2. Expired pharmaceutical products were stored in Medication Cart #2. 3. Pharmaceutical products stored in Med Cart# 2 were opened and not dated. 4. Non-pharmaceutical products were stored in the Medication Cart #2. This failure had the potential for residents to receive ineffective medications and treatments. Findings: 1. During a concurrent observation and interview on 8/28/23 at 11:22 a.m. with Licensed Vocational Nurse (LVN) 1 in the medication room [ROOM NUMBER], LVN 1 stated, the temperature of the medication refrigerator containing pharmaceutical products, was 32-33 degrees Fahrenheit (unit of measurement). LVN 1 stated, the recommended temperature is 36-46 F. During a concurrent observation and interview on 8/29/23 at 9:37 a.m. with LVN 1 in the medication room [ROOM NUMBER], LVN 1 stated, the temperature of the medication refrigerator was 32 F- out of acceptable range. During an interview on 8/29/2023 at 11:02 a.m. with Director of Nursing (DON), the DON stated, the medications in the refrigerator would not be effective, if stored outside the recommended temperature range of 36 F - 46 F. During a review of facility's document titled Temperature Log, dated August 2023, the document indicated the medication refrigerator acceptable range: 36 F - 46 F. 2. During an inspection on 8/28/23 at 11:27 a.m. of medication cart 2 in nursing Station 2, LVN 14 verified, two insulin pens (medication used to lower high blood sugar levels) and one insulin bottle was out of date. During an interview on 8/29/23 at 11:05 a.m. with the DON, the DON stated expired medications should have been pulled out of the medication cart as the expired medications will not be effective. During a review of the facility's policy and procedure (P&P) titled, Storage of Medications, dated April 2007, the P&P indicated, All medications maintained in the facility shall be properly labeled in accordance with current state and federal regulations .the facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed. 3. During an inspection on 8/28/23 at 11:29 a.m. of medication cart 2 in nursing Station 2, LVN 14 verified two bottles of blood glucose strips (test strips used to measure the blood sugar level in the blood) had no open date. During an inspection on 8/28/23 at 11:31 a.m. of medication cart 2 in nursing Station 2, LVN 14 verified three bottles of latanoprost eyedrop (used to treat eye condition) had no open date and a bottle of brimonidine tartrate eyedrop (also used to treat a certain eye condition) had an unreadable black marking. During an interview on 8/29/23 at 11:35 a.m. with LVN 14, LVN 14 was unable to determine the proper expiration date for the pharmaceutical products. During an interview on 8/29/23 at 11:37 a.m. with DON, she stated eyedrops and blood glucose strips were to be labeled with open date once opened. DON stated, eyedrops expires within 28 days and blood glucose strips were according to manufacturer's expiration date. During a review of the facility's policy and procedure (P&P) titled, Labeling of Medication Containers, dated April 2007, the P&P indicated, All medications maintained in the facility shall be properly labeled in accordance with current state and federal regulations .Medication labels must be legible at all times .Any medication packaging or containers that are inadequately or improperly labeled shall be returned to the issuing pharmacy .Labels for each floor's stock medications shall include all necessary information, such as: the expiration date when applicable. 4. During an inspection on 8/28/23 at 11:33 a.m. of medication cart 2 locked box for controlled drugs, LVN 14 verified items of: jewelry on a zip lock bag, keys on a plastic container, an opened box of wander guard (device worn by resident to alert staff when resident wanders out of the facility) wander guard testing device, and envelope with a black paper clip. During an interview on 8/29/23 at 11:35 a.m. with LVN 14, LVN 14 acknowledged that the non-pharmaceutical products should not have been stored in the medication cart. During an interview on 8/29/2023 at 11:39 a.m. with DON, DON she stated, medications only should be on the medication carts. The DON also acknowledged that having random non-pharmaceutical items in the medication cart could potentially contaminate the medications stored in the cart. During a review of the facility's policy and procedure (P&P) titled, Storage of Medications, dated April 2007, the P&P indicated, The facility shall store all drugs and biologicals in a safe, secure, and orderly manner .The nursing staff shall be responsible for maintaining medication storage and preparation areas in a clean, safe and sanitary manner.

Based on interviews and record review, the facility failed to ensure three (Resident 12, 28 and 40) of five sampled residents were free from unnecessary drugs when; Resident 12, 28 and 40 with Alzheimer Dementia were administered antipsychotic medications without adequate clinical indication for use: Resident 12 was administered Olanzapin (Zyprexa) an antipsychotic medication for fighting and resisting care. Resident 28 was administered Risperdal an antipsychotic for people conspiring against her. Resident 40 was administered Seroquel an antipsychotic for combativeness and hitting staff for no reasons. {Alzheimer's Dementia-is a progressive disease that destroys memory and other important mental functions}. {Antipsychotic medication are drugs used to treat schizophrenia and bipolar serious mental health conditions, capable of affecting the mind, emotions, and behavior}. According to the manufacturer, elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death. Risperidal, Seroquel and Zyprexa can increase the risk of death in elderly people who have memory loss and is not approved for use in psychotic conditions related to dementia. [Reference: https://www.[NAME].com]. These failures had the potential for residents to receive unnecessary drugs and to suffer adverse medication side effects. Findings: Review of Minimum Data Set (MDS), Resident Assessment and care guide tool, dated 7/17/23, MDS indicated, Resident 12 had short-term and long-term memory problems. Resident 12 was incoherent with rambling conversation was not able to express herself and could not understand others. Resident 12 exhibited no physical or verbal behavioral symptoms towards others such as hitting or scratching and screaming. Resident 12's diagnoses included Non-Alzheimer's Dementia (a group of diseases characterized by progressive deficits in behavior, executive function or language), Review of alteration in behavior care plan initiated 4/12/19, care plan indicated, Resident 12 had behavior manifested by calling out continuously, refuses care/ restlessness, refuses to wear armband and climb out of bed. Review of order summary report dated 6/30/23, summary report indicated, physician prescribed Resident 12 Olanzapine (Zyprexa) 10 mg give one tablet via G-Tube (tube inserted through the belly that brings nutrition directly to the stomach) at bedtime for psychotic disorder manifested by disorganized behavior, fighting and resisting care. Review of the Medication Administration Record (MAR), dated June, July and August 2023, MAR indicated, Resident 12 was administered Zyprexa 10 mg by via G-tube at bedtime for fighting and resisting care. During an interview on 8/29/23 at 8:51am, with Resident 12, in bed in her room. Resident 12 was verbal with incomprehensible sounds. During an interview on 8/29/23 at 8:55 am, with Certified Nursing Assistant (CNA1), CNA1 stated, she was Resident 12's care giver during the morning shift. CNA1 stated, Resident 12 had no behavioral problems, no kicking or fighting. CNA 1 said Resident 12 only screams and talks aloud sometimes. During an interview on 8/31/23 at 10:23 am, Licensed Vocational Nurse/Nurse Supervisor (LVN1) in the presence of Director of Nursing (DON), LVN1 stated, Resident 12 was referred to the psychiatrist and was prescribed Zyprexa for fighting and kicking staff. Review of Consultant Pharmacist note to attending physician, dated 10/19/22, the pharmacist note indicated, Resident 12 has been receiving the antipsychotic medication Zyprexa 10 mg every hour of sleep since 7/2022 for behavioral and psychological symptoms of psychosis/dementia. Please evaluate for possible discontinuation or gradual dose reduction. Further review indicated, the attending physician/Physician Assistant ordered no change to current order. Review of Minimum Data Set (MDS), Resident Assessment and care guide tool, dated 7/29/23, MDS indicated, Resident 28 had clear speech, able to express herself and could understand what others said to her. Resident 28 exhibited no physical or verbal behavioral symptoms towards others such as hitting, kicking, scratching and screaming. Resident 28's diagnoses included Non-Alzheimer's Dementia and psychotic disorder (a mental disorder characterized by a disconnection from reality) Review of alteration in behavior care plan initiated 8/2/21, behavior care plan indicated, Resident 28 behavior manifestation included agitation causing distress and paranoia related to diagnosis of dementia, depression, anxiety and psychosis. Review of order summary report dated 9/10/22, the order summary report indicated, physician prescribed Resident 28 Risperidone tablet 0.25 mg give one tablet by mouth at bedtime for paranoid thoughts. Review of the Medication Administration Record (MAR), dated June, July and August 2023, the MAR indicated, Resident 28 was administered Risperidone tablet 0.25 mg give one tablet by mouth at bedtime for paranoid thoughts. During an interview on 8/29/23 at 10:38 am, with CNA2, CNA2 stated, Resident 28 was pleasant and had no aggressive behavior. CNA2 stated, she was a regular' care giver for Resident 28 during morning shift. During an interview on 8/29/23 at 10:42 am, withLicensed Vocational Nurse (LVN3), LVN3 stated, Resident 28 behavioral symptoms for use of risperdal included refusing medication During an interview on 8/31/23 at 10:23 am, with LVN1 in the presence of DON, LVN1 stated, Resident 28 diagnosis was dementia. After psychiatrist consultation Resident 28 was prescribed Risperdal and diagnosed with psychosis for paranoid thought, people conspiring against her. Review of Consultant Pharmacist note to attending physician, dated 11/28/22, the consultant pharmacist note indicated, Resident 28 had been receiving the antipsychotic medication Risperdal 0.25 mg every hour of sleep since 8/2022 for behavioral and psychological symptoms of psychosis/dementia. Please evaluate for possible discontinuation or gradual dose reduction. During an interview on 9/1/23 at 9:46 a.m., in the presence of DON, with Resident 28's physician (MD 1), MD1stated, Resident 28 felt her family did not frequently visit and support her. MD1 stated, low dose Risperdal was prescribed to make Resident 28's life comfortable. Review of Minimum Data Set (MDS), Resident Assessment and care guide tool, dated 6/18/23, MDS indicated, Resident 40 had a clear speech, sometimes understood and respond adequately to simple direct communication only. Resident 40 exhibited no physical or verbal behavioral symptoms towards others such as hitting, kicking, pushing, screaming at others, scratching or grabbing. Resident 40's diagnoses included Non-Alzheimer's Dementia. Review of alteration in behavior care plan initiated 8/12/21, the care plan indicated, Resident 40 had behavior manifested by striking out, angry outburst, kicking and continuous yelling and screaming. Review of order summary report dated 4/3/23, the order summary report indicated, physician prescribed Resident 40 Seroquel tablet 25 mg give one tablet by mouth at bedtime for dementia with behavior disturbances manifested by combativeness, hitting staff for no reason. Review of the Medication Administration Record (MAR), date June, July and August 2023, the MAR indicated, Resident 40 was administered Seroquel tablet 25 mg one tablet by mouth at bedtime for dementia with behavior disturbances. During an observation on 8/29/23 at 8:59 am, Resident 40 was awake in bed in her room. Resident 40 was pleasant, smiled and whispered during conversation. Resident 40 stated, she was okay. During an interview on 8/29/23 at 9:00 am, with CNA 1, CNA1 stated, Resident 40 was pleasant and no behaviors. During an interview on 8/29/23 at 9:03 a.m., with LVN2, LVN2 stated, Resident 40's behavioral symptoms included throwing object, combativeness, agitation and restlessness. Review of Consultant Pharmacist note to attending physician, dated 10/19/22, Pharmacist note indicated, Resident 40 has been receiving the antipsychotic medication Seroque 12.5 mg every morning since 7/2022 for behavioral and psychological symptoms of psychosis/dementia. Please evaluate for possible discontinuation or gradual dose reduction. Further review indicated the attending physician/Physician Assistant ordered no change to current order. Review of the facility's policy and procedure, titled, Antipsychotic Medication Use revised December 2016, policy and procedure indicated, Diagnosis of a specific condition for which antipsychotic medications are necessary to treat will be based on a comprehensive assessment of the resident. Diagnoses alone do not warrant the use of antipsychotic medication. Antipsychotic medications will not be used if the only symptoms are one or more of the followings: a. Wandering; b. Poor self-care; c. Restlessness; d. Impaired memory; e. Mild anxiety; f. Insomnia; g. Inattention or indifference to surroundings; h. Sadness; i. Fidgeting; j. Nervousness; or k. Uncooperativeness.

Based on interviews and record review, the facility failed to coordinate care planning in collaboration with resident, family and hospice care provider for one (Resident 2) of two sampled residents. This failure had the potential to result in residents to not received person centered care. Findings: Review of Resident 2's Minimum Data Set, Resident Assessment and Care Screening, dated 6/11/23, indicated Resident 2 diagnoses included Non-Alzheimer's Dementia (a group of diseases characterized by progressive deficits in behavior, executive function or language), schizophrenia ( a disorder that affects a person's ability to think, feel and behave clearly) and encounter for palliative care and on hospice care ( a type of care that focuses on interdisciplinary approach to specialized nursing care for people with life limiting illnesses, available to people with a life expectancy of six months or less, does not focus on treatments to cure the cause of the terminal illness. It seeks to keep the individual comfortable and make their remaining time as meaningfully as possible). Review of order summary report, dated 12/5/2020, the summary report indicated, Resident 2 was admitted to hospice care. Review of hospice care plan initiated 12/6/2020, the care plan indicated, Resident 2's was on routine level of hospice care with terminal diagnosis of COPD ( a group of lung disease that block airflow and make it difficult to breathe). Further review of Resident 2's care plans on 8/30/23 at 8:57 a.m., with Registered Nurse/Assistant Director of Nursing (ADON) in the presence of Director of Nursing (DON), the care plan indicated, hospice representatives did not participate in Resident 2's care planning. During an interview on 8/29/23 at 9:50 a.m., with the Social Service Designee (SSD), SSD stated, facility had invited hospice provider for care plan conferences. SSD stated, hospice staff had not attended and participated in Resident 2's care plan conferences because hospice case manager said they cannot attend because they are short of staff. SSD could not provide documentation of communication with Resident 2's hospice provider regarding coordination of care plan conferences. During an interview on 8/30/23 at 8:57 a.m., with ADON in the presence of DON, ADON stated, she and Social Services Director (SSD) were assigned as contact with hospice provider. ADON stated, facility's Interdisciplinary Team (IDT -group of healthcare professionals with various areas of expertise who work together toward the goals of their clients ) had not met with hospice representatives to coordinate care planning conference with Resident 2, family and hospice provider. ADON stated, hospice provider did not participate in Resident 2's care plan conferences. The facility's policy and procedure, titled, Hospice Program, revised July 2017, policy and procedure indicated, Collaborating with hospice representatives and coordinating facility staff participation in the hospice care planning process for residents receiving these services. Coordinated care plans for residents receiving hospice services will include the most recent hospice plan of care as well as the care and services provided by our facility including the responsible provider and discipline assigned to specific tasks in order to maintain the resident's highest practicable physical, mental, and psychosocial well-being.

Based on interview and record review, the facility failed to assess and respond to changes in condition for one of six sampled residents (Resident 1). The facility did not recognize, address symptoms, or properly document recurrent [MEDICAL CONDITION] (C. diff, diarrhea) infection. This failure resulted in a delay in [DIAGNOSES REDACTED]. (life-threatening reaction of the body to an infection) Definitions: The body increases production of white blood cells in response to bacterial or [MEDICAL CONDITION] infection. Normally there are 4,,[DATE],000 white blood cells per microliter (mcL) of blood. (Reference: http://www.nlm.nih.gov/medlineplus/ency/article/ 3.htm) [MEDICAL CONDITION] (C. diff) is a contagious bacterium that infects the digestive system. It is characterized by diarrhea, though other symptoms include fever and nausea. It can lead to perforation (tears) of the large intestine,[MEDICAL CONDITION] (infection in the blood), and death. [DIAGNOSES REDACTED] is diagnosed by testing a sample of the diarrhea for signs of the bacteria. The Centers for Disease Control (CDC) recommends that when a person who has had [DIAGNOSES REDACTED] in the recent past develops diarrhea again, then the first episode of diarrhea should be tested for the infection. (Reference: CDC Healthcare Associated Infections (HAI) [MEDICAL CONDITION] (CDI) Infections Toolkit) A leukemoid reaction is a life-threatening reaction of the body to an infection. When a person has an infection, the body's normal response is to fight back using its white blood cells, which tend to increase in number while the infection is present in the body. In a leukemoid reaction, the white blood cell count increases far beyond what is typical. Studies have shown that when a person with [DIAGNOSES REDACTED] has a leukemoid reaction to the infection, with a white blood cell count greater than 50,000, he or she is much more likely to die of the infection. (Reference: Markert, Ronald J. 2004 "Leukemoid reactions complicating [MEDICAL CONDITION] due to [MEDICAL CONDITION].") Findings: Record review, on [DATE], showed that Resident 1 was a [AGE] year old woman admitted to the facility on [DATE], following an acute care hospital stay for kidney failure and pneumonia (a lung infection). While in the acute care hospital, she developed and was successfully treated for [REDACTED]. The hospital transferred Resident 1 to the facility for physical therapy, and Resident 1 was expected to return home to her family. Resident 1 developed diarrhea on [DATE], was transferred back to the hospital on [DATE], and died of a leukemoid reaction and [DIAGNOSES REDACTED] on [DATE]. Resident 1's clinical record showed that she had an episode of diarrhea in the evening of [DATE], which was documented on the Certified Nursing Assistant (CNA) Activities of Daily Living record. The medical record showed no evidence of a facility assessment for reoccurrence of a [DIAGNOSES REDACTED] infection and the physician was not notified. A note signed by Occupational Therapist (OT) 1 showed that Resident 1 had another episode of, "Loose stool" on [DATE]. The medical record showed no evidence of a facility assessment for reoccurrence of a [DIAGNOSES REDACTED] infection and the physician was not notified. Further review of the facility's licensed nurses' notes, from [DATE] to [DATE], showed no documentation of diarrhea or loose stool at any point during Resident 1's stay at the facility. In an interview with a family member (FM) 1 on [DATE] at 12:30 p.m., she stated that she was concerned because of Resident 1's decline in condition. FM 1 took Resident 1 to see her primary care physician (MD 1) on [DATE] for an examination. MD 1 ordered a stool culture, to test for [DIAGNOSES REDACTED]. The facility collected a stool sample for [DIAGNOSES REDACTED] testing on [DATE] at 10:00 a.m. The laboratory reported positive test results for [DIAGNOSES REDACTED] toxin on [DATE] at 8:22 p.m. According to the facility nurses' notes, dated [DATE], Resident 1 was, "Sluggish", and, "Lethargic" (unusually sleepy), had a temperature of 99.4? Fahrenheit, and began having more difficulty breathing than usual. The facility transferred Resident 1 to the acute care hospital for an evaluation via ambulance on [DATE] at 2:45 p.m. Review of hospital records on [DATE], showed that after an evaluation in the hospital emergency department, the hospital admitted Resident 1 to the intensive care unit. The hospital emergency room nurses' notes reflected that facility staff reported that Resident 1 had an altered level of consciousness at 8:00 a.m. that day. Resident 1's white blood cell count on [DATE] at 5:03 p.m., was 62,400, or more than six times the upper limit of normal. Resident 1 was unable to recover from the infection and leukemoid reaction and died on [DATE]. A document titled, "Death Summary", dated [DATE] and signed by MD 1, showed the final [DIAGNOSES REDACTED]. In an interview on [DATE] at 12:20 p.m., a family member (FM 2) of Resident 1 stated that he visited Resident 1 every weekday and frequently on weekends. He stated that he witnessed an episode of diarrhea on [DATE]. In an interview on [DATE] at 12:30 p.m., FM 1 stated that LVN 5 reported to her on [DATE] that Resident 1 had had diarrhea. FM 1 stated that she witnessed an episode of diarrhea herself on [DATE]. In an interview on [DATE] at 2:30 p.m., a companion hired by the family (CG 3) stated that she had spent ,[DATE] hours per day, ,[DATE] days per week with Resident 1. CG 3 stated that she witnessed Resident 1 have episodes of diarrhea on [DATE], [DATE], and [DATE]. In an interview on [DATE] at 12:10 p.m., CNA 1 stated that if a resident had diarrhea, she would tell the charge nurse and record it in the Activities of Daily Living book. In an interview on [DATE] at 12:15 p.m., LVN 1 stated that if a resident developed diarrhea, she would call the physician as soon as possible to ask for a [DIAGNOSES REDACTED] test. She further stated that if a resident had a fever, changes in mental status, or changes in breathing, blood pressure, or pulse, she would call the physician and check on the resident every 30 minutes. In an interview on [DATE] at 12:15 p.m., LVN 2 stated that diarrhea with a foul odor would be a, "Red flag", but that if it did not have an odor he would wait before calling the physician. He stated that signs of infection included fever, chills, decreased blood pressure, confusion, and changes in mental status. In an interview on [DATE] at 12:33 p.m., CNA 2 stated that, "Having fever or diarrhea are things that I would report to the nurse." In an interview on [DATE] at 12:45 p.m., CNA 3 stated that, "Changes in condition" are reported to the charge nurse. She stated that a one-time episode of diarrhea is not reported; there would have to be three or four episodes before she would notify the charge nurse. In interviews on [DATE] at 2:28 p.m. and 2:57 p.m., the Director of Nursing (DON) stated that a resident who was admitted with risk for recurrent infection (of the same disease) would receive, "Intensive monitoring" for 72 hours, and that the monitoring would focus on the specific body system that the disease would impact. The DON was given an example of a resident who had a history of [REDACTED]. She stated, "It would take two to three loose smelly stools for the staff to alert me." In an interview on [DATE] at 2:25 p.m., LVN 4 stated that if a resident who had had [DIAGNOSES REDACTED] in the past developed new diarrhea, she would call the physician after the second episode of diarrhea. Review of the undated facility policy "Change in Resident Condition", received on [DATE], showed that facility staff were expected to report, "All symptoms and unusual signs" to the physician by the end of the shift in which they occurred.