Every finding on record at Woodland Care Center

Based on observation, interview, and record review, the facility failed to ensure a call light (a device used by a resident to signal his/her need for assistance from staff) was within a resident's reach while in bed for one of three sampled residents (Resident 4). This deficient practice had the potential to delay the provision of services and resident's needs not being met.Findings: During a review of Resident 4's admission Record, the admission Record indicated the facility initially admitted the resident on 4/20/2026 and readmitted the resident on 6/9/2026 with diagnoses including end stage renal disease (ESRD-irreversible kidney failure), type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) with diabetic neuropathy (a type of nerve damage caused by long term high blood sugar) unspecified, and muscle wasting and atrophy (wasting away due to lack of use) not elsewhere classified, unspecified site. During a review of Resident 4's Minimum Data Set (MDS, a resident assessment tool) dated 6/12/2026, the MDS indicated that Resident 4 was cognitively (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) intact and required moderate assistance from staff for toileting hygiene, sit to lying, and lying to sitting on side of bed. During a concurrent observation and interview on 7/15/2026 at 1:35 p.m., with Licensed Vocational Nurse 1 (LVN 1), observed Resident 4 lying in bed with his call light on the floor not within reach. LVN 1 stated the call light should have been within reach of Resident 4 to be able to call for assistance. LVN 1 also stated without the call light within reach of Resident 4, it will result in delay of care and services. During an interview on 7/16/2026 at 4:15 p.m., with the Director of Nursing (DON), the DON stated the call light should have been within reach of Resident 4 to be able to call for assistance. The DON also stated without the call light within reach of Resident 4, it will result in delay of care and services that Resident 1 needs. During a review of the facility's policy and procedure titled, Answering the Call Light, dated 1/15/2026, the policy indicated ensure timely responses to the resident's requests and needs. Ensure that the call light is accessible to the resident when in bed, from the toilet, from the shower or bathing and from the floor.

Based on interview and record review, the facility failed to ensure nursing staff implemented and documented the required 72-hour monitoring (closely observing and evaluating a resident for three days after something important changes in their health) following a change in condition for two of four sampled residents (Resident 2 and Resident 3). This failure had the potential to delay the identification of a worsening clinical condition, timely physician notification and the implementation of necessary interventions. a. During a review of Resident 2's admission Record, the admission Record indicated the facility originally admitted Resident 2 on 1/27/2023 and readmitted the resident on 3/10/2026 with diagnoses that included, but were not limited to, subluxation (a joint is partially out of place but not completely dislocated) of C4/C5 cervical vertebrae (the seven bones in the neck that support the head and protect the spinal cord), diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing), and hypertension (HTN- high blood pressure). During a review of Resident 2's Minimum Data Set (MDS - a resident assessment tool) dated 4/20/2026, the MDS indicated Resident 2's cognitive (the mental action or process of acquiring knowledge and understanding through thought, experience, and senses) skills for daily decision making were intact. The MDS further indicated Resident 2 was independent with oral hygiene, toileting and personal hygiene, upper and lower body dressing, and eating. The MDS also indicated Resident 2 needed supervision with showering or bathing. During a review of Resident 2's Care Plan (CP) initiated on 6/12/2026, the CP indicated Resident 2 reported that a CNA (Certified Nursing Assistant) hit the roommate. The CP further indicated Resident 2 was to be monitored for psychosocial distress (refers to the emotional, mental, and social suffering a resident experiences when struggling to cope with their health, environment, or losses). b. During a review of Resident 3's admission Record, the admission Record indicated the facility originally admitted Resident 3 on 4/20/2022 and readmitted the resident on 3/19/2026 with diagnoses that included, but were not limited to, encounter for palliative care (specialized medical care that focuses on improving the quality of life for people with serious illnesses), Parkinson's disease (a condition that affects the brain and makes it harder to control body movements) without dyskinesia (uncontrolled, involuntary movements that a person cannot stop), acute kidney failure (the kidneys suddenly stop working properly over a short period of time, usually hours to days), and congestive heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling). During a review of Resident 3's Minimum Data Set (MDS - a resident assessment tool) dated 5/25/2026, the MDS indicated Resident 3's cognitive skills for daily decision-making were severely impaired. The MDS further indicated Resident 3 was dependent on staff for oral hygiene, toileting and personal hygiene, upper and lower body dressing, showering, and eating. During a review of Resident 3's Care Plan (CP) initiated on 6/12/2026, the CP indicated Resident 3 was at risk for psychosocial distress due to a roommate who claimed a CNA hit the resident. The CP intervention indicated Resident 3 was to be monitored for signs and symptoms of psychosocial distress and to offer support as indicated. During a concurrent interview and record review on 6/25/2026 at 1:00 p.m., with the Director of Nursing (DON), Resident 2's and Resident 3's Licensed Nurse Progress Notes from 6/12/2026 through 6/15/2026 were reviewed. The Licensed Nurse Progress Notes did not indicate the required 72-hour monitoring was implemented and documented by the licensed nurse. The DON stated there was no documentation in the Licensed Nurse Progress Notes indicating Resident 2 and Resident 3 were monitored for 72 hours following their (Resident 2 and Resident 3) change in condition. The DON further stated licensed nurses should perform and document 72-hour monitoring of residents following a change in condition to facilitate early identification of a declining health status and ensure timely physician notification for appropriate treatment. During an interview on 6/25/2026 at 3:08 p.m., with Licensed Vocational Nurse 3 (LVN 3), LVN 3 stated it is important to monitor residents after a change in condition to identify signs of decline and determine whether reevaluation by the physician is needed. LVN 3 further stated that monitoring residents after a change in condition promotes resident safety. During a review of the facility's policy and procedure (P&P) titled, Acute Condition Changes - Clinical Protocol last revised on 1/15/2026, the P&P indicated, The staff will monitor and document the resident/patient's progress and responses to treatment, and the physician will adjust treatment accordingly.

Based on observation, interview, and record review, the facility failed to dispose garbage and refuse properly when the dumpster's (a movable waste container designed to be brought and taken away by special collection vehicle, or to a bin that specially designed garbage truck lifts) surrounding floors had trash and litter. This failure had potential to attract birds, flies, insects, pests (animal or microorganism that has a negative effect on humans) and possibly spread infection to 138 of 138 facility residents. Findings: During a concurrent observation and interview on 6/3/2026 at 11:25 a.m., of the dumpster area with the Dietary Supervisor (DS), observed soiled gloves, napkins, and disposable spoons on the dumpster floor surroundings. The DS stated they needed to maintain the cleanliness of the dumpster surroundings and not have trash to prevent mice and flies coming into the facility for infection control purposes. During a review of the facility's policy and procedure (P&P) titled, Environment, dated 1/15/2026, the P&P indicated, 6. All trash will be contained in covered, leak-proof containers that prevent cross contamination. 7. All trash will be properly disposed of in external receptacles (dumpsters) and the surrounding area will be free of debris. During a review of the facility's P&P titled, Dispose of Garbage and Refuse, dated 1/15/2026, the P&P indicated, All garbage will be collected and disposed of in a safe and efficient manner. (1). The Dining Service Director coordinates with the Director of Maintenance to ensure that the area surrounding the exterior dumpster is maintained in a manner free of rubbish or other debris. During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated, 5-501.116 Cleaning Receptacles. Proper storage and disposal of garbage and refused are necessary to minimize the development of odors, prevent such waste from becoming an attractant and harborage of breeding places for insects and rodents, and prevent the soiling of food preparation and food service areas. Improperly handled garbage creates nuisance conditions, makes housekeeping difficult, and may be possible source of contamination of food, equipment, and utensils. Outside receptacles must be constructed with tight-fitting lids or covers to prevent the scattering of the garbage or refuse by birds, the breeding of flies, or the entry of rodents. Proper equipment and supplies must be made available to accomplish thorough and proper cleaning of garbage storage areas and receptacles so that unsanitary conditions can be eliminated.

Based on observation, interview, and record review, the facility failed to implement the facility's Water Management Program ([WMP] - a written, step-by-step plan for buildings to ensure their water system was safe, clean, and efficient) by failing to ensure the hot water tank was flushed monthly. This failure placed the residents, staff and visitors at risk for exposure to unsafe water conditions. Findings: During a concurrent interview and record review on 6/4/2026 at 9:25 a.m. with the Maintenance Supervisor (MS), the facility's Water Management Program (WMP) was reviewed. The MS stated that he and the Infection Preventionist Nurse (IPN) was responsible for the implementation of the facility's WMP. The MS stated that, in accordance with WMP control measures, hot water tanks should be flushed monthly to eliminate impurities from the bottom of the tank. The MS stated that he flushed the hot water tank every two to three months. The MS stated he did not have documentation for this control measure. The MS stated that he flushed the hot water tank to prevent growth of opportunistic waterborne pathogens such as legionella (type of bacterium that lives naturally in fresh water) by eliminating stagnant water and controlling temperatures. The MS stated that residents, facility staff and visitors are placed at risk when exposed to stagnant water which has the potential to cause illness and lead to health complications. During an interview on 6/4/2026 at 10:35 a.m. with IPN, the IPN stated that she collaborates with the MS in the implementation of the facility's WMP. The IPN stated that the MS was responsible for monitoring the facility's water system. The IPN explained that the purpose of the WMP is to prevent bacterial growth or outbreaks originating from the building's water system. The IPN stated that the facility aims to eliminate any risk of disease transmission. The IPN stated that Legionella is a bacterium commonly present in water systems; its proliferation within the facility's water system poses significant concern as exposure may result in fever, gastrointestinal symptoms, and pneumonia. The IPN added that given that all individuals utilize the water facilities, everyone is potentially at risk. The IPN further stated the importance of implementing WMP control measures to inhibit bacterial growth and transmission, which is essential to safeguard the health of residents, particularly those who are immuno-compromised (weakened immune system). During a review of facility's WMP, titled Risk management plan for Legionella Control, undated, the WMP indicated the plan aimed to control the growth and survival of Legionella and other waterborne pathogens in water systems and manage epidemics in the facility. Operational monitoring includes the use of both preventative maintenance programs and internal facility procedures to oversee the implementation of control measures. The effectiveness of the control plan will be evaluated through infection control surveillance. During a review of facility's Policy and Procedures (P&P), titled, Legionella Surveillance and Detection, last reviewed 1/15/2026, the P&P indicated that a commitment to the prevention, detection, and control of water-borne contaminants, including Legionella. Surveillance for Legionnaire's disease (severe type of lung infection caused by breathing in mist or water droplets containing legionella bacteria) was incorporated into the facility's infection monitoring activities.

Based on observation, interview, and record review, the facility failed to obtain a physician's order for the use of continuous glucose (sugar) monitoring (CGM-glucose monitor uses a sensor that is placed on the back of the upper arm and worn externally by the user, allowing glucose information to be monitored using a mobile application; the hand held reader is used to scan the glucose without the need to prick the fingers) for one of one sampled residents (Resident 145). This deficient practice had the potential to result in inaccurate blood sugar readings due to the lack of training provided to the licensed nurses on the functionality of the CGM device which could negatively affect management of Resident 145's diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). Findings: During a review of Resident 145's admission Record, the admission Record indicated that the facility initially admitted Resident 145 to the facility on 8/27/2025 and readmitted the resident on 3/27/2026 with diagnoses including DM, chronic heart failure (a condition in which the heart does not pump blood as well as it should), chronic kidney disease (gradual loss of kidney function), and hypertension (high blood pressure [the force of the blood pushing on the blood vessel walls is too high]). During a review of Resident 145's Minimum Data Set (MDS - a resident assessment tool) dated 3/30/2026, the MDS indicated that Resident 145's cognition (mental action or process of acquiring knowledge and understanding) was intact. The MDS indicated Resident 145 required ranging from independent (no assistance from a helper) to moderate (helper does less than half the effort) physical assistance from staff for activities of daily living (ADLs - eating, toileting, hygiene, shower/bathing). The MDS also indicated that Resident 145 received insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) injection during the last seven days of the assessment. During a review of Resident 145's Order Summary Report, the Order Summary Report indicated the following orders: -Insulin aspart (fast acting type insulin) inject four (4) units subcutaneously (injection under the skin) with meals for DM, rotate injection sites, dated 3/28/2026. -Insulin glargine (long-acting insulin) inject 14 units subcutaneously at bedtime for DM, rotate injection sites, dated 3/28/2026. During a review of Resident 145's care plan (a document that summarizes a resident's needs, goals, and care/treatment) titled, Diagnosis of DM type 2, uncontrolled blood sugar, revised on 5/27/2026, the care plan indicated a goal for the resident to remain free from all signs and symptoms of hypoglycemia (low blood sugar) and hyperglycemia (high blood sugar). The interventions outlined include ongoing monitoring and providing education to Resident 145 regarding the signs and symptoms of both hypoglycemia and hyperglycemia, as well as related complications associated with DM. During a concurrent observation and interview on 6/1/2026 at 10:47 a.m., with Resident 145, observed Resident 145 with a small patch sensor under the skin in his left upper arm. Resident 145 stated that he has DM, receives insulin and the nursing staff use his blood sugar reading from his CGM. During a concurrent interview and record review on 6/2/2026 at 1:21 p.m., with Licensed Vocational Nurse 2 (LVN 2), reviewed Resident 145's physician orders and Medication Administration Record (MAR, a report detailing the medications administered to a resident by the licensed nurse in the facility). LVN 2 stated that Resident 145 had physician orders for insulin glargine and insulin aspart. LVN 2 also stated the importance of blood glucose monitoring prior to insulin administration. LVN 2 indicated that during her shift, she used Resident 145's CGM readings prior to administering mealtime insulin dose. LVN 2 stated there was no physician order and documentation for the use of Resident 145's CGM for monitoring blood sugars. LVN 2 further stated that failure to monitor the CGM could result in potentially serious complications, including uncontrolled blood glucose levels and delayed wound healing. During a concurrent interview and record review on 6/3/2026 at 11:30 a.m., with Registered Nurse 1 (RN 1), reviewed Resident 145's physician Order Summary Report. RN 1 stated that there was no documented physician order for the use of the CGM device or specifying monitoring procedures for blood glucose readings obtained from the CGM device for Resident 145. RN 1 also stated that the necessity of having a physician order to ensure accurate blood sugar monitoring by the nursing staff is essential for the safe administration of medication to residents. During an interview on 6/4/2026 at 3:06 p.m., with the Director of Nursing (DON), the DON stated that a physician order and ongoing monitoring are required for the use of CGM. The DON further stated the importance of assessments to ensure that residents are properly monitored for signs and symptoms of hypoglycemia and hyperglycemia while using CGM. During a review of the facility's Policy and Procedure (P&P) titled, Diabetes-Clinical Protocol, reviewed 1/15/2026, the P&P indicated requirements for providers to prescribe appropriate glucose targets and monitoring regimens, as well as parameters for reporting information related to blood sugar management. The P&P also indicated that staff are expected to integrate these orders and reporting criteria into both the medication administration record and the care plan. During a review of the facility's P&P titled, Insulin Administration Purpose, reviewed 1/15/2026, the P&P indicated that the procedure specifies checking blood glucose according to the physician's orders or the facility protocol as part of the steps for insulin injections.

Based on observation, interview, and record review, the facility failed to provide an environment that is free from accident hazards for seven (Resident 58, Resident 84, Resident 125, Resident 15 and Resident 9, Resident 101, Resident 4) of nine residents investigated for accidents by failing to: 1. Ensure Resident 58, 84, 125, and 15 did not have an over-bed table on top of the landing pad (a mat placed on the floor next to a resident's bed or chair to minimize the impact of a fall). 2. Ensure Resident 9's bed was left in its lowest position 3. Ensure Resident 101's bed upper side rails (adjustable metal or rigid plastic bars that attach to the bed) were fully covered by padding per the physician's orders. 4. Ensure Resident 4 was kept safe from swallowing injury when Family Member 2 (FM 2) fed Resident 4 who was prescribed a puree diet (foods that are smooth with pudding like consistency), regular texture food (texture of food with no modifications and restrictions). These failures placed Resident 58, Resident 84, Resident 125, Resident 15 and Resident 9, Resident 101 at increased risk for injury in the event of a fall and placed Resident 4 at risk for aspiration (accidentally inhaling food or liquids into the airway and lungs, potentially causing lung infection) and choking (foreign body airway obstruction). Findings: 1 a. During a review of Resident 58's admission Record the admission Record indicated that the facility initially admitted Resident 58 to the facility on 3/30/2025, with diagnoses including dementia (a progressive state of decline in mental abilities), difficulty in walking, adult failure to thrive (a decline caused by chronic diseases and functional impairments which can cause weight loss, decreased appetite, poor nutrition, and inactivity) and right femur closed fracture (a break, crack or crush injury of the thigh bone). During a review of Resident 58's Minimum Data Set (MDS- a resident assessment tool), dated 4/28/2026, the MDS indicated that Resident 58's cognition (mental action or process of acquiring knowledge and understanding) was severely impaired. The MDS indicated Resident 58 required ranging from supervision (helper provides touching or contact guard assistance) to moderate (helper does less than half the effort) physical assistance from staff for activities of daily living (ADLs – eating, toileting, hygiene, shower/bathing) The MDS also indicated that Resident 58 used a manual wheelchair for mobility device. During a review of Resident 58's Order Summary Report, dated 6/4/2026, the Order Summary Report indicated the following physician's order dated 12/15/2025: -Lowbed with bilateral landing pad on both sides of the bed. Monitor for placement every shift. During a review of Resident 58's Nursing Documentation Evaluation, dated 4/28/2026, the Nursing Documentation Evaluation indicated that Resident 58 had fall risk factors such as disorientated/confused, poor safety judgement, predisposing disease and that she was on cardiac medications (used to lower blood pressure, reduce chest pain, prevent blood clots, and help your heart pump more efficiently). During a review of Resident 58's Care Plan Report (a document that outlines a resident's healthcare needs, goals, and the interventions planned to achieve those goals) titled At risk for falls/injury revised on 12/15/2025, the care plan indicated interventions including provision of a low bed with bilateral landing pads on each side, maintaining a clutter-free environment within the resident's room, and ensuring consistent furniture arrangement. During a concurrent observation and interview on 6/1/2026 at 10:13 a.m. with Licensed Vocational Nurse 1 (LVN 1) in Resident 58's room, an over-bed table with a broken wheel was placed on top of the left side landing pad and a wheelchair on top of the right-side landing pad. LVN 1 stated that there should not be any objects on top of the landing pads, as these items could create tripping hazards, cause injuries, and pose dangers. LVN 1 stated she would educate the certified nursing assistants (CNAs) about keeping the landing pads clear since Resident 58 was identified as a fall risk. LVN 1 further stated that objects need to be removed from the landing pad area, and that broken wheels on bedside tables can also present hazards. 1.b. During a review of Resident 84's admission Record, the admission Record indicated that the facility initially admitted Resident 84 to the facility on 3/31/2025, with diagnoses including right hip osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage), syncope (fainting or passing out), legal blindness (partial or complete loss of vision) and hypertension (HTN-high blood pressure). During a review of Resident 84's MDS dated [DATE], the MDS indicated that Resident 84's cognition was severely impaired. The MDS indicated Resident 84 required ranging from supervision to maximal (helper does more than half the effort) physical assistance from staff for ADLs. During a review of Resident 84's History and Physical (H&P), dated 4/22/2026, the H&P indicated that resident 84 was able to make needs known but not medical decisions. The H&P also indicated Resident 84 was on fall and safety precautions. During a review of Resident 84's Order Summary Report, dated 6/4/2026, the Order Summary Report indicated the following physician's order dated 7/18/2025: -Lowbed with bilateral landing pad on both sides of the bed. Monitor for placement every shift. During a review of Resident 84's Nursing Documentation Evaluation, dated 3/25/2026, the Nursing Documentation Evaluation indicated that Resident 84 had fall risk factors such as visually impaired, poor safety judgement, predisposing disease, requires assist for toileting and Resident 84 was on pain and cardiac medications. During a review of Resident 84's Care Plan Report titled At risk for falls/injury revised on 3/02/2026, the care plan indicated interventions including maintaining a clutter-free environment within the resident's room and ensuring consistent furniture arrangement. During a concurrent observation and interview on 6/1/2026 at 10:39 a.m. with LVN 1 in Resident 84's room, an over-bed table was placed on the left side landing pad. LVN 1 stated that overbed tables should not be placed on top of the landing pad. LVN 1 also stated that Resident 84 requires assistance and is considered a fall risk. LVN 1 further stated that if a resident falls, they could hit the table and sustain an injury. LVN 1 emphasized the importance of educating CNAs to keep the landing pad clear of any objects. 1 c. During a review of Resident 125's admission Record, the admission Record indicated that the facility admitted Resident 125 to the facility on [DATE], with diagnoses including history of falling, dementia, Parkinson's disease (a chronic brain disorder that causes movement problems, and can also affect mental health, sleep, and pain) and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 125's MDS dated [DATE], the MDS indicated that Resident 125's cognition was intact. The MDS indicated Resident 125 required ranging from supervision to maximal physical assistance from staff for ADLs. During a review of Resident 125's H&P, dated 12/5/2025, the H&P indicated that Resident 125 had fluctuating capacity to make decisions. The H&P also indicated Resident 125 was on precautions for fall. During a review of Resident 125's Order Summary Report, dated 6/4/2026, the Order Summary Report indicated the following physician's order dated 12/15/2025: -Lowbed with bilateral landing pad on both sides of the bed. Monitor for placement every shift. During a review of Resident 125's Nursing Documentation Evaluation, dated 3/4/2026, the Nursing Documentation Evaluation indicated that Resident 125 had fall risk factors such as predisposing disease and Resident 125 was on psychotropic (medication that affects how your brain works, directly altering your mood, thoughts, feelings, or behavior), pain and cardiac medications. During a review of Resident 125's Care Plan Report titled At risk for falls/injury revised on 12/15/2025, the care plan indicated interventions including provision of a low bed with bilateral landing pads on each side, maintaining a clutter-free environment within the resident's room, and ensuring consistent furniture arrangement. During a concurrent observation and interview on 6/1/2026 at 11:20 a.m. with the Assistant Director of Nursing (ADON) in Resident 125's room, an over-bed table was placed on the left side landing pad. The ADON stated that the landing pad must remain free of any items to ensure safety. The ADON stated the over-bed table should be removed on top of the landing pad, as its presence could pose a risk of injury if a resident were to fall and come into contact with the object placed on top of the landing pad. 1 d. During a review of Resident 15's admission Record, the admission Record indicated that the facility admitted Resident 15 to the facility on 2/18/2024, with diagnoses including right femur closed fracture, osteoporosis (weak and brittle bones due to lack of calcium and Vitamin D), atrial fibrillation (afib- an irregular and very rapid heart rhythm that and can lead blood clots in the heart), major depressive disorder and dementia. During a review of Resident 15's MDS dated [DATE], the MDS indicated that Resident 15's cognition was severely impaired. The MDS indicated Resident 15 required ranging from moderate physical assistance to dependent (helper does all the effort) from staff for ADLs. During a review of Resident 15's H&P, dated 1/25/2026, the H&P indicated that resident 15 does not have the capacity to understand and make decisions. During a review of Resident 15's Order Summary Report, dated 6/4/2026, the Order Summary Report indicated the following physician's order dated 1/23/2026: -Lowbed with bilateral landing pad on both sides of the bed. Monitor for placement every shift. During a review of Resident 15's record titled Nursing Documentation Evaluation, dated 5/24/2026, the Nursing Documentation Evaluation indicated that Resident 15 had fall risk factors such as history of falls, disorientated/confused, poor safety judgement, impaired balance, predisposing disease, requires assist for toileting, unsteady gait, and the use of psychotropic and cardiac medication. During a review of Resident 15's Care Plan Report titled At risk for falls/injury revised on 2/3/2026, the care plan indicated interventions such as provision of a low bed with bilateral landing pads on each side, maintaining a clutter-free environment within the resident's room, and ensuring consistent furniture arrangement. During a concurrent observation and interview on 6/1/2026 at 11:34 a.m. with LVN 1 in Resident 15's room, an over-bed table was placed on the left side landing pad. LVN 1 indicated that overbed tables should not be positioned on the landing pad. LVN 1 stated that she reported this concern to the ADON to facilitate educational initiatives for the nursing staff. LVN 1 further stated that placing any object on the landing pad poses a hazard and may result in injury to residents. During a review of the facility's policy and procedure (P&P) titled, Fall Management, last reviewed 1/15/2026, the P&P indicated that patients will be evaluated for fall risk during nursing assessment. The P&P also indicated that when patient was identified as at risk, patients will receive interventions to lower their risk and minimize injury, including reviewing nursing documentation to identify risk, communicating fall risk status to caregivers, developing an individualized care plan, and regularly reviewing and updating the care plan as needed. 2. During a review of Resident 9's admission Recor, the admission Record indicated that the facility admitted Resident 9 to the facility on 7/31/2021 with diagnosis including muscle wasting (weakening, shrinking, and loss of muscle), history of falling, atrial fibrillation and parkinsonism (a term that refers to brain conditions that cause slowed movements, rigidity [stiffness] and tremors [uncontrollable, shaking movements]). During a review of Resident 9's MDS dated [DATE], the MDS indicated that Resident 9's cognition was moderately impaired. The MDS indicated Resident 9 required ranging from independent to dependent (helper does all the effort) physical assistance from staff for ADLs. During a review of Resident 9's H&P, dated 11/20/2025, the H&P indicated that Resident 9 does have the capacity to understand and make decisions. The H&P also indicated that Resident 9 was on fall precautions. During a review of Resident 9's Care Plan Report titled At risk for falls related to impaired mobility, generalized weakness, revised on 11/20/2025, the care plan indicated a goal that Resident 9 will have no falls with injury by maintaining a clutter-free environment within the resident's room and ensuring consistent furniture arrangement. During a concurrent observation and interview on 6/1/2026 at 09:35 a.m. with Certified Nursing Assistant 1 (CNA) in Resident 9's room, the total height of Resident 9's bed was left elevated to waist level. CNA 1 stated that the total height of Resident 9's bed was high and should be lowered for safety reasons as Resident 9 could fall. During an interview on 6/1/2026 at 09:38 a.m. with LVN 1, LVN 1 stated Resident 9 was not identified as fall risk as Resident 9 was alert, oriented and cooperative. During an interview on 6/3/2026 at 10:51 a.m. with Registered Nurse (RN) 1, RN 1 stated that the bed height for residents should consistently be kept at its lowest setting, as elevating the bed increases the risk of injury. During an interview on 6/4/2026 at 3:06 p.m. with Director of Nursing (DON), the DON stated that landing pads are used to reduce the risk of injury should a resident experience a fall, thereby enhancing resident safety. The DON indicated that nursing staff are responsible for conducting visual assessments of residents' environments to ensure that landing pads remain free of clutter. The DON further stated that any object placed on top of a landing pad is considered a trip hazard and may increase the risk of injury, such as bruising, skin tears, or other harm, should a resident fall onto the object. During a follow-up interview on 6/4/2026 at 3:06 p.m. with the DON, the DON stated that the facility uses fall prevention strategies, including keeping beds at their lowest height, using landing pads, conducting frequent rounds to address residents' needs, and positioning residents near the nurses' station. The DON also stated that keeping beds at their lowest position is crucial for resident safety, as it helps prevent injury if a fall occurs. During a review of the facility's policy and procedure (P&P) titled, Fall Management, last reviewed 1/15/2026, the P&P indicated that patients will be evaluated for fall risk during nursing assessment. The P&P also indicated that when patient was identified as at risk, patients will receive interventions to lower their risk and minimize injury, including reviewing nursing documentation to identify risk, communicating fall risk status to caregivers, developing an individualized care plan, and regularly reviewing and updating the care plan as needed. 3. During a review of Resident 101's admission Record, the admission Record indicated the facility admitted Resident 101 on 2/26/2025 with diagnoses including epilepsy (a brain disorder that causes seizures) contracture (a stiffening/shortening at any joint, that reduces the joint's range of motion) of left upper arm, and weakness. During a review of Resident 101's MDS, dated [DATE], the MDS indicated Resident 101 had moderate cognitive impairment. The MDS indicated Resident 101 as makes self-understood (able to express ideas and wants) and is able to understand others (clear comprehension understanding verbal content). The MDS indicated Resident 101 had seizure disorder or epilepsy as active diagnoses in the last 7 days. During review of Resident 101's History and Physical (H&P), dated 2/27/2025, the H&P indicated Resident 101 does not have the capacity to understand and make own decisions. During a review of Resident 101's Physician Order Summary Report (POR), dated 6/5/2026, the POR indicated an order for bilateral upper padded siderails as enabler for mobility and positioning and for seizure precaution every shift. During a review of Resident 101's care plan titled Risk for injury: Diagnosis Seizure Disorder, the care plan indicated the intervention of padded siderails as ordered. During a concurrent observation and interview on 6/1/2026 at 11:01 a.m., with Licensed Vocational Nurse 3 (LVN 3), observed Resident 101 lying in bed with padding applied outside the right upper side rail. LVN 3 stated the padding was placed incorrectly and should be on the inside of the right upper side rail. LVN 3 stated that the padding is intended to protect the resident from injury in case of a seizure by preventing direct contact with the metal side rail. LVN 3 stated that with the padding not placed on the inside of the rail facing the resident, the resident could hit her head against the metal bar, potentially resulting in bruising or head injury. During an interview on 6/1/2026 at 9:45 a.m. with the DON, the DON stated that the reason for padded side rails is to protect residents from injury when a resident has a seizure. The DON stated that when the padding is not applied or applied incorrectly, it leaves the resident at risk of potential skin tears, bruising or head injury from direct contact with the side rail. During a review of the facility's policy and procedure (P&P) titled, Seizures and Epilepsy – Clinical Protocol last reviewed 1/15/2026, the P&P indicated The physician will identity and order appropriate treatment for an acute seizure and a seizure disorder. During a review of the facility's P&P titled, Siderails last reviewed 1/15/2026, the P&P indicated Side rails with padding may be used to prevent resident injury in situations of uncontrollable movement disorders but are still restraints if the meet the definition of a restraint.Safety: a. Nursing Staff will check side rails periodically for safety and security and alert Maintenance Department when side rails need repair. 4. During a review of Resident 4's admission Record, the admission Record indicated the facility admitted the resident on 10/30/2023 and re-admitted on [DATE] with diagnoses that included dysphagia (difficulty swallowing) and dementia. During a review of Resident 4's MDS, dated [DATE], the document indicated Resident 4 was severely impaired in cognition with skills required for daily decision making. The MDS indicated Resident 4 required partial/moderate assistance (helper does less than half the effort) with eating. During a review of Resident 4's Physician's Orders, the orders indicated Resident 4 is prescribed a regular diet, pureed texture, mildly thick consistency (liquid consistency of pouring quickly from a spoon, but slower than water), dated 3/02/2025. During a dining observation on 6/02/2026 at 12:30 p.m., observed Resident 4's Family Member 2 (FM 2) offering the resident food and assisting with feeding. Observed FM 2 hand a piece of a white meat from a black disposable container and was not from the facility's tray. Observed Resident 4 eating food not provided by the facility. During an interview with the DON on 6/02/2026 at 2:10 p.m., the DON stated she noticed FM 2 was feeding regular texture food to Resident 4. The DON stated she observed FM 2 was tearing the food into small pieces and feeding that to Resident 4. The DON stated the AD told her to come to the dining room because FM 2 is feeding regular food to Resident 4 which is not allowed on a puree diet. The DON stated the facility notifies a residents' family of residents' diet order and that FM 2 knew Resident 4's prescribed diet. The DON stated the process is when family brings in outside food for a resident, the family member tells the licensed nurse, and they assess to see if the food is appropriate for the resident's prescribed diet. The DON stated the food brought by FM 2 was flaked and not pureed as ordered by the physician. The DON stated Resident 4 could have been at risk for aspiration with such symptoms as coughing, trouble swallowing, and shortness of breath. During an interview with the DON and the Administrator (ADM) on 6/02/2026 at 3:07 p.m., the ADM stated he confirmed with FM 2 that he was aware that he should have notified staff of the food brought from the outside for Resident 4. The DON stated FM 2 did not notify any staff that day that they brought food into the facility. The DON stated FM 2 told them he brought the food for himself. The DON stated she did not know if he ate any of the food, but he fed the food to Resident 4. During an interview with the AD on 6/02/2026 at 3:40 p.m., she stated she was standing near Resident 4 and FM 2 in the dining room. The AD stated she noticed there was a surveyor observing FM 2 feeding Resident 4. The AD stated she went and told the Infection preventionist nurse (IPN) who was also in the dining room and was checking the physician diet orders with the trays that were just brought from the kitchen. The AD stated the IPN told her she was busy and to go find the DON and tell her. The AD stated she left the dining room and found the DON in station 1 and told her that FM 2 was in the dining room with Resident 4 and had brought outside food. The AD stated the DON and ADM came to the dining room and spoke to FM 2. During an interview with the IPN on 6/02/2026 at 3:54 p.m., she stated the AD approached her to let her know FM 2 had food in front of him but was not sure if it was his food or her food. The IPN stated she was checking the physician diet orders with what the kitchen trays to ensure the diets matched with the physician's order. The IPN stated since she was busy checking she asked the AD to go find the DON to notify her. During a telephone interview with FM 2 on 6/03/2026 at 9:57 a.m., he stated he visited with Resident 4 the previous day on 6/02/2026 at lunchtime and brought her cold cuts. FM 2 stated he realized that Resident 4 is on a puree diet but wanted to give her a break. FM 2 stated he realized that he must check what he brings with the dietician. FM 2 stated he believed Resident 4 can eat soft food with someone present while she eats but realized there is a process to go through before she is allowed to eat non-puree food. During an interview with LVN 5 on 6/03/2026 at 11:07 a.m., LVN 5 stated she was in the dining room on 6/02/2026 during lunchtime checking trays against the physician's diet orders. LVN 5 stated no one notified her that Resident 4's FM 2 was feeding her non-puree food. During a review of the facility's P & P titled, Therapeutic Diets, last reviewed 1/15/2026, the P & P indicated the following: A therapeutic diet must be prescribed by the resident's attending physician. A therapeutic diet is considered a diet ordered by a physician, practitioner or dietician as part of treatment for a disease or clinical condition, to modify specific nutrients in the diet, or to alter the texture of a diet. If the resident or resident's representative declines the recommended therapeutic diet, the interdisciplinary team (a group of healthcare professionals such as nursing, dietary, and social services who meet to help a resident accomplish a specific medical goal) will collaborate with the resident or representative to identify possible alternatives. During a review of the facility's P & P titled, Safe Handling of Foods From Visitor, last reviewed 1/15/2026, the P & P indicated the following: Family members and visitors will be educated to inform nursing staff of their desire to bring food into the facility. Food brought by family/visitors for individual residents may not be shared with or distributed to other residents.

Based on observation, interview, and record review, the facility failed to provide nutritional care and services consistent with resident's nutritional assessment and physician orders for one of two sampled residents (Resident 145) by failing to: 1. Ensure weekly weight monitoring was conducted in accordance with physician's order. 2. Ensure that the nutritional assessment conducted by Registered Dietician's (RD- expert on diet and nutrition) was completed in accordance with physician's order. These deficient practices had the potential to result in further risk of weight loss for Resident 145.Findings: During a review of Resident 145's admission Record, the admission Record indicated that the facility admitted Resident 145 to the facility on 8/27/2025, with diagnoses including diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), chronic heart failure (a condition in which the heart does not pump blood as well as it should), chronic kidney disease (CKD-a longstanding disease of the kidneys leading to renal failure) and hypertension (HTN-high blood pressure). During a review of Resident 145's Minimum Data Set (MDS - a resident assessment tool) dated 3/30/2026, the MDS indicated that Resident 145's cognition (mental action or process of acquiring knowledge and understanding) was intact. The MDS indicated Resident 145's varying levels of assistance ranging from independent (no assistance from a helper) to moderate (helper does less than half the effort) physical assistance from staff for activities of daily living (ADLs - eating, toileting, hygiene, shower/bathing). The MDS indicated that Resident 145 had no swallowing disorder. The MDS indicated Resident 145 height was 72 inches (unit of measurement) and weighed 208 pounds The MDS also indicated Resident 145 was on therapeutic diet (specialized meal plans designed to treat or manage specific medical conditions by controlling nutrient intake) and the resident had no weight loss of 5% in the last month or loss of 10% or more in last 6 months. During a review of Resident 145's Weights and Vitals Summary, dated 6/4/2026, the Weights and Vitals Summary indicated Resident 145's weight was as follows: -On 4/20/2026 Resident 145 was 210 lbs. -On 5/14/2026 Resident 145 was 195 lbs. (7.14% weight loss). -On 6/2/2026 Resident 145 was 189 lbs. (10% weight loss). During a review of Resident 145's Order Summary Report, dated 6/4/2026, the Order Summary Report indicated the following physician orders dated 12/15/2025: -Carbohydrate Controlled Diet Regular texture, thin consistency, requesting 2 cups of juice and lactose free milk for all meals, add melted margarine to meals, initiated on 3/29/2026. -Nourishment three times a day for supplement 1 bottle to be given in between meals, initiated on 6/3/2026. -for RD consult, initiated on 3/29/2026. During a review of Resident 145's Laboratory Results Report, dated 5/26/2026, the CMP results report indicated Resident 145's albumin (protein made by your liver) was 3.1 grams per deciliter (g/dL-reference range is 3.2 to 5.5 g/dL). During a review of Resident 145's Change in Condition Evaluation, dated 5/14/2026, the change in Condition Evaluation indicated that the resident has a weight loss of 15 lbs. (7.1%) over the past 30 days. Oral intake observed at 50 to 100% with intermittent episodes of meal refusal noted. The summary indicated that the primary physician was notified with orders for RD to continue following nutritional status, oral intake, supplement tolerance, continue weekly weights and report further significant changes in condition. During a review of Resident 145's Interdisciplinary Care Conference, dated 5/14/2026, the interdisciplinary care conference indicated that the plan of care outlined the following actions: monitoring weight trends, assessing oral intake, reviewing laboratory results as they become available, and having the Registered Dietitian evaluate the resident in accordance with recommendations provided during the meeting. During a review of Resident 145's Care Plan Report titled Unplanned/unexpected weight loss, revised on 6/2/2026, the care plan indicated the goal was to keep the resident's nutritional status stable, prevent further significant weight loss, and ensure they consume at least 75% of their meals and prescribed supplements as tolerated. The care plan included interventions such as encouraging adherence to the prescribed diet and supplements, educating the resident about the importance of proper nutrition for strength and health, contacting the physician and notifying the dietician if weight continues to decline, monitoring and evaluating weight loss, determining the percentage lost and following facility protocol, arranging a registered dietitian consult, and recording weekly weights for four weeks. During a review of Resident 145's Care Plan Report titled Nutritional Risk, revised on 3/28/2026, the care plan included interventions including honoring food preferences within meal plan, monitoring for changes in nutritional status and reporting to food and nutrition/physician as indicated. During a concurrent observation and interview on 6/1/2026 at 10:47 a.m. with Resident 145, Resident 145 was awake, alert and able to communicate verbally. Resident 145 stated a decrease in meal intake was due to dissatisfaction with the food provided and indicated that he has been experiencing weight loss. Resident 145 stated that I think I am down to 180 lbs. something. During an interview on 6/2/2026 at 1:15 p.m. with Certified Nursing Assistant (CNA) 2, CNA 2 stated Resident 145 did not like the breakfast served in the morning and she reported it to Licensed Vocational Nurse (LVN) 2. During a concurrent interview and record review on 6/2/2026 at 1:21 p.m. with LVN 2, Resident 145's weight, physician order summary and change of condition evaluation were reviewed. LVN 2 reported that Resident 145 expressed dissatisfaction with the meals provided and communicated this concern to the Dietary Supervisor (DS). LVN 2 stated that according to the change of condition evaluation dated 5/14/2026, the physician ordered monitoring of the resident's oral intake, weekly weight checks, and a consultation with the RD. However, LVN 2 stated the order for weekly weight checks was not carried out and that there were no weekly weights recorded after 5/14/2026. During an interview on 6/2/2026 at 2:25 p.m. with Assistant Director of Nursing (ADON), the ADON stated that she was responsible for monitoring weight changes but had overlooked Resident 145's weight loss and failed to conduct weight checks as ordered by the physician. The ADON also stated that weekly weight monitoring was not done after 5/14/2026. Additionally, the ADON stated that the last nutritional assessment was completed on 4/29/2026, with no further assessments conducted after 5/14/2026. During a concurrent interview and record review on 6/3/2026 at 11:50 a.m. with Registered Nurse 1 (RN) 1, Resident 145's weight summary, physician order summary, change of condition evaluation and nutrition assessment were reviewed. RN 1 stated that there was no nutritional assessment conducted following the weight loss documented on 5/14/2026, the physician order for ongoing weight monitoring was not carried out and implemented, and there were no documented weights after 5/14/2026. RN 1 stated it is important to monitor weights to evaluate the nutritional health status of the resident and to revise the care plan as necessary, ensuring the effectiveness of interventions. RN 1 further stated that failure to implement the care plan may result in continued weight loss, which could go unaddressed, potentially leading to failure to thrive, electrolyte imbalances, reduced mobility, and diminished strength. During a concurrent interview and record review on 6/3/2026 at 1:48 p.m. with the RD, Resident 145's nutritional assessments were reviewed. The RD stated that the Director of Nursing (DON) or ADON informs her when there are weight variances for a resident. The RD stated she is responsible for conducting nutritional assessments, which include laboratory reviews, documentation of weight changes, supplement intake, and presence of wounds. The RD stated that these assessments are typically completed within one to two days after a weight variance is identified, to determine underlying factors and prevent further weight loss. The RD stated that a nutritional assessment was not completed for Resident 145 after a weight loss was identified on 5/14/2026. The RD further stated that the absence of an assessment could have potentially contributed to continued weight loss for Resident 145. During an interview on 6/4/2026 at 3:06 p.m. with DON, the DON stated that when weight variance is identified, a change in condition is initiated which includes notifying the physician, resident or their representative, consulting the RD, involving the interdisciplinary team (IDT - a group of dedicated healthcare professionals who work to bring knowledge together to help residents receive the care they need) weekly, and monitoring weights weekly. The DON added that the RD conducts a nutrition assessment and the nursing staff follows recommendations that can be implemented for the resident. The DON also stated that weekly weight monitoring is essential for evaluating whether interventions are effective or need adjustment to maintain the resident's nutritional status and prevent further weight loss. The DON further stated that not following physician orders for weekly weight checks and RD nutritional assessment could potentially affect further weight loss for Resident 145. During a review of facility's Policy and Procedure (P&P) titled, Nutritional Assessment, reviewed on 1/15/2026, the P&P indicated that dietitian, along with nursing staff and healthcare practitioners, will assess each resident's nutrition at admission (within baseline timeframes) and whenever there is a condition change that impacts nutrition. The assessment uses a systematic, multidisciplinary approach to gather and interpret data, guiding interventions for residents at risk of impaired nutrition. The team reviews nursing components such as usual body weight, current height and weight, intake and appetite description, and food preferences or dislikes. After analyzing risks and conditions, individualized care plans are developed according to the resident's prognosis and personal preferences. During another review of facility's P&P titled, Weight Management, reviewed on 1/15/2026, the P&P indicated that baseline weight is documented at admission to identify and investigate significant changes. The P&P also indicated that nursing staff records initial weight in the nursing assessment, admission note, MDS for skilled nursing facilities, and nutrition assessment. All weights are entered or tracked electronically. Residents' weights are taken weekly for the first four weeks, then monthly unless more frequent checks are needed by physician orders or patient condition. Additionally, for unplanned weight loss/gain triggers intervention if it reaches: 2% in a week, 5% in 30 days, 7.5% in 90 days, or 10% in 180 days with the following interventions to be carried out: -Nursing notifies physician and family/RP. -Dietetic professional assesses and documents, recommending interventions and obtaining orders for supplements or other needs. -Interdisciplinary team evaluates need to change frequency of weight measurements per physician order.

Based on interview and record review, the facility failed to assess and monitor a resident's pain every shift per the physician's order for one of seven sampled residents (Resident 101). This deficient practice had the potential to result in undetected, untreated, and unrelieved pain. Findings: During a review of Resident 101's admission Record, the admission Record indicated the facility admitted Resident 101 on 2/26/2025 with diagnoses that included epilepsy (a disorder in which nerve cell activity in the brain is disturbed, causing seizures [sudden, uncontrolled body movements and changes in behavior that occur because of abnormal electrical activity in the brain]), contracture (a stiffening/shortening at any joint, that reduces the joint's range of motion) of left upper arm, and muscle spasm (involuntary and uncontrolled tightening or shortening of a muscle). During a review of Resident 101's Minimum Data Set (MDS - a resident assessment tool) dated 2/25/2026, the MDS indicated Resident 101 had moderate cognitive impairment. The MDS indicated Resident 101 makes self-understood and able to understand others. The MDS indicated Resident 101 received pain medication, received PRN (given as needed or requested) pain medication or was offered and declined, and received non-medication intervention for pain. During a review of Resident 101's care plan (a document that summarizes a resident's needs, goals, and care/treatment) titled, Resident exhibits or is at risk for alterations in comfort/pain related to multiple complex medical conditions, abdominal pain, contracture of left upper extremity, muscle spasm, initiated 2/27/2026, the care plan indicated interventions that included complete pain assessment per protocol, monitor for non-verbal signs of pain: increase in agitation, grimace, resistance to care, and monitor frequency of episodes of breakthrough pain to determine the need for pain medication adjustment. During concurrent interview and record review on 6/3/2026 at 10:33 a.m., with Licensed Vocational Nurse 3 (LVN 3), reviewed Resident 101's physician orders dated 2/26/2026 and Medication Administration Record (MAR, a report detailing the medications administered to a resident by the licensed nurse in the facility) for 6/2026. LVN 3 stated that Resident 101's physician order indicated to monitor Resident 101 for pain every shift. LVN 3 stated that pain monitoring is documented on the MAR. LVN 3 stated Resident 101's MAR for 6/2026 did not indicate pain monitoring every shift was performed. LVN 3 stated that because the physician's order was entered incorrectly, the order for pain monitoring every shift is not on the MAR for nurses to know it is to be done. LVN 3 stated that the absence of documentation of Resident 101's pain assessment every shift means that Resident 101's pain was not monitored every shift. LVN 3 stated that it is important to implement physician orders since it is the care of the residents and determined to be necessary for the resident. LVN 3 stated that failing to monitor Resident 101's pain every shift, as ordered, could mean the facility is not effectively managing Resident 101's pain. During an interview on 6/5/2026 at 9:45 a.m., with the Director of Nursing (DON), the DON stated Resident 101's pain was not monitored every shift as ordered. The DON stated physician orders must be implemented as ordered to ensure residents receive appropriate care and treatment tailored to their individual needs. The DON stated that monitoring pain according to prescribed physician order is essential for maintaining resident comfort, preventing unaddressed discomfort, and promoting effective pain management. During a review of the facility's policy and procedure (P&P) titled, Physician Orders, last reviewed 1/15/2026, the P&P indicated, Medication/treatment orders will be transcribed onto the appropriate resident administration record. Orders pertaining to the other health care disciplines will be transcribed onto the appropriate communication system for that discipline. Documentation pertaining to physician orders will be maintained in the resident's medical record. During a review of the facility's P&P titled, Charting and Documentation, last reviewed 1/15/2026, the P&P indicated, The following is to be documented in the resident medical record: a. Objective observations. Documentation in the medical record will be objective, complete, and accurate.

Based on observation, interview, and record review, the facility failed to prepare food by methods that conserved flavor, appearance and palatable temperatures when: a. The grilled bratwurst (a fresh German sausage traditionally made from pork, veal, or beef, seasoned with spices like marjoram, nutmeg and pepper) had black burnt ends. b. Hot foods were not at palatable temperatures for breakfast on 6/2/2026. c. Turkey patty was dry for easy to chew (diet consist of soft, tender, and moist food that require minimal biting and less chewing effort) diet. These failures had potential to result in 128 of 138 facility residents including Resident 155, Resident 72, Resident 157, and Resident 120 at risk of unplanned weight loss, a consequence of poor food intake, getting food from the kitchen. Findings: During a review of the facility's menu spreadsheet (a sheet containing the kind and amount of food each diet would receive) titled Spring 2026, dated 6/1/2026, the spreadsheet indicated residents on regular diet would include the following foods on the tray: -Grilled bratwurst 3 ounces (oz, a unit of measurement) -Buttered new potatoes 1/2 cup (c, a household measurement) -Sauerkraut 1/2 c -Roll/margarine 1 each -Oatmeal/Raisin Cookie 1 each During an observation on 6/1/2026 at 11:41 a.m. of the trayline (an area where foods were assembled form the steamtable [kitchen appliance that keeps food warm at a safe temperature for serving] to resident's plates), observed a pan of bratwurst with burnt edges on several pieces. During an observation on 6/1/2026 at 12:35 p.m., of the second pan of bratwurst, observed pieces of bratwurst with burnt edges. During an interview on 6/1/2026 at 1:25 p.m., with [NAME] 1, [NAME] 1 stated she cooked the sausage in the oven, and the sausages were premade but uncooked. The DS stated she cooked the bratwurst in the oven and knew it was already cooked when it reached an internal temperature of 165 degrees Fahrenheit ( F, a scale of temperature), During a concurrent test tray (a process of tasting, temping, and evaluating the quality of food) observation and interview on 6/1/2026 at 1:34 p.m., of the regular diet with the DS, observed the bratwurst had burnt edges. The DS stated she did not feel that the bratwurst was burnt but a little overcooked and well done. The DS stated the bratwurst could have been taken off the trayline because of its appearance which could cause residents to complain about how it looks. The DS further stated the residents would not eat the food and would get upset as a potential outcome. During a review of the facility's policies and procedures (P&P) titled, Menus, dated 1/15/2026, the P&P indicated, Menus will be planned in advance to meet the nutritional needs of the residents/patients in accordance with established national guidelines. Menus will be developed to meet the criteria through the use of an approved menu planning guideline. Procedure: Menu cycles will include standardized recipes. During a review of the facility's recipe titled, Grilled Bratwurst dated 1/15/2026, the recipe indicated, 1. Place bratwurst on prepared grill. 2. Cook, turning for even cooking until internal temperature reaches 165 F. Alternate method: Place sausage on sheet pans and bake in a 350 F oven for approximately 30 minutes or until internal temperature reaches 165 F. During a review of Resident 155's admission Record, the admission Record indicated the facility admitted Resident 155 on 5/24/2026 with diagnoses including, but not limited to dysphagia (difficulty swallowing, essential hypertension (HTN, high blood pressure), mild protein calorie malnutrition (early stage of nutritional deficit and it occurs when individual's intake for calorie and/or protein is inadequate to meet the body's needs resulting to weight loss, or reduced food intake). During a review of Resident 155's Minimum Data Sheet (MDS- a resident assessment tool) dated 5/27/2026, the MDS indicated Resident 155 understood others and can make self-understood. The MDS indicated Resident 155 needed set-up and clean up assistance (helper provides verbal cues and/or touching/steadying and/or contract guard assistance as resident completes the activity. Assistance may be provided throughout the activity or intermittently) when eating. During a review of Resident 155's Order Summary Report, dated 5/24/2025, the report indicated Resident 155 was ordered regular diet texture with thin consistency (diet with no restrictions). During an interview on 6/1/2026 at 12:10 p.m., with Resident 155, Resident 155 stated he has not had any warm meals since he his admission to the facility. During an interview on 6/1/2026 at 8:59 a.m., with Resident 155, Resident 155 stated yesterday's lunch and today's breakfast were cold. During a review of Resident 72's admission Record, the admission Record indicated the facility initially admitted Resident 72 on 12/19/2025 and readmitted on [DATE] with diagnoses including, but not limited to dysphagia, type 2 diabetes (a chronic condition that affects the way the body processes blood sugar) with hyperglycemia (high blood sugar) and chronic kidney disease (CKD, a condition which kidneys are damaged and cannot filter blood as well as they should). During a review of Resident 72's MDS dated [DATE], the MDS indicated Resident 50 understood others and make self-understood. The MDS indicated Resident 72 is independent (resident completes the activity by themselves with no assistance from the helper) when eating. During a review of Resident 72's Order Summary Report, dated 6/11/2026, the report indicated Resident 72 was ordered regular diet, regular texture with thin liquid consistency. During an interview on 6/2/2026 at 10:25 a.m. with Resident 72, Resident 72 stated food was cold. During a review of Resident 157's admission Record, the admission Record indicated the facility admitted Resident 157 on 5/27/2026 with diagnoses including but not limited to hypotension (low blood pressure), pain in the right ankle and joints of right foot and nondisplaced oblique fracture of shaft of left fibula (a break in the calf bone that runs at a diagonal angle). During a review of Resident 157's MDS dated [DATE], the MDS indicated Resident 157 understood others and make self-understood. The MDS indicated Resident 157 needed set-up and clean up assistance when eating. During a review of Resident 157's Order Summary, dated 5/27/2026, the report indicated Resident 157 was ordered regular diet, regular texture with thin consistency. During an interview on 6/2/2026 at 10:37 p.m., with Resident 157, Resident 157 stated the bacon, and fried eggs were cold for breakfast. During a review of the facility's menu spreadsheet titled Spring 2026, dated 6/2/2026, the spreadsheet indicated residents on easy to chew would include the following foods on the tray: -Juice 4 fluid oz -Hot or cold cereal 4 oz -Fried egg 1 piece (pc) -Sausage patty 1 pc -Banana Muffin 1 pc -Milk 2% 8 fluid oz -Coffee 8 fluid oz During a concurrent test tray observation and interview on 6/2/2026 at 8:24 a.m. with the DS, observed the DS took the temperature of the following foods on the tray using the facility thermometer. The DS stated the following food temperatures were as follows: -Turkey patty 94 F -Fried egg 105 F -Oatmeal 112 F The DS stated the fried egg did not hold temperature well and the hot foods were under 120 F and it could have been better. The DS stated the sausage patty was cut into pieces, and the heat retention was less resulting to non-palatable temperatures of food. The DS stated residents would be unsatisfied with the food and would not eat the food resulting in weight loss as a potential outcome. c. During a review of Resident 120's admission Record, the admission Record indicated the facility admitted Resident 120 on 3/27/2026 with diagnoses including, but not limited to gastrointestinal reflux disease (GERD, stomach acid or contents frequently flow back in to the esophagus [the tube connecting the mouth and stomach]) without esophagitis (swelling or irritation of the tissues lining the esophagus), dysphagia and essential HTN. During a review of Resident 120's MDS dated [DATE], the MDS indicated Resident 120 understood others and make self-understood. The MDS indicated Resident 120 needed supervision and touching assistance (helper provides verbal cues and/or touching/steadying and or contact guard assistance as resident completes the activity. Assistance may be provided throughout the activity or intermittently) when eating. During a review of Resident 120's Order Summary, dated 3/27/2026, the report indicated Resident 120 was ordered Cardiac (low fat, low cholesterol, two (2) grams sodium [diet the avoids fried, fatty foods and salty foods]), easy to chew texture, thin consistency, no pork, no beef soft and bite meat only. During an interview on 6/1/2026 at 9:20 a.m., with Resident 120, Resident 120 stated the toast was over toasted, and the sausage was hard to chew. During a concurrent test tray observation and interview on 6/2/2026 at 8:24 a.m. with the DS, observed the DS tasting the turkey patty. The DS stated the turkey patty was dry and gravy would help. The DS stated it was a food product substitution, and it was a precooked product. The DS further stated the residents would be unsatisfied with dry turkey patty and would refuse to eat the meal resulting in weight loss as a potential outcome. During a review of the facility's P&P titled Food: Quality and Palatability, dated 1/15/2026, the P&P indicated, Food will be prepared by methods that conserve nutritive value, flavor, and appearance. Food will be palatable, attractive and served in a manner, form, and texture to meet resident's needs. Definitions: -Food attractiveness refers to the appearance of the food when served to the residents. -Food palatability refers to the taste and flavor of the food. -Proper (safe and appetizing) temperature- food should be at the appropriate temperature as determined by the type of food to ensure residents' satisfaction and minimize the risk of scalding and burns. 1. The dining services director and cook(s) are responsible for the food preparation. Menu items are prepared according to the menu, production guidelines, and standardized recipes. 2. The cook(s) prepare food in accordance with the recipes, and season for region and/or ethnic preferences, as appropriate. (2) [NAME] use proper cooking techniques to ensure color and flavor retention.

Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen when: Kitchen and storage areas were not free from dirt and debris. Reach-in refrigerator shelves contained dried food debris and amber discoloration particles. Walk-in refrigerator floors had dry spills, red Jello pieces, butter and trash. Walk-in refrigerator shelves had dried up milk residues. Dry storage floor contained oatmeal particles Cambro (a brand name of container that are insulated or durable plastic commonly used in restaurants, hospital and catering) containers had sticker residues Drying racks for domes had dirt residues. Freezer gasket was torn. No thermometer on the chest freezer 1. Three (3) dented cans were found with non-dented cans. [NAME] chopping boards had burnt marks, cracked and scratches. Cross contamination Clear Cambro containers for scoops and kitchen utensils were not covered, resulting in dirt debris contamination. Soap was spilling from the first compartment sink to the upper counter where pans are air-dried during dishwashing in the three-compartment sink. Oven grill was on the floor Cambro containers were stacked wet. Four of 4 residents' trays had cracks and chips Dietary Aide 1 (DA 1) did not wash his hands after cleaning the second compartment sink then touched coffee creamer and jams. Vannilla bars in the residents' refrigerator were not labeled, and 2 food items were not labeled with resident's name. These failures had the potential to result in harmful bacterial growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to foodborne illness (a disease caused by consuming food or drinks that are contaminated by germs or chemicals) in 128 of 138 medically compromised residents who received food and ice from the kitchen. Findings: 1. a. During an initial kitchen tour observation on 6/1/2026 at 8:25 a.m., of the reach-in refrigerator by the trayline (an area where foods were assembled form the steamtable [kitchen appliance that keeps food warm at a safe temperature for serving] to resident's plates), observed the shelves had amber discoloration and food debris. During an interview on 6/1/2026 at 8:55 a.m., with the Dietary Supervisor (DS), the DS stated refrigerator cleaning is done at the end of each shift and the last time the staff cleaned the refrigerator was last night. The DS stated there was dry food debris and debris that was orange in color on the shelves and it was not okay as the refrigerator contained ready-to-eat food and there could be cross-contamination to food. The DS stated the debris that was orange in color comes out when touched but the staff needed to clean it. During a review of the facility's policies and procedures (P&P) titled Equipment dated 1/15/2026, the P&P indicated, All foodservice equipment will be clean, and in proper working order. During a review of Food Code 2022, the Food Code 2022 indicated, 4-601.11 (E) Except when dry cleaning methods are used as specified under S 4-603.11, surfaces of utensils and equipment contacting food that is not time/temperature control for safety food shall be cleaned: (1) At anytime when contamination may have occurred; (2) At least every 24 hours for iced tea dispensers and consumer self-service utensils such as tongs, scoops, or ladles; (3) Before restocking consumer self-service equipment and utensils such as condiment dispensers and display containers; and (4) In equipment such as ice bins and beverage dispensing nozzles and enclosed components of equipment such as ice makers, cooking oil storage tanks and distribution lines, beverage and syrup dispensing lines or tubes, coffee bean grinders, and water vending equipment: (a) At a frequency specified by the manufacturer, or (b) Absent manufacturer specification, at a frequency necessary to preclude accumulation of soil or mold. b & c. During an observation on 6/1/2026 at 8:33 a.m., of the walk-in refrigerator observed dirt, butter, and paper trash on the floor. During an interview on 6/1/2026 at 9:11 a.m., with the DS, the DS stated the walk-in refrigerator is cleaned every shift, floors are mopped three times a day and power washed once a week. The DS stated there was gelatin on the floor and dry food debris. The DS further stated there was dry milk residue on the walk-in refrigerator shelves and needed to be cleaned. The DS stated it was important to maintain the cleanliness of the walk-in refrigerator to prevent cross contamination resulting in food borne illnesses to residents. During a review of the facility's P&P titled Environment, dated 1/15/2026, the P&P indicated, All food preparation areas, food service areas, and dining area will be maintained in a clean and sanitary condition. d. During concurrent observation and interview on 6/1/2026 at 9:41 a.m., of the dry storage room with the DS, observed oatmeal particles on the floor. The DS stated it was not okay to have food and oatmeal debris on the floor as it could attract rodents. The DS further stated it was important to have a rodents-free facility because rodents (a small animal with continuously growing front teeth that they use for chewing like mice, rats, squirrels) carry bacteria and they could also go to food resulting to foodborne illness to the residents. During a review of the facility's P&P titled Environment, dated 1/15/2026, the P&P indicated, 1. The Dining Services Director will ensure that the kitchen is maintained in a clean and sanitary manner, including floors, walls, ceilings, lighting, and ventilation. e. During an observation on 6/2/2026 at 12:19 p.m. of the drying racks, observed Cambro containers had sticker residues and debris. During an interview on 6/3/2026 at 10:54 a.m., with the DS, the DS stated there were sticker residues on the Cambro containers and it was not okay due to cross-contamination. The DS stated they were having issues with their label machine, and the stickers were hard to clean. During a review of the facility's P&P titled Environment, dated 1/15/2026, the P&P indicated, 3. All food contact surfaces will be cleaned and sanitized after each use. f. During an observation on 6/2/2026 at 12:22 p.m., of the drying racks used for domes and cover, observed dirt debris on the bottom of the racks. During an interview on 6/3/2026 at 10:49 a.m., with the DS, the DS stated the drying racks are clean daily before placing the plate covers and domes and it was important to clean it to prevent the dishes from being contaminated. The DS stated the bottom of the 2 racks had dirt and dust, and she did not think it was cleaned today before drying the clean cover and domes. During a review of the facility's P&P titled Equipment, dated 1/15/2026, the P&P indicated, (1) All equipment will be routinely cleaned and maintained in accordance with manufacturer's directions and training materials. (4) All non-food contact equipment will be clean and free of debris. During a review of Food Code 2022, the Food Code 2022 indicated,4-602.13 Nonfood-Contact Surfaces. Nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues. During an observation on 6/1/2026 at 8:30 a.m., of the freezer by the exit door, observed the freezer gasket was torn. During an interview on 6/1/2026 at 9:02 a.m., with the DS, the DS stated the Freezer 3 gasket was ripped, and it was not okay as gasket helps maintain the refrigerator and freezer temperature and the flow of air. The DS stated residents could potentially get sick of food borne illness if the freezer and refrigerator temperatures were not maintained. During a review of the facility's P&P titled Equipment, dated 1/15/2026, the P&P indicated, All food service equipment will be clean, sanitary, and in proper working order. 5. The Dining Service Director will submit requests for maintenance or repair to the Administrator and or Maintenance director as needed. During a review of the facility's P&P titled, Refrigerator and Freezer, dated 1/15/2026, the P&P indicated, 10. Supervisor inspects refrigerators and freezers monthly for gasket condition, fan condition, presence of rust, excess condensation, and any other damage or maintenance needs. Necessary repairs are initiated immediately. During an observation on 6/1/2026 at 9:18 a.m. of the chest freezer, observed that there was no thermometer inside the freezer. During an interview on 6/1/2026 at 9:21 a.m., with the DS, the DS stated that there was no thermometer inside the chest freezer. The DS further stated that it was important to place a thermometer in the chest-freezer for temperature control and check if the temperature was at an acceptable range because there is frozen food stored in it. The DS stated it was important to maintain the freezer temperatures to prevent foodborne illnesses. During a review of the facility's P&P titled Cold Foods, dated 1/15/2026, the P&P indicated, 3. Freezer temperatures will be maintained at a temperature of 0 F or below. 4. An accurate thermometer will be kept in each refrigerator and freezer. A written record of daily temperatures will be recorded. During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated 4-204.112 Temperature Measuring Devices. (A) In a mechanically refrigerated or hot FOOD storage unit, the sensor of a TEMPERATURE MEASURING DEVICE shall be located to measure the air temperature or a simulated product temperature in the warmest part of a mechanically refrigerated unit and in the coolest part of a hot FOOD storage unit. (B) Except as specified in (C) of this section, cold or hot holding EQUIPMENT used for TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be designed to include and shall be equipped with at least one integral or permanently affixed TEMPERATURE MEASURING DEVICE that is located to allow easy viewing of the device's temperature display. During a concurrent observation and interview on 6/1/2026 at 9:26 a.m., of the dry storage room with the DS, observed 3 dented cans stored with non-dented cans. The DS stated dented cans are separated into an area to prevent staff from using them. The DS further stated residents could have food borne illness from botulism (rare but serious illness caused by bacteria leading to difficulty breathing, muscle paralysis and it could be fatal if not treated promptly) as chemical is released from the dented can. During a review of the facility's P&P titled Receiving, dated 1/15/2026, the P&P indicated, 4. All canned goods will be appropriately inspected for dents, rust or bulges. Damaged cans will be segregated and clearly identified for return to vendor or disposal, as appropriate. During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated, 3-101.11 Safe Unadulterated, and Honestly Presented. Food shall be safe, unadulterated, and, as specified under 3-601.12, honestly presented. 3-201.11 Compliance with Food Law. A primary line of defense ensuring that food meets the requirements of S3-101.11 is to obtain food from approved sources, the implications of which are discussed below. However, it is also critical to monitor food products to ensure that, after harvesting, processing, they do not fail victim to conditions that endanger their safety, make them adulterated, or compromise their honest presentation. The regulatory community, industry, and consumers should exercise vigilance in controlling the conditions to which foods are subjected and be alert to signs of abuse. FDA considers food in hermetically sealed containers that are swelled or leaking to be adulterated and actionable under the Federal Food, Drug, and Cosmetic Act. Depending on the circumstances, rusted, and pitted or dented cans may also present a serious potential hazard. During an observation on 6/2/2026 at 7:33 a.m. of the chopping boards, observed two (2) green chopping boards have brownish discoloration and scratches. During an interview on 6/2/2026 at 8:38 a.m. with the DS, the DS stated the green chopping boards had burned and cut marks. The DS stated the green chopping board had brownish discoloration, and it was not okay as there could be bacterial growth to it causing cross contamination and food borne illness to the residents. The DS further stated the discoloration would not come off when they wash it During a review of the facility's P&P titled Equipment, dated 1/15/2026, the P&P indicated, All food service equipment will be clean, sanitary, and in proper working order. During a review of Food Code 2022, dated 1/18/2023 the Food Code 2022 indicated, 4-501.12 Cutting Surfaces. Cutting surfaces such as cutting boards and blocks that become scratched and scored may be difficult to clean and sanitize. As a result, pathogenic microorganisms transmissible through. a. During an observation on 6/2/2026 at 7:39 a.m. of the clear Cambro clear container where scoops and utensils were stored, observed 2 Cambro containers were not covered and there was dirt debris inside of the container. During an interview on 6/2/2026 at 8:40 a.m. with the DS, the DS stated they cover the scoop container with the lid so that food particles does not fall in it and contaminate the whole container. The DS stated there were two containers not covered and they had dirty debris. b. During an observation on 6/4/2026 at 9:22 a.m., of the manual dishwashing process, observed Dietary Aide 1 (DA 1) scrubbed the pots with soap and the soap spilled on the pans on top of the drying area. During an interview on 6/4/2026 at 9:44 a.m., with the DS, the DS stated soap spilling on the pots and dishes were not okay due to cross contamination of the sanitized pans. During a review of the facility's P&P titled Food: Preparation, dated 1/15/2026, the P&P indicated, Dining Services Staff will be responsible for food preparation procedures that avoid contamination by potentially harmful physical, biological, and chemical contamination. During a review of Food Code 2022, dated 1/18/2022, the Food Code 2022 indicated, 4-601.11 (A) Equipment Food Contact Surfaces and utensils shall be cleaned: (1) Except as specified in (B) of this section, before use with a different type of raw animal food such as beef, fish, lamb, pork or poultry; (2) Each time there is a change from working with raw foods to working with ready-to-eat food; (3) Between uses with raw fruits and vegetables and with time/temperature control for safety food. (4) Before using or storing a food temperature measuring device, and (5) At the time during the operation when contamination may have occurred. During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated, 3-307.11 Miscellaneous Sources of Contamination. Food shall be protected from contamination that may result from a factor or source not specified under subparts 3-391 - 3-306. During a review of Food Code 2022, the Food Code 2022 indicated, 4-701.10 Food Contact Surfaces and Utensils shall be sanitized. 4-702.11 Before use After cleaning. Utensils and Food-Contact Surfaces of Equipment shall be sanitized before use after cleaning. During an observation on 6/2/2026 at 8:03 a.m., of the floor by the oven, observed the grill was on the floor. During an interview on 6/2/2026 at 8:42 a.m., with the DS, the DS stated the oven grill, and rack was touching the floor, and it should be on the rack. The DS stated they avoid storing food and utensils on the floor to prevent cross contamination. During a review of the facility's P&P titled Dry Goods, dated 1/15/2026, the P&P indicated, All items will be stored on shelves at least 6 inches above the floor. During a review of the facility's P&P titled, Food: Preparation, dated 1/15/2026, the P&P indicated, All utensils, food contact equipment, and food contact surfaces will be cleaned and sanitized after every use. During an observation on 6/2/2026 at 12:19 p.m., of the Cambro containers on the shelves, observed the Cambro containers were stored stacked wet. During an interview on 6/3/2026 at 10:59 a.m., with the DS, the DS stated there were still water particles on the Cambro containers and it was stacked wet. The DS further stated their process was to air dry food containers to prevent water nesting (wet nesting, a sanitation risk in the kitchen occurs when containers are still wet and stack together causing airflow restriction and moisture becomes trapped creating the perfect environment for rapid bacterial growth) causing bacterial and cross contamination. During a review of the facility's P&P titled Manual Ware washing (3-Compartment Sink), dated 1/15/2026, the P&P indicated, 2. All service ware and cookware will be air dried prior to storage. During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated, 4-901.11 Equipment and Utensils, air-drying required. After cleaning and sanitizing equipment and utensils: (A) Shall be air-dried or used after adequate draining as specified in the first paragraph of 40 CFR 180.940 tolerance exemptions for active and inert ingredients for use in antimicrobial formulations (food-contact surface sanitizing solutions), before contact with food and; (B) May not be cloth dried except that utensils that have been air-dried may be polished with cloths that are maintained clean and dry. During a concurrent observation and interview on 6/3/2026 at 11:03 a.m., of the resident's trays with the DS, observed 4 of 4 trays had visible cracks. The DS stated cracked trays are hard to clean, and bacteria could grow causing potential cross contamination of food. During a review of the facility's P&P titled Equipment, dated 1/15/2026, the P&P indicated, All food service equipment will be clean, sanitary, and in proper working order. During a review of Food Code 2022, dated 1/18/2023 the Food Code 2022 indicated, 4-202.11 Food-Contact Surfaces. (A) Multiuse Food-contact surfaces shall be (1) Smooth (2) Free of breaks, open seams, cracks, chips, inclusions, pits, and similar imperfections. (3) Free of sharp internal angles, corners, and crevices, (4) Finished to have smooth welds and joints. During an observation on 6/4/2026 at 9:07 a.m., of the manual dishwashing process, observed Dietary Aide 1 (DA 1) working on scraping the dishes and washing them on the wash sink and DA 2 was working on the clean side near the sanitizing sink. Observed DA 2 drained the rinse compartment sink, cleaned it and went to grab a cart then placed the soiled trays from the dish machine area to the three-compartment sink. Observed DA 2 got a towel, wiped his hands and dipped his hand in the first compartment sink containing soap, water and dishes. Observed DA 2 went and grabbed a floor squeegee (a tool used to remove or push water off the floor) and removed water from the floor then proceeded to dip his hands on the rinse compartment sink with dishes. During an observation on 6/4/2026 at 9:16 a.m. of DA 2 dishwashing, observed DA 2 wore gloves then removed the utensils from the second compartment to the third compartment then touched the clean scoops and put it away for storage. During an observation on 6/4/2026 at 9:29 a.m., observed DA 2 got a creamer and jam after dishwashing without washing his hands. During an interview on 6/4/2026 at 9:44 a.m. with the DS, the DS stated DA 2 should have washed his hands after cleaning the rinse compartment sink and before handling clean pots and dishes to prevent cross-contamination. During a review of the facility's P&P titled Food Preparation, dated 1/15/2026, the P&P indicated, All staff will practice proper hand-washing techniques and glove use. During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated 2-301.14 When to Wash. FOOD EMPLOYEES shall clean their hands and exposed portions of their arms as specified under S 2-301.12 immediately before engaging in FOOD preparation including working with exposed FOOD, clean EQUIPMENT and UTENSILS, and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLESP and: (A) After touching bare human body parts other than clean hands and clean, exposed portions of arms; P (B) After using the toilet room; P (C) After caring for or handling SERVICE ANIMALS or aquatic animals as specified in 2-403.11(B); P (D) Except as specified in 2-401.11(B), after coughing, sneezing, using a handkerchief or disposable tissue, using TOBACCO PRODUCTS, eating, or drinking; P (E) After handling soiled EQUIPMENT or UTENSILS; P (F) During FOOD preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; P (G) When switching between working with raw FOOD and working with READY-TO-EAT FOOD; P (H) Before donning gloves to initiate a task that involves working with FOOD; P and (I) After engaging in other activities that contaminate the hands. During a concurrent observation and interview on 6/4/2026 at 9:53 a.m., of the resident's refrigerator with the DS and Activities Director (AD), observed an ice cream box in the freezer with no label and a plastic bag of food in the refrigerator without label. The AD stated it was important to label the food item, so they know which residents it belongs to however she does not know the potential outcome of not labeling the food. The DS stated it was important to label the food items to make sure residents receive the right diet, cater to food allergies and right texture to residents to prevent allergic reactions. During a review of the facility's P&P titled, Food Brought in By Visitors, dated 1/15/2026, the P&P indicated, 5. When food items are intended for later consumption, the staff responsible will: c. Label foods with the resident's name and the receive date. Items will be thrown out after 48 hours.

Based on interview and record review the facility failed to maintain accurate clinical records in accordance with accepted professional standards and practices for 3 (Resident 1, Resident 5, and Resident 18) of 29 sampled residents by failing to: Ensure the diagnosis of diabetes mellitus ((DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) was reflected in Resident 1's and Resident 5's list of diagnoses in the medical record. This failure had the potential to result in inaccurate medical records, missed care planning, and inadequate treatment and management of the residents' diabetes. 2. Ensure Restorative Nursing Assistant 1 (RNA 1, a certified Nursing Assistant with specialized training in physical rehabilitation) documented a treatment until after it was completed and did not document the treatment before it was provided for Resident 18. This failure had the potential to cause confusion among staff regarding the provision and timing of the resident's treatment and result in inaccurate medical records. Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility originally admitted the resident on 12/30/2024, and most recently readmitted the resident on 2/9/2026, with diagnoses including, but not limited to, metabolic encephalopathy (the loss of brain function due to a chemical imbalance in the blood) and acute (severe, sudden onset) respiratory failure (a condition where the lungs cannot release enough oxygen into the blood) with hypoxia (an insufficient amount of oxygen in your body tissues). The admission Record did not include DM in the resident's list of diagnoses. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 4/24/2026, the MDS indicated the resident was sometimes able to make himself understood and sometimes understands others. The MDS indicated Resident 1 was dependent (helper does all of the effort) on staff for most activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 1's Order Summary Report, the Order Summary Report indicated the following active order for insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication): Insulin Aspart (a rapid-acting insulin) to inject per sliding scale (a reactive method of managing blood sugar where the dose of short- or rapid-acting insulin is adjusted based on your pre-meal or bedtime blood sugar levels) for DM type 2 (a type of DM where the body cannot use insulin correctly) before meals and at bedtime. During a concurrent interview and record review on 6/3/2026 at 3:54 p.m. with the Minimum Data Set Nurse (MDSN), Resident 1's medical record, did not indicate a diagnosis of DM under the resident's list of active diagnoses. The MDSN stated DM should be listed in the resident's diagnoses in the medical record because it was identified that he does have that diagnosis and the facility is providing treatment for it. The MDSN stated the diagnosis list should be complete, so staff is all aware of the resident's DM. The MDSN stated all basic information needed should be listed on the resident's admission Record to give proper information to facility staff as well as the staff of any outside facility they need to transfer the resident to so they will have complete information about the resident. During a review of the facility's policy and procedure (P&P) titled, Charting and Documentation, last reviewed on 1/15/2026, the P&P indicated documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate. 2. During a review of Resident 5's admission Record, the admission Record indicated that the facility admitted Resident 5 to the facility on [DATE], with diagnoses including hypertension (HTN-high blood pressure), schizophrenia (a mental illness that is characterized by disturbances in thought), epilepsy (a disorder in which nerve cell activity in the brain is disturbed causing seizures) and cerebral infarction (lack of blood flow resulting in severe damage to some of the brain tissue). During a review of Resident 5's MDS dated [DATE], the MDS indicated that Resident 5's cognition (mental action or process of acquiring knowledge and understanding) was severely impaired. The MDS indicated Resident 5 was dependent (helper does all the effort) for physical assistance from staff for activities of daily living (ADLs – eating, toileting, hygiene, shower/bathing). The MDS also indicated that Resident 5 was receiving insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) injections. During a review of Resident 5's History and Physical (H&P) from the general acute care hospital (GACH), dated 2/23/2026, the H&P indicated that Resident 5 has a medical diagnosis of type 2 diabetes mellitus with hyperglycemia (the body cannot properly process sugar, resulting in too much sugar building up in the bloodstream). During a review of Resident 5's Order Summary Report, dated 6/4/2026, the Order Summary Report indicated the following physician orders: -Insulin Glargine (a long-acting basal insulin used to control high blood sugar) inject 10 units subcutaneously (under the skin) every 12 hours for Diabetes rotate injection site, initiated on dated 5/13/2026. -Insulin Lispro (fast-acting, mealtime insulins used to control blood sugar) Inject as per sliding scale: if 71 - 150 = 0; finger stick blood sugar (FSBS- test used to measure how much sugar [glucose] is in your blood) less than 70 Call Medical Doctor (MD-Doctor of Medicine); 151 - 200 = 2 units; 201 - 250 = 4 units; 251 - 300 = 6 units; 301 - 350 = 8 units; 351 - 400 = 10 units FSBS >401 give 12 units and call MD, subcutaneously before meals and at bedtime for diabetes, rotate injection site, initiated on 2/25/2026. During a review of Resident 5's Laboratory Results Report, dated 5/13/2026, the laboratory result report indicated that Resident 5's hemoglobin A1C (test measures your average blood sugar levels over the past 2 to 3 months) was 8.3% (greater than 6.4% which was indicative of DM). During a concurrent interview and record review on 6/3/2026 at 11:06 a.m. with Registered Nurse (RN) 1, Resident 5's records including summary report, medical diagnosis and care plan were reviewed. RN 1 stated that Resident 5 had physician orders for insulin glargine and insulin lispro, both indicated for DM. RN 1 stated that the nursing staff who enters physician orders is responsible for verifying that the resident has diagnoses corresponding to the prescribed medications, ensuring that unnecessary medications are not administered for safety reasons. RN 1 stated that the Minimum Data Set Nurse (MDSN) was responsible for medical diagnosis coding. RN 1 further stated that there was no care plan in place for diabetes management or insulin administration. RN 1 stated that Resident 5 was at risk for uncontrolled blood sugar and potential complications due to the absence of a documented plan of care. During a concurrent interview and record review on 6/3/2026 at 4:00 p.m. with MDSN, Resident 5's MDS, medical diagnosis and care plan were reviewed. The MDSN stated her responsibilities include working with the interdisciplinary team (IDT - a group of dedicated healthcare professionals who work to bring knowledge together to help residents receive the care they need), conducting assessments, and completing MDS and care plan documentation. The MDSN stated that the admission Record contains basic resident information and diagnosis history. The MDSN stated that for residents with DM, she creates a care plan for medication, monitoring, and treatment. The MDSN further stated when insulin therapy is ordered, an active medical diagnosis must be documented to initiate treatment promptly and failure to document may lead to missing care plans and risks like hyperglycemia, hypoglycemia, neuropathy, and vision impairment for Resident 5. During a review of facility's Policy and Procedure (P&P) titled Charting and Documentation, last reviewed 1/15/2026, the P&P indicated that all services rendered to residents, progress toward care plan objectives, and any alterations in medical, physical, functional, or psychosocial status must be recorded in the resident's medical record. The medical record serves as a communication tool for the interdisciplinary team regarding the resident's condition and response to care. All entries are required to be objective, comprehensive, and accurate, avoiding subjective or speculative statements. 3. During a review of Resident 18's admission Record, the admission Record indicated the facility admitted the resident on 10/25/2024 with diagnoses that included right hip contusion (a bruise that appears on the skin of the hip after an injury). During a review of Resident 18' s MDS, the MDS indicated Resident 18 was moderately impaired in cognition (the process of acquiring knowledge and understanding through thought, experience, and the senses) with skills required for daily decision making. The MDS indicated Resident 18 required partial/moderate assistance (helper does less than half the effort) with walking. During a review of Resident 18's Physician's Orders, the orders indicated the following: RNA for ambulation (walking) with front wheeled walker five times a week, as tolerated every day shift, dated 4/30/2026. RNA for active range of motion (AROM) to bilateral upper extremities (BUE, both arms) five times a week as tolerated, every day shift, dated 4/30/2026. During a review of Resident 18's Care Plan for Restorative Ambulation/Mobility, initiated 3/25/2026, the care plan indicated a goal that Resident 18 will maintain current level of ambulation for 90 days. The care plan indicated an intervention that the RNA will assist Resident 18 with ambulation with a front wheeled walker, five times a week as tolerated. During a review of Resident 18's Restorative Administration Record (RAR, a daily documentation record used by an RNA to document RNA treatments given to a resident) indicated RNA 1 signed Resident 18's ambulation treatment as being completed on 6/01/2026. During a concurrent observation, interview, and record review with the Director of Staff Development (DSD) on 6/01/2026 at 4:35 p.m., the DSD reviewed Resident 18's RAR which indicated Resident 18's ambulation had been completed. However, the survey team and DSD immediately observed that RNA 1 was walking with Resident 18 in the station one hallway with her walker. The DSD stated RNA 1 signed the RAR ambulation task as completed before completing the treatment. The DSD stated the practice is to complete a task first and then sign that it was completed afterwards. During an interview with RNA 1 on 6/01/2026 at 4:56 p.m., he stated he completed the upper extremity range of motion movements task with Resident 18 in the morning. RNA 1 stated Resident 18 told him she wanted to complete the walking activity later in the day. RNA 1 stated he signed the ambulation task as completed right before he started the task with Resident 18 because Resident 18 told him then that she wanted to walk in the hallway. RNA 1 stated he knew he was supposed to sign the RAR record after completing the task. RNA 1 stated it is important to sign the RAR afterwards because a resident might change their mind at the last minute and say they do not want to do the activity. During a concurrent interview and record review with the Minimum Data Set Nurse (MDSN) on 6/04/2026 at 12:41 p.m., the MDSN reviewed the facility's policy and procedure titled, Charting and Documentation, last reviewed 1/15/2026. The MDSN stated in the policy under number 7. that documentation of procedures and treatments will include care-specific details, including the date and time the procedure/treatment was provided by the name and title of the individual (s) who provided the care. The MDSN stated the part was provided, infers that this signing is to be after the care was provided. The MDSN stated this is important for accuracy of records. During an interview with the Director of Nursing (DON) on 6/04/2026 at 2 p.m., she stated the facility's practice is to document care was provided after it is completed and not before. The DON stated this is important for accuracy of records.

Based on observation, interview, and record review, the facility failed to maintain sanitary conditions in the food services department when three (3) flies (a type of insect) were observed in trayline (an area where foods were assembled form the steamtable [kitchen appliance that keeps food warm at a safe temperature for serving] to resident's plates) and dishwashing area in the kitchen. This failure had the potential to result in 128 of 138 residents, who received food from the kitchen, to acquire food borne illnesses (illness caused by consuming contaminated foods or beverages) by consuming potentially contaminated food. Findings: During an observation on 6/1/2026 at 12:18 p.m., of the trayline, observed a fly flying around the trayline and landed on the stove dial. During a concurrent observation and interview on 6/1/2026 at 12:24 p.m., with the Corporate Dietitian (CRD), observed a fly lingering around the trayline area. The CRD stated the fly most likely came from the door when the staff opened it. During an observation on 6/1/2026 at 12:30 p.m., observed a fly land on the disposable box container for food in trayline. During an observation on 6/1/2026 at 12:41 p.m., observed a fly land on the fly light top surface and staff killed it. During an observation on 6/1/2026 at 12:56 p.m., of the lunch trayline, observed a fly landing on the disposable food container and heard the Dietary Supervisor (DS) telling the staff to close the door. During an observation on 6/1/2026 at 12:59 p.m., observed a fly landing on the food container and heard the Corporate District Manager (CDM) instruct staff to remake the food. During an interview on 6/1/2026 at 1:31 p.m., with the DS, the DS stated flies were coming from the front door dining room and the staff should not leave it open. The DS stated pest control came and installed fly traps outside the back door. The DS stated it was important not to have flies in the kitchen to prevent cross-contamination. During an observation on 6/4/2026 at 9:22 a.m., of the three-compartment sink, observed a fly flying around the area. During a review of facility's policy and procedure (P&P) titled, Pest Control, dated 1/15/2026, the P&P indicated, A program will be established for control of insects and rodents for the Dining Services Department. During a review of the facility's pest control report titled, Customer Service Report, dated 5/10/2026, the report indicated, There was no fly noted during the inspection and service at 9:11 p.m. and a demand CS insecticide was applied in the exterior area slide door to target flies. The report further indicated a stealth maxima flight light was used to target flies in the kitchen. During a review of Food Code 2022, dated 1/18/2026, the Food Code 2022 indicated, 6-501.11 Controlling Pests. The premises shall be maintained free of insects, rodents and other pests. The presence of insects, rodents, and other pests shall be controlled to eliminate their presence on the premises by (a) routinely inspecting incoming shipments of food and supplies; (b) routinely inspecting the premises for evidence of pests. (c) using methods, if pests are found such as trapping devices or other means of pest control (d) eliminating harborage conditions.

Based on observation, interview, and record review, the facility failed to provide care in a manner that promoted resident dignity and respect for two of 29 sampled residents (Resident 22 and Resident 4) when: 1. The facility failed to inform Resident 22 of the reason for the use of single-use disposable food containers and plastic utensils when serving meals. This deficient practice had the potential to violate the resident's rights to be treated with respect and dignity and negatively affect resident's sense of self-worth and self-esteem. 2. Speech Therapist 1 (ST 1, a healthcare professional who evaluates and treats swallowing disorders in residents) was observed standing over Resident 4 while assisting with eating. This deficient practice had the potential to affect a resident's self-worth and self-esteem and would not provide an accurate assessment of Resident 4's swallowing ability. Findings: 1. During a review of Resident 22's admission Record, the admission Record indicated the facility originally admitted Resident 22 on 6/30/2025 and re-admitted the resident on 3/21/2026 with diagnoses that included metabolic encephalopathy (general term that describes brain disease, damage, or malfunction usually related to inflammation within the body), acute (sudden onset) respiratory failure (a condition where the lungs cannot release enough oxygen into the blood) with hypoxia (an insufficient amount of oxygen in your body tissues) and need for assistance with personal care. During a review of Resident 22's Minimum Data Set (MDS – a resident assessment tool) dated 3/24/2026, the MDS indicated Resident 22 is able to make self-understood and is able to understand others. The MDS indicated Resident 22 required set-up assistance (helper sets up or cleans up; resident completes activity). During review of Resident 22's History and Physical (H&P) dated 3/22/2026, the H&P indicated Resident 22 had the capacity to make own decisions. During a concurrent observation and interview on 6/1/2026 at 1:13 p.m., with Resident 22, observed Resident 22 eating her meal from a brown, single-use disposable food container and using plastic, disposable utensils. Resident 22 stated the facility has been serving meals the past two (2) days in these cardboard things, disposable box and plastic utensils. Resident 22 stated the food gets cold quickly when served in the disposable container. Resident 22 stated she liked it better when real dishes were being used. Resident 22 stated, I don't know why they (referring to the facility) is being so cheap, using disposables. What is going on that we can't have the real stuff? It doesn't make a whole lot of sense why the change. At home, I use real plates and utensils and I want it back the way it was. No one explained why the switch. Resident 22 stated that there has been other times since she has been in the facility that meals were served in disposable containers and staff do not explain why they are being used. During an interview on 6/1/2026 at 3:43 p.m., with Licensed Vocational Nurse 1 (LVN), LVN 1 stated that she was not sure when the kitchen started using disposable containers and utensils, however, she is able to attest she observed meals were served in disposable container and utensils on 5/31/2026 evening and on 6/1/2026. LVN 1 stated the nursing staff were not informed when the kitchen started using the disposable containers and utensils. LVN 1 stated she did not inform Resident 22 or any of the residents the reason why the disposables were being used because she did not know what to tell the residents. LVN 1 stated that it is the residents' right to know when and why disposables are being used for their meals. LVN 1 stated that regular dishes are what is used in a home like setting, and if there is a change where disposables are being used instead of regular dishes, residents should be informed of the reason since the facility serves as their home. During an interview of 6/5/2026 at 8:48 a.m., with the Administrator (ADM), the ADM stated administration did not inform the staff about the switch from using regular dishes and utensils to disposables when serving meals and the rationale for it. The ADM stated it is important to keep staff informed so they can effectively share information with residents who have the right to know. The ADM stated the facility is the residents' home and it is important for residents to be well informed of changes in their home to avoid confusion. The ADM stated giving residents advance notice about switching to disposable dishes and utensils helps ensure residents do not become confused or concerned that there may other issues with the building or other matters. During a review of the facility's policy and procedure (P&P) titled, Resident Rights, last reviewed 1/15/2026, the P&P indicated, Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: be treated with respect, kindness, and dignity. During a review of the facility's P&P titled, Dignity, last reviewed 1/15/2026, the P&P indicated, Each resident is cared for in manner that promotes and enhances individuality, a sense of well-being, satisfaction with life, and feelings of self-worth and self-esteem. 2. During a review of Resident 4's admission Record, the admission Record indicated the facility admitted the resident on 10/30/2023 and re-admitted the resident on 10/29/2024 with diagnoses that included dysphagia (difficulty swallowing) and dementia (a progressive state of decline in mental abilities). During a review of Resident 4's MDS dated [DATE], the MDS indicated Resident 4 was severely impaired in cognition (the process of acquiring knowledge and understanding through thought, experience, and the senses) with skills required for daily decision making. The MDS indicated Resident 4 required partial/moderate assistance (helper does less than half the effort) with eating. During a review of Resident 4's Physician's Orders, the Physician's Orders indicated an order for a regular diet (food with no modifications and restrictions), pureed texture (foods that are smooth with pudding like consistency), mildly thick consistency (liquid consistency of pouring quickly from a spoon, but slower than water), dated 3/2/2025. During a dining observation on 6/2/2026 at 12:56 p.m., with the Director of Nursing (DON), the DON observed Resident 4 being fed lunch by ST 1. ST 1 was observed not feeding Resident 4 at eye level. ST 1 was observed standing beside Resident 4. When asked, ST 1 stated she usually sits down at the resident's eye level when feeding a resident and was going to sit down. ST 1 stated the practice of sitting at eye level is easier in positioning for feeding. ST 1 stated sitting at eye level is important so she can access Resident 4's eating, how the resident's mouth is moving, and observe better how they are eating. During an interview on 6/4/2026 at 4:19 p.m., with the DON, the DON stated residents that need assistance with eating are to be fed at eye level to provide dignity for the residents and to ensure a resident's swallowing is being fully assessed. During a concurrent interview and record review on 6/5/2026 at 10:39 a.m., with the DON, reviewed the facility's policy and procedure titled, Quality of Life – Dignity, last reviewed 1/15/2026 and an in-service (training intended for those actively engaged in a profession or activity) titled, Assistance During Eating, dated 6/2/2026. The DON reviewed the policy that indicated that residents are treated with dignity and respect at all times. The DON stated the Quality of Life policy does not contain specific verbiage regarding sitting at eye level when feeding a resident but is a practice that the staff follow. The DON presented the ST 1's in-service which indicated the practice is to feed a resident at eye level, sitting down to ensure staff are assessing a resident while eating.

Based on observation, interview, and record review, the facility failed to provide the full six page of the arbitration agreement (a voluntary binding agreement by the parties to submit to an arbiter [a lawyer or retired judge, not a court judge] all or certain disputes which have arisen or may arise for a resident while staying in the facility) for one of four sampled residents (Resident 154). This deficient practice violated Resident 154's rights to make a fully informed decision. Findings: During a review of Resident 154's admission Record, the admission Record indicated the facility admitted the resident on 5/30/2026 with diagnoses that included nontraumatic intracerebral hemorrhage (bleeding directly into the brain tissue not caused by head trauma). During a review of Resident 154' s Minimum Data Set (MDS, a resident assessment tool), dated 6/4/2026, the MDS indicated Resident 154 was cognitively (the process of acquiring knowledge and understanding through thought, experience, and the senses) intact with skills required for daily decision making. The MDS indicated Resident 154 required setup or clean-up assistance (helper sets up or cleans up; resident completes activity) with eating. During a concurrent interview and record review on 6/1/2026 at 10 a.m., with Resident 154, Resident 154 stated the facility gave him some admission paperwork to look over. Reviewed the admission paperwork which included an arbitration signature page. Resident 154 did not know what that page was. During an interview on 6/1/2026 at 10:20 a.m., with Admissions Coordinator 1 (AC 1), AC 1 stated the admission packet with the one Arbitration Agreement page was given to Resident 154 over the weekend by another staff and the arbitration agreement should contain six pages. AC 1 stated she would redo the packet so Resident 154 would have all the arbitration agreement pages. AC 1 stated this is important for residents' rights so that residents are fully informed about the arbitration agreement. During a concurrent interview and record review on 6/4/2026 at 3:24 p.m., with AC 1, reviewed the facility's policy and procedure titled, Binding Arbitration Agreement, last reviewed 1/15/2026. AC 1 stated to make an informed decision on whether to enter into the arbitration agreement, as per policy, residents have the right to make informed decisions about important aspects of their health, welfare and safety. AC 1 stated to achieve this, Resident 154 should have received all pages of the arbitration agreement. During an interview on 6/5/2026 at 2:07 p.m., with the Administrator (ADM), the ADM stated the admissions department gives all pages of the arbitration agreement so the residents can understand the agreement. The ADM stated this is important for residents' rights so they can make an informed decision on whether to enter into the agreement.

Based on observation, interview, and record review, the facility failed to provide a resident with a safe, clean, comfortable, and homelike environment for one of 29 sampled residents (Resident 58) when the over bed table was wobbly and missing one wheel. This deficient practice violated the resident's right to a safe, clean, comfortable and homelike environment and had the potential to affect the resident's self of worth.Findings: During a review of Resident 58's admission Record, the admission Record indicated the facility initially admitted Resident 58 on 3/30/2025 with diagnoses including dementia (a progressive state of decline in mental abilities), difficulty in walking, adult failure to thrive (a decline caused by chronic diseases and functional impairments which can cause weight loss, decreased appetite, poor nutrition, and inactivity), and right femur closed fracture (a break, crack or crush injury of the thigh bone). During a review of Resident 58's Minimum Data Set (MDS - a resident assessment tool) dated 4/28/2026, the MDS indicated that Resident 58's cognition (mental action or process of acquiring knowledge and understanding) was severely impaired. The MDS indicated Resident 58 required ranging from supervision (helper provides touching or contact guard assistance) to moderate (helper does less than half the effort) physical assistance from staff for activities of daily living (ADLs - eating, toileting, hygiene, shower/bathing) The MDS also indicated that Resident 58 used a manual wheelchair for mobility device. During a review of Resident 58's Care Plan (a document that summarizes a resident's needs, goals, and care/treatment) titled, At risk for falls/injury related to impaired mobility, generalized weakness, multiple complex medical conditions, revised on 12/15/2025, the care plan indicated interventions such as provision of a low bed with bilateral landing pads on each side, maintaining a clutter-free environment within the resident's room, and ensuring consistent furniture arrangement. During a concurrent observation and interview on 6/1/2026 at 10:13 a.m., with Licensed Vocational Nurse 1 (LVN 1) in Resident 58's room, observed an over-bed table with a broken wheel on the left side landing pad. LVN 1 stated that broken wheels on over-bed tables should be removed from Resident 58's room because it poses hazards and do not contribute to a home-like environment for Resident 58. LVN 1 further stated that the damaged wheel must be repaired or replaced by the Maintenance Supervisor (MS). During an interview on 6/4/2026 at 3:06 p.m., with Director of Nursing (DON), the DON indicated that all staff members are responsible for ensuring furniture and equipment remain in good working order. The DON stated that if any issues arise, it is MS who was responsible for addressing and fixing them as needed. The DON also stated that keeping furniture and equipment well-maintained helps prevent accidents and injuries, and is vital for creating a comfortable, homelike environment for residents. During a review of facility's Policy and Procedure (P&P) titled, Home Like Environment, reviewed 1/15/2026, the P&P indicated that residents are provided with a safe, clean, comfortable, and homelike setting. The P&P also states that facility staff and management strive to maximize aspects of the facility that create a personalized, home-like atmosphere, while maintaining a clean, sanitary, and orderly environment.

Based on interview and record review, the facility failed to ensure two of two sampled resident's (Resident 1 and Resident 5) diagnosis of diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) was reflected in the resident's list of diagnoses in the Minimum Data Set (MDS - a resident assessment tool). This deficient practice resulted in Resident 1 and Resident 5 having an inaccurate MDS assessment and has the potential to negatively affect in plan of care and treatment. Findings: a. During a review of Resident 5's admission Record, the admission Record indicated that the facility initially admitted Resident 5 to the facility on [DATE], with diagnoses including hypertension (high blood pressure [the force of the blood pushing on the blood vessel walls is too high]), schizophrenia (a mental illness that is characterized by disturbances in thought), and cerebral infarction (lack of blood flow resulting in severe damage to some of the brain tissue). During a review of Resident 5's MDS dated [DATE], the MDS indicated that Resident 5's cognition (mental action or process of acquiring knowledge and understanding) was severely impaired. The MDS indicated Resident 5 was dependent (helper does all the effort) for physical assistance from staff for activities of daily living (ADLs – eating, toileting, hygiene, shower/bathing). The MDS also indicated that Resident 5 was receiving insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) injections. During a review of Resident 5's General Acute Care Hospital 1 (GACH 1) History and Physical (H&P) dated 2/23/2026, the H&P indicated that Resident 5 had a medical diagnosis of type two (2) diabetes mellitus with hyperglycemia (the body cannot properly process sugar, resulting in too much sugar building up in the bloodstream). During a review of Resident 5's Order Summary Report dated 6/4/2026, the Order Summary Report indicated the following physician orders: -Insulin glargine (a long-acting insulin) inject 10 units subcutaneously (under the skin) every 12 hours for diabetes rotate injection site, dated 5/13/2026. -Insulin lispro (fast-acting insulin) inject as per sliding scale (progressive increase in the insulin dosage, based on pre-defined blood glucose ranges) subcutaneously before meals and at bedtime for diabetes, rotate injection site, dated 2/25/2026. During a concurrent interview and record review on 6/3/2026 at 11:06 a.m., with Registered Nurse 1 (RN 1), reviewed Resident 5's Order Summary Report, medical diagnosis, and MDS dated [DATE]. RN 1 stated that Resident 5 had physician orders for insulin glargine and insulin lispro, both indicated for DM. RN 1 stated that the nursing staff who enter physician orders are responsible for verifying that the resident has diagnoses corresponding to the prescribed medications, ensuring that unnecessary medications are not administered. RN 1 stated that the Minimum Data Set Nurse (MDSN) was responsible for medical diagnosis coding. During a concurrent interview and record review on 6/3/2026 at 4:00 p.m., with the MDSN, reviewed Resident 5's MDS dated [DATE] and medical diagnosis. The MDSN stated that her responsibilities include collaboration with the interdisciplinary team (IDT - a group of dedicated healthcare professionals who work to bring knowledge together to help residents receive the care they need), conduct assessments and evaluations, and completing both the MDS and care plan documentation. The MDSN stated that when a physician orders insulin therapy, an active medical diagnosis must be documented within the MDS. The MDSN stated Resident 5 does not have an active diagnosis of DM listed on their MDS dated [DATE] and should because they have orders for insulin. The MDSN added that the importance of accurately identifying diagnoses in the MDS is to enable timely initiation of treatment. The MDSN further stated failure to do so may result in the absence of a formulated care plan, placing Resident 5 at risk for hyperglycemia, hypoglycemia, neuropathy, and vision impairment. During a review of facility's Policy and Procedure (P&P) titled, Resident Assessment, reviewed 1/15/2026, the P&P indicated that the resident assessment coordinator makes sure the interdisciplinary team completes assessments for residents promptly and accurately. The details recorded in MDS assessments should always match what's found in progress notes, care plans, and observations or interviews with residents. All resident assessments from the last 15 months are kept in each resident's current clinical record. The results are used to create, update, and revise the resident's comprehensive care plan. b. During a review of Resident 1's admission Record, the admission Record indicated the facility originally admitted the resident on 12/30/2024 and readmitted the resident on 2/9/2026 with diagnoses including metabolic encephalopathy (the loss of brain function due to a chemical imbalance in the blood) and acute (severe, sudden onset) respiratory failure (a condition where the lungs cannot release enough oxygen into the blood) with hypoxia (an insufficient amount of oxygen in your body tissues). During a review of Resident 1's MDS dated [DATE], the MDS indicated the resident was sometimes able to make himself understood and sometimes understands others. The MDS indicated Resident 1 was dependent on staff for most ADLs. The MDS did not indicate Resident 1 had DM under the Active Diagnoses section. During a review of Resident 1's Order Summary Report, the Order Summary Report indicated the following active order for insulin: Insulin aspart (fast-acting insulin) to inject per sliding scale for DM type 2 before meals and at bedtime, ordered 3/4/2026. During a concurrent interview and record review on 6/3/2026 at 3:54 p.m., with the MDSN, reviewed Resident 1's MDS dated [DATE]. The MDSN stated Resident 1's MDS did not indicate a diagnosis of DM under the Active Diagnoses section. The MDSN stated the diagnosis of DM should be in the MDS because they are providing treatment for this diagnosis. The MDSN stated all the relevant diagnoses should be in the MDS to reflect the resident's information and what treatment they are providing for them. During a review of the facility's P&P titled, Resident Assessments, last reviewed on 1/15/2026, the P&P indicated information in MDS assessments will consistently reflect information in the progress notes, plans of care, and resident observations and interviews.

Based on interview and record review, the facility failed to develop and implement comprehensive care plan (a document that summarizes a resident's needs, goals, and care/treatment) for two of five sampled residents (Resident 1 and Resident 5) for diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) and the administration of insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) injections. This deficient practice had the potential to result in a delay of nursing care and medical interventions for Resident 1 and Resident 5. Findings: a. During a review of Resident 1's admission Record, the admission Record indicated the facility originally admitted the resident on 12/30/2024 and readmitted the resident on 2/9/2026 with diagnoses including metabolic encephalopathy (the loss of brain function due to a chemical imbalance in the blood) and acute (severe, sudden onset) respiratory failure (a condition where the lungs cannot release enough oxygen into the blood) with hypoxia (an insufficient amount of oxygen in your body tissues). During a review of Resident 1's the Minimum Data Set (MDS – a resident assessment tool) dated 4/24/2026, the MDS indicated the resident had was sometimes able to make himself understood and sometimes understands others. The MDS indicated Resident 1 was dependent (helper does all of the effort) on staff for most activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily). The MDS did not indicate Resident 1 had DM under the Active Diagnoses section. During a review of Resident 1's Order Summary Report, the Order Summary Report indicated the following active order for insulin: Insulin aspart (fast-acting insulin) to inject per sliding scale (progressive increase in the insulin dosage, based on pre-defined blood glucose ranges) for DM type 2 before meals and at bedtime, ordered 3/4/2026. During a concurrent interview and record review on 6/3/2026 at 3:54 p.m., with the Minimum Data Set Nurse (MDSN), reviewed Resident 1's care plan. The MDSN stated Resident 1's care plans did not include goals or interventions related to DM or insulin administration. The MDSN stated because Resident 1 has DM, the care plan should include goals related to Resident 1's DM and treatment for it to ensure they provide the necessary medications, do blood sugar checks and monitoring, and provide all necessary treatments to manage their DM. During a review of the facility's policy and procedure (P&P) titled, Care Plan Comprehensive, last reviewed on 1/15/2026, the P&P indicated an individualized comprehensive care plan must be created for each resident and should include clear objectives and timelines to address each resident's medical, physical, mental, and psychosocial needs. b. During a review of Resident 5's admission Record, the admission Record indicated that the facility initially admitted Resident 5 to the facility on [DATE], with diagnoses including hypertension (high blood pressure [the force of the blood pushing on the blood vessel walls is too high]), schizophrenia (a mental illness that is characterized by disturbances in thought), and cerebral infarction (lack of blood flow resulting in severe damage to some of the brain tissue). During a review of Resident 5's MDS dated [DATE], the MDS indicated that Resident 5's cognition (mental action or process of acquiring knowledge and understanding) was severely impaired. The MDS indicated Resident 5 was dependent (helper does all the effort) for physical assistance from staff for ADLs. The MDS also indicated that Resident 5 was receiving insulin injections. During a review of Resident 5's General Acute Care Hospital 1 (GACH 1) History and Physical (H&P) dated 2/23/2026, the H&P indicated that Resident 5 had a medical diagnosis of type two (2) diabetes mellitus with hyperglycemia (the body cannot properly process sugar, resulting in too much sugar building up in the bloodstream). During a review of Resident 5's Order Summary Report dated 6/4/2026, the Order Summary Report indicated the following physician orders: -Insulin glargine (a long-acting insulin) inject 10 units subcutaneously (under the skin) every 12 hours for diabetes rotate injection site, dated 5/13/2026. -Insulin lispro (fast-acting insulin) inject as per sliding scale subcutaneously before meals and at bedtime for diabetes, rotate injection site, dated 2/25/2026. During a concurrent interview and record review on 6/3/2026 at 11:06 a.m., with Registered Nurse 1 (RN 1), reviewed Resident 5's Order Summary Report, medical diagnosis, and care plans. RN 1 stated that Resident 5 had physician orders for insulin glargine and insulin lispro, both indicated for DM. RN 1 stated that a care plan was an individualized plan of care for each resident. RN 1 stated that all nursing staff are responsible for developing a care plan. RN 1 stated that Resident 5 had no care plan for diabetes management and insulin administration. RN 1 stated that Resident 5 was at risk for uncontrolled blood sugar and potential complications due to the absence of a documented plan of care. During a concurrent interview and record review on 6/3/2026 at 4:00 p.m., with the MDSN, reviewed Resident 5's medical diagnosis and care plans. The MDSN stated that her responsibilities include collaboration with the interdisciplinary team (IDT - a group of dedicated healthcare professionals who work to bring knowledge together to help residents receive the care they need), conduct assessments and evaluations, and completing both the MDS and care plan documentation. The MDSN indicated that when a resident has a medical diagnosis of DM, she formulates a care plan to facilitate medication administration, monitor the condition appropriately, and ensure the implementation of necessary treatments to manage the disease effectively. The MDSN further stated failure to do so may result in the absence of a formulated care plan, placing Resident 5 at risk for hyperglycemia, hypoglycemia, neuropathy, and vision impairment. The MDSN stated there was no care plan for Resident 5's diagnosis of DM or insulin use. During a review of the facility's P&P titled, Care Plan Comprehensive, reviewed 1/15/2026, the P&P indicated that an individualized comprehensive care plan must be created for each resident. This plan should include clear objectives and timelines to address each resident's medical, physical, mental, and psychosocial needs. The facility's IDT, with input from the resident and/or their family or representative, is responsible for developing and implementing this person-centered care plan. It must outline measurable goals and timeframes, based on the needs identified during a comprehensive assessment. The procedures used should reflect current professional standards of practice for any problem areas or conditions. Any concerns identified during the resident assessment are further evaluated using specific tools, such as Care Area Assessments, before interventions are added to the care plan. These interventions are carefully designed after considering how the resident's problem areas relate to their causes. The comprehensive care plan must be completed within seven days after the MDS is completed.

Based on observation, interview, and record review, the facility failed to ensure residents receive proper treatment and assistive devices to maintain hearing abilities for one of one resident (Resident 101) investigated under the communication-sensory care area by failing to ensure Resident 101 received proper evaluation for hearing loss. This deficient practice had the potential for Resident 101 not to receive necessary medical treatments or assistive accommodation to maintain or improve their hearing. Findings: During a review of Resident 101's admission Record (the front page of the chart that contains a summary of basic information about the resident), the admission Record indicated the facility admitted Resident 101 on 2/26/2025 with diagnoses that included epilepsy (a brain disorder that causes seizures) contracture (a stiffening/shortening at any joint, that reduces the joint's range of motion) of left upper arm, and weakness. During a review of Resident 101's Minimum Data Set (MDS - a resident assessment tool) dated 2/25/2026, the MDS indicated Resident 101 had moderate cognitive impairment. The MDS indicated Resident 101 as makes self-understood (able to express ideas and wants) and able to understand others (clear comprehension understanding verbal content). The MDS indicated Resident 101 had adequate hearing (no difficulty in normal conversation, social interaction, listening to tv) and did not use hearing aid or other hearing appliance. During review of Resident 101's History and Physical (H&P), dated 2/27/2025, the H&P indicated Resident 101 does not have the capacity to understand and make own decisions. During a concurrent observation and interview on 6/2/2026 at 8:38 a.m. with Resident 101, observed Resident 101 speaking in an elevated, strong voice when communicating. Resident 101 stated she could not hear when spoken to in a normal tone of voice from the foot of her bed. The resident stated she was still unable to hear when addressed from directly next to her bed. Resident 101 asked surveyor to remove the worn mask while speaking to her so she could hear and better understand surveyor when speaking. Resident 101 stated that she is hard of hearing and does not possess or use a hearing aid. During a concurrent interview and record review on 6/2/2026 at 9:36 a.m. with the Minimum Data Set Nurse (MDSN), Resident 101's Minimum Data Set (MDS) upon admission dated 3/1/2025 and most recent MDS dated [DATE] were reviewed. Both MDSs indicated Resident 101 had adequate hearing. The MDSN stated that it was her assessment of Resident 101's hearing that is documented on the MDS dated [DATE] and 2/25/2026. The MDSN stated that on 6/1/2026, upon responding to Resident 101's call light, the MDSN observed that Resident 101's hearing has changed since the previous assessment and is currently noted to be impaired. The MDSN stated she had to increase the volume of her voice in order for Resident 101 to hear her. During review of Resident 101's History and Physical (H&P), dated 2/27/2025, the H&P indicated Resident 101 does not have the capacity to understand and make own decisions. During a review of Resident 101's Psychological Evaluation, dated 3/5/2025, the Psychological Evaluation indicated Resident 101 was hard of hearing. During a review of Resident 101's Psychological Consult, dated 3/18/2025, the Psychological Evaluation indicated Resident 101 was hard of hearing. During a review of Resident 101's Recreation Comprehensive Assessment, dated 2/25/2026, the assessment indicated Resident would benefit from accommodation for hearing loss. During a review of Resident 101's care plan While in the facility, resident states that it is important that she has the opportunity to engage in daily routines that are meaningful relative to their preference will do independent activity, created on 3/6/2026, the care plan indicated the intervention of I would benefit from accommodation for hearing loss by speaking loudly, initiated 3/6/2026. During an interview on 6/4/2026 at 3:15 p.m. with the Activities Director (AD), the AD stated she observed Resident 101's hearing impairment upon admission to the facility. The AD stated that when she was speaking with normal voice and tone to Resident 101 during her admission assessment, Resident 101 kept saying huh? The AD stated she had to get close to Resident 101 for Resident 101 to hear her as she spoke in a slightly elevated voice and tone. The AD stated that she noticed Resident 101 looked at the AD's lips when speaking. The AD stated that Resident 101 seemed to understand better when Resident 101 is able to see AD's mouth. The AD stated that between being close to Resident 101 and raising her voice and tone when speaking and not wearing a mask that covers her mouth, Resident 101 was able to understand her. The AD stated that the licensed nurse was aware of Resident 101's hearing impairment and informed the AD to get close to Resident 101 when speaking with Resident 101. During an interview on 6/4/2026 at 3:25 p.m. with Activities Assistant (AA), AA stated Resident 101 has been hard of hearing since being admitted to the facility. AA stated that he noted Resident 101's hearing difficulty varied from day to day-sometimes it was less severe, however, it has worsened over the past two months. AA stated he shared his observation to the Certified Nursing Assistant (CNA) taking care of Resident 101. AA stated the CNA told him that that the issue was being addressed and was advised to speak loudly to Resident 101. During an interview on 6/4/2026 at 3:50 p.m. with Certified Nursing Assistant (CNA) 3, CNA 3 stated Resident 101 has been hard of hearing since being admitted to the facility. CNA 3 stated she needs to be close to Resident 101 when speaking or remove her mask so Resident 101 can see her mouth. CNA 3 stated that Resident 101 understands her better when she takes off her mask, likely because Resident 101 watches her mouth and reads her lips to help understand what is being said. During an interview on 6/5/2026 at 9:45 a.m. with the Director of Nursing (DON), the DON stated that Resident 101's hearing has been assessed as adequate, no impairment, from review of Weekly Summary Documentation from admission date to 5/26/2026. The DON stated that the facility failed to assess Resident 101's hearing impairment. The DON stated that proper assessment is important to determine what type of care and treatment the resident needs. The DON stated that if the hearing impairment is not addressed according to its specific cause, hearing may not improve. The DON stated that this results in Resident 101's struggle to hear, need to exert extra effort, and experience delays in receiving hearing aids if necessary. During a review of the facility's job description titled, Licensed Practical (Vocational) Nurse (LPN) (LVN) revised 7/2024, the job description indicated, Resident Care Functions: Provide nursing services to residents accordance with scope of practice, facility policies and professional standards of care.Monitor residents for development of acute changes of condition including confusion, fever, difficulty breathing, increased pain, difficulty urination, loss of appetite, constipation, diarrhea, vision or hearing loss, general malaise or decreased range of motion (ROM); conduct assessments and notify provider as needed. During a review of the facility's job description titled, Registered Nurse (RN) revised 7/2024, the job description indicated, Resident Care Functions: Provide nursing services to residents accordance with scope of practice, facility policies and professional standards of care.Monitor residents for development of acute changes of condition including confusion, fever, difficulty breathing, increased pain, difficulty urination, loss of appetite, constipation, diarrhea, vision or hearing loss, general malaise or decreased range of motion (ROM); conduct assessments and notify provider as needed.

Based on observation, interview, and record review, the facility failed to ensure a resident's low air loss mattress (LALM or LAL, a mattress designed to distribute a resident's body weight over a broad surface area and help prevent skin breakdown) was set to the resident's weight for one of one sample resident (Resident 156) investigated for pressure ulcer/injury (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence). This deficient practice placed Resident 156 at risk for development of new pressure ulcers. Findings: During a review of Resident 156's admission Record, the admission Record indicated the facility admitted the resident on 5/21/2026 with diagnoses including quadriplegia (paralysis from the neck down, including legs, and arms, usually due to a spinal cord injury) and sacral (the large, upside-down triangular bone located at the base of the spine between the lower back vertebrae and the tailbone) pressure ulcer stage four (full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone). During a review of Resident 156' s Minimum Data Set (MDS, a resident assessment tool) dated 5/25/2026, the MDS indicated Resident 156 was moderately impaired in cognition (the process of acquiring knowledge and understanding through thought, experience, and the senses) with skills required for daily decision making. The MDS indicated Resident 154 was dependent (helper does all of the effort; resident does none of the effort) on staff for rolling left and right (the ability to roll from lying on back to left and right side and return to lying on back on the bed). The MDS indicated Resident 156 had four (4) stage four pressure ulcers. During a review of Resident 156's physician orders, the physician orders indicated the following: - LAL mattress for skin management every day shift, dated 5/31/2026. - LAL mattress for skin management at 165 pounds (lbs., a unit for weight) every day shift, dated 6/01/2026. During a review of Resident 156's Care Plan (a document that summarizes a resident's needs, goals, and care/treatment) for risk for Skin Breakdown, initiated 5/22/2026, the care plan indicated a goal that resident will not show signs of skin breakdown for 90 days. The care plan indicated an intervention to set the LAL mattress for skin management settings at 165 lbs. During a review of Resident 156's Weights, the Weights indicated Resident 156 weighs 165 lbs., dated 5/29/2026. During a concurrent observation and interview on 6/1/2026 at 9 a.m., with the Director of Staff Development (DSD), in Resident 156's room, observed Resident 156's LAL mattress which was set between the numbers 120 and 150. The ADON stated that the setting is not accurate with Resident 156's physician order. The DSD stated the setting appeared to be at 130 or 140 lbs. The DSD stated that the setting should be closer to Resident 156's weight of 165 lbs. During a concurrent observation and interview on 6/1/2026 at 9:12 am., with Licensed Vocational Nurse 4 (LVN 4), observed Resident 156's LAL mattress setting appeared to be at 130 or 140 lbs. LVN 4 stated she needed to correct Resident 156's LAL mattress to set according to Resident 156's weight at 165 lbs. LVN 4 stated it is important to set the LAL mattress according to a resident's weight to help with skin wound management. LVN 4 stated Resident 4 had a skin wound. During a concurrent interview and record review on 6/4/2026 at 4:17 p.m., with the Minimum Data Set Nurse (MDSN), reviewed Resident 156's LAL Mattress Operational Manual, revised 3/15/2016. The MDSN, referred to page ten which indicated when the normal pressure indicator lights up (green), the pressure in the mattress has reached the pre-defined level, and the patient can then be placed on the mattress. The MDSN stated this pre-defined level refers to placing the settings according to a resident's weight. The MDSN referred to page 11 which indicated the following: The pressure of the mattress can be adjusted by choosing the patient's corresponding weight setting using the weight setting buttons (+) and (-). Use the weight setting buttons to select the desired level.

Based on interview and record review, the facility failed to accurately assess and complete the fall risk factors in the Nursing Documentation Evaluation for three of five sampled residents (Resident 1, Resident 2, and Resident 3).This deficient practice had the potential to place the residents at increased risk for injury related to falls.Findings:a. During a review of Resident 1's admission Record, the admission Record indicated that the facility admitted Resident 1 on 3/21/2026 with diagnoses that included traumatic brain injury (TBI - a disruption in the normal function of the brain that can be caused by a bump, blow, or jolt to the head), epilepsy (a brain condition that causes people to have repeated, unexpected seizures [a sudden, temporary surge of abnormal electrical activity in the brain that disrupts its normal function]), anemia (a condition where the body does not have enough healthy red blood cells), dementia (a progressive state of decline in mental abilities), and history of falling.During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 3/24/2026, the MDS indicated that Resident 1's cognition (ability to think, reason, and function) was severely impaired. The MDS further indicated that Resident 1 was dependent on staff with Activities of Daily Living (ADLs - activities such as bathing, dressing and toileting a person performs daily) except eating which required maximal assistance.During a review of Resident 1's Change in Condition (COC - an acute, abnormal alteration in a resident's physical or mental baseline) Evaluation form dated 4/7/2026 timed at 5:10 a.m., the COC Evaluation form indicated that staff found Resident 1 lying on the floor next to bed; Resident 1 was unable to state what happened but upon assessment Resident 1 had stated that Resident 1wanted to be assisted to the bathroom. Resident 1 had minimal bleeding on the right lower lip. Resident 1's Transfer Form dated 4/7/2026 indicated that the facility transferred Resident 1 to general acute care hospital 1 (GACH 1) on 4/7/2026 at 8:57 a.m. due to the fall.During a review of Resident 1's Fall Risk Factor in the Nursing Documentation Evaluation dated 3/21/2026, the Nursing Documentation Evaluation indicated check marks for history of falls within the last six (6) months, poor safety judgement, and impaired balance. However, the following fall risk factors: disorientated/confused, predisposing disease or injury, requires assist for toileting, or unsteady gait (a person's particular manner, style, or pattern of walking or running) were left unchecked and blank.During a concurrent interview and record review on 5/1/2026 at 3:32 p.m., with the Director of Nursing (DON), the DON reviewed Resident 1's Fall Risk Factor in the Nursing Documentation Evaluation dated 3/21/2026 and stated that the following fall risk factors: disorientated/confused, predisposing disease or injury, requires assist for toileting, or unsteady gait were not marked. The DON stated the assessment was not completed accurately or its entirety.b. During a review of Resident 2's admission Record, the admission Record indicated that the facility originally admitted Resident 2 on 3/8/2019 and readmitted on [DATE] with diagnoses that included disorders of bone density and structures, lumbar vertebra (lower backbone) compression fracture (when part of a vertebra, or the vertebral body, collapses), dementia, and history of falling.During a review of Resident 2's MDS dated [DATE], the MDS indicated that Resident 2's cognition was severely impaired. The MDS further indicated that Resident 2 required supervision or touching assistance on staff with oral, toileting and personal hygiene, shower and bathe self, dressing, bed mobility (movement), and transfer.During a review of Resident 2's COC Evaluation form dated 4/22/2026 timed at 2:06 a.m., the COC Evaluation form indicated that Certified Nursing Assistant 4 (CNA 4) heard a loud sound coming from Resident 2's room. Upon entering the room to check on Resident 2, CNA 4 observed Resident 2 lying on the floor outside the restroom. Resident 2 was noted to have minimal bleeding to the right side of the face with an abrasion (a superficial injury where skin is scraped or rubbed off) and a laceration (a torn or jagged wound in the skin or soft body tissue) to the right index finger (the finger located immediately next to the thumb). Resident 2's Transfer Form dated 4/22/2026 indicated that the facility transferred Resident 2 to GACH 1 on 4/22/2026 at 6:30 a.m. following the fall.During a review of Resident 2's COC Evaluation form dated 4/26/2026 timed 3:40 p.m., the COC Evaluation form indicated that Resident 2's chair alarm activated and Resident 1 was found lying on the floor on the resident's left side of the wheelchair. During a review of Resident 2's Fall Risk Factor in the Nursing Documentation Evaluation dated 4/22/2026, the Nursing Documentation Evaluation indicated check marks for disorientated/confused, poor safety judgement, predisposing disease or injury, and requires assist for toileting. However, the following fall risk factors: history of falls in the last 6 months, impaired balance, or unsteady gait were left unchecked and blank.During a concurrent interview and record review on 5/1/2026 at 4:01 p.m., with the DON, the DON reviewed Resident 2's Fall Risk Factor in the Nursing Documentation Evaluation dated 4/22/2026 and stated that the DON did not mark the fall risk factor for history of falls within the last 6 months, despite the COC Evaluation form (dated 4/22/2026) indicating a fall incident on the same date. The DON stated the actual fall incident that occurred on 4/22/2026 was not included in the assessment because the incident occurred on the day the assessment was completed. c. During a review of Resident 3's admission Record, the admission Record indicated that the facility originally admitted Resident 3 on 8/29/2023 and readmitted on [DATE] with diagnoses that included hemiplegia (total paralysis [loss of ability to move part or all of the body] of the arm, leg, and trunk on the same side of the body) and hemiparesis (paralysis or weakness on one side of the body) following cerebral infarction (known as stroke, loss of blood flow to a part of the brain resulting in damage to brain tissue), abnormality of gait and mobility, left femur (thigh bone) fracture (broken bone), epilepsy, and history of falling.During a review of Resident 3's MDS dated [DATE], the MDS indicated that Resident 3's cognition was severely impaired. The MDS further indicated that Resident 3 required maximal assistance on staff with toileting hygiene, shower and bathe self, dressing, and moderate assistance with bed mobility and transfer.During a review of Resident 3's COC Evaluation form dated 4/27/2026 timed at 12:56 p.m., the COC Evaluation form indicated that at 1 p.m., staff heard Resident 3 calling for help and was found sitting on the floor next to the resident bed.During a review of Resident 3's Fall Risk Factor in the Nursing Documentation Evaluation dated 4/27/2026, the Nursing Documentation Evaluation indicated check marks for poor safety judgement, impaired balance, predisposing disease or injury, and requires assist for toileting. However, the following fall risk factors: history of falls within the last 6 months, disorientated/confused, or unsteady gait were left unchecked and blank.During a concurrent interview and record review on 5/1/2026 at 4:14 p.m., with the DON, the DON reviewed Resident 3's Fall Risk Factor in the Nursing Documentation Evaluation dated 4/27/2026 and stated that the DON did not mark the fall risk factor for history of falls within the last 6 months, despite the COC Evaluation form (dated 4/27/2026) indicating a fall incident on the same date. The DON stated the assessment was completed incorrectly and incompletely and stated that inaccurate or incomplete assessments could prevent the facility from developing and implementing appropriate care plans to reduce residents' risk for falls. During a review of the facility's policy and procedures (P&P) titled, Fall Risk Assessment last reviewed 1/15/2026, the P&P indicated, The nursing staff, in conjunction the attending physician, consultant pharmacist, therapy staff, and other, will seek to identify and document resident risk factors for falls and establish a resident-centered falls prevention plan based on relevant assessment information. Assessment data shall be used to identify underlying medical conditions that may increase the risk of injury from falls.During a review of the facility's P&P titled, Fall Management last reviewed 1/15/2026, the P&P indicated, To reduce risk falls and minimize the actual occurrence of falls. Patient experiencing a fall will receive appropriate care and investigation of the cause. If patient falls. Interdisciplinary (combining two or more academic, scientific, or artistic fields into one activity, study, or project) to review post Fall.

Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 71) with known food allergies (a substance that causes an allergic reaction [a condition that causes illness when someone eats certain foods or touches or breathes in certain substances]), was not served food containing allergens, by: 1. Serving for breakfast, on 4/8/2025, cream of wheat (a type of hot cereal that contains gluten [a protein found in the wheat plant and some other grains]; wheat is commonly used in breads, baked goods, and pastas) to Resident 71, who was known to be allergic to gluten as indicated in Resident 71's Physician's Order, Care Plan (a form where you can summarize a person's health conditions, specific care needs, and current treatments), Allergy List, Dietary Profile (based on individual assessments that consider factors like medical conditions, allergies, preferences, and chewing/swallowing abilities), History and Physical (H&P, a physician's examination of a patient), Interdisciplinary (IDT) Care Conference (a meeting where people from different fields [like doctors, therapists, social workers, nurses, and dietitian] come together to discuss a patient's situation and work as a team to create a coordinated plan for their care) notes, Medication Administration Record (MAR, a report detailing the drugs administered to a resident by a healthcare professional), and Nutritional Assessment (a check-up to see how well a person's body is getting the nutrients it needs). 2. Resident 71's meal ticket (a slip of paper or digital record that specifies which meal a resident is supposed to have and when and used by the kitchen staff to ensure each resident receives the correct food at the correct time) not indicating cream of rice was the choice. 3. Dietary staff in the tray line (an assembly line used in healthcare settings to prepare and distribute meals to patients) and Licensed Vocational Nurse 3 (LVN 3) lacking knowledge that cream of wheat should not be served to Resident 71. 4. Not having cream of rice in stock to provide Resident 71 as substitute for cream of wheat. 5. The food service manager or supervisor not checking Resident 71's tray for correct diet before the tray was transported to it designated area, in accordance with the facility's policy and procedures (P&P) titled, Tray Identification. As a result, this deficient practice had the potential to cause a life-threatening condition such as anaphylactic shock (severe allergic reaction including closure of airways), severe tachycardia (increased heart rate), cardiac arrest (sudden loss of heart function, breathing, and consciousness [the state of being awake and aware of one's surroundings]), diarrhea, dehydration (occurs when your body loses too much water and other fluids), and/or death for Resident 71. On 4/9/2024 at 11:08 a.m., the State Survey Agency (SSA) called an Immediate Jeopardy (IJ- a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death of a resident) under 42 CFR S483.60(d)(4) Resident Allergies, Preferences and Substitutes in the presence of the Administrator (ADM) and the Director of Nursing (DON) for the facility's failure to ensure that facility staff did not provide food containing a known allergen to Resident 71. On 4/10/2025 at 3:32 p.m., the ADM provided an IJ Removal Plan (a plan that identifies all actions the facility will take to immediately address the noncompliance that has resulted in the IJ situation) which included the following summarized actions: 1. On 4/8/2025, the DON immediately assessed Resident 71 for any adverse reaction and there were none noted. 2. On 4/8/2025 the facility notified Resident 71's attending physician and Resident 71's family of the incident of giving food containing allergies. The attending physician did not give any new orders. 3. On 4/8/2025, the Minimum Data Set Coordinator 1 (MDSC 1) updated Resident 71's allergy Care Plan to remove gluten allergy and Resident 71's nutrition risk Care Plan to reflect gluten intolerance prior to a diagnostic test for allergies. 4. On 4/8/2025, the Registered Dietitian (RD) evaluated Resident 71 and updated food preferences, reviewed allergies and food intolerances, and completed a nutritional assessment. 5. On 4/8/2025, the Director of Staff Development (DSD) provided one-on-one (1:1 - when one trainer works with one learner at a time) in-service training to Licensed Vocational Nurse 3 (LVN 3, who checked Resident 71's breakfast prior to serving) to ensure: a. Identification of food allergies using the daily Allergy Report provided by DON and/or designee. The daily Allergy Report can be found in a special needs binder located at each nursing station and dining room. b. Prior to tray passing to residents during mealtimes, a licensed nurse will check all trays for accuracy of meal ticket a printed sheet or card that details the meal items to be served to a patient or resident) and physician diet orders against what is on the residents' meal tray using the diet report. c. Prior to passing the meal trays to the residents during mealtimes, a licensed nurse will check the diet type report and the meal ticket on each tray against the food on the resident's meal tray. d. Prior to tray passing to residents during mealtime, a licensed nurse will check all the trays to ensure any resident with a gluten allergy is not served unless food item on food tray is labeled gluten free. 6. On 4/8/2025 and 4/9/2025, the DON, the DSD, the RD, the Dietary Supervisor (DS) initiated an in-service to staff (including Registered Nurses (RNs), LVNs, Certified Nursing Assistants (CNAs), Rehabilitation Therapists, the Dietary Manager, cooks, tray line (a system of food preparation, in which trays move along an assembly line) staff, dishwashers, Dietary Preparation staff, and Department Heads) about identification of food allergies using the daily Allergy Report, 2 licensed nurse will check all the trays to ensure meal ticket, physicians orders and Diet Type Report are accurate against resident's food trays. The in-service also included checking all the trays to ensure all trays are checked for gluten allergies and not served foods containing gluten. Snacks for residents on gluten free diet will be labeled gluten free. A licensed nurse will check the diet type report, snacks label and food to ensure accuracy before serving it to the residents. 7. On 4/8/2025 and 4/9/2025, the DS completed an in-service to the dietary staff (Dietary Manager, cooks, tray line staff, dishwashers, and dietary preparation staff) related to food allergy, labeling of gluten-free food items, and ensuring all trays are checked accurately to ensure residents are not served a food item they are allergic prior to trays being sent out of the kitchen. Tray line staff will refer to Diet Manual for Guidance on alternatives for residents on gluten restricted diet/gluten allergy/intolerance. Staff that have not yet been in-serviced (those on vacation and per diem employees) will be in-serviced on their first reported day back to work. 8. The DON and or designee will update the Allergy report daily starting 4/9/2025 at the clinical meeting (Monday to Friday), and ensure it is available at each nursing station and dining room and a copy will be provided to the kitchen. 9. On 4/9/2025 for breakfast, the DON, the Assistant DON (ADON), the MDS Nurse and the DSD observed the licensed nurses checking for tray accuracy prior to trays being served to residents. No issues were identified and the 10 residents who had food allergies and or food intolerances had accurate trays. The DON and ADON assessed the 10 residents for any signs and symptoms of allergic reaction, and none noted. 10. On 4/9/2025, the RD provided in-service to final tray line staff who checked Resident 71's breakfast tray on 4/8/2025. 11. On 4/9/2025, the DON reviewed all residents and identified 10 residents with food allergies. Resident 71 the only resident identified to be on a gluten restricted diet. One resident identified having gluten allergy had been hospitalized since 4/3/2025 for unrelated medical condition. Upon this resident readmitted to the facility, the nurse will obtain an order from the MD for allergy test. 12. On 4/9/2025, the Regional RD observed breakfast tray line to ensure accuracy of the meal tickets to what was being placed on resident's meal trays. There were no issues identified and the 10 residents who had food allergies and or intolerances had accurate trays. 13. On 4/9/2025, the DON completed competency for the licensed nurse who checked Resident 71's tray and met expectations as evidenced by the licensed nurse being able to correctly check the diet orders, resident allergies against the food tray. 14. The DON and or designee will complete a random daily visual check of meal trays starting 4/9/2025 for residents with identified food allergies using the Daily Food Allergy Audit Form. This audit will remain on-going until the goal is achieved. 15. The DON and or designee will review the change in conditions daily starting 4/10/2024 related to food allergies. 16. The DON and or designee will complete a Monthly Food Allergy Interview Audit Tool to ensure that each residents allergies are current, and up to date starting 4/10/2025. This audit will remain ongoing until the goal is achieved. 17. On 4/10/2025, the DON obtained an order from Medical Doctor (MD) for Tissue Transglutaminase ([tTG-igA], blood test to diagnose celiac disease, a disease in which the small intestine is hypersensitive to gluten, leading to difficulty in digesting food) to be drawn on 4/14/2025. 18. On 4/10/2025, the DON discussed with MD to update Resident 71's gluten intolerance to gluten allergy. The DON updated allergy profile and care plan to reflect resident's gluten allergy. The DON provided dietary communication form to dietary staff on 4/10/2025 for gluten allergy update. 19. On 4/10/2025, Registered Nurse Supervisor obtained order from MD for Resident 71 for psychology consult for psychosocial support. 20. The RN Supervisor and or designee will update the Allergy report and special needs binder on the weekends (Saturday and Sunday) starting 4/12/2025 at each nursing station, and dining room. 21. The RD will check food inventory weekly based on the upcoming week's menu using the Inventory form. If any items are missing, the RD will notify the Dietary Manager/designee, and the RD will approve appropriate alternative with same nutritional value if necessary. On 4/11/2025 at 3:51 p.m., while onsite and after verifying the facility's full implementation of the IJ removal plan, the SSA accepted the IJ Removal Plan and removed the IJ in the presence of the ADM and DON. Findings: During a review of Resident 71's Admission Record (or Face Sheet, placed at the front of the medical chart summarizing the patient's key details), the Admission Record indicated the facility initially admitted Resident 71 on 8/18/2022 and readmitted Resident 71 on 7/15/2025 with diagnoses including cachexia (a condition marked by a loss of more than 10% of body weight, including loose of muscle mass and fat, in a person who is not trying to lose weight), intestinal malabsorption (a disorder that prevents your body from effectively absorbing nutrients from your food), and non-celiac gluten sensitivity (when the digestive system cannot tolerate any form of the protein gluten). During a review of Resident 71's Care Plan, initiated on 8/19/2022, revised 5/2/2024 and ongoing as of 4/8/2025, the Care Plan indicated Resident 71 had allergies to lactose (a sugar that is a normal part of milk products) and gluten. The Care Plan goal was for Resident 71 not to be exposed to allergen and not having adverse reactions daily for three months. Resident 71's Care Plan included the following interventions: -Inform staff or caregivers of resident's allergy. -Resident is allergic to lactose and gluten and these allergies are listed in special needs binder. -Label physician's order sheet, MAR, treatment sheet, Face Sheet and diet sheet of resident's allergy. -Notify pharmacy of resident's allergy. -Observe for any signs and symptoms of allergic reaction to drugs/food administered and notify MD immediately. During a review of Resident 71's Allergy List, dated 5/2/2024, the Allergy List indicated Resident 71 was allergic to lactose and gluten. During a review of Resident 71's Dietary Profile, dated 5/21/2024, the Dietary Profile indicated Resident 71 was allergic to gluten and milk. During a review of Resident 71's H&P, dated 8/21/2024, the H&P indicated Resident 71's past medical history included significant for presumed gluten enteropathy (an autoimmune inflammatory disease of the small intestine that is precipitated by the ingestion of gluten) with chronic cachexia. During a review of Resident 71's IDT Care Conference notes, dated 10/11/2024, the IDT Care Conference notes indicated Resident 71 to receive gluten and lactose free diet. During a review of Resident 71's Physician's Order, dated 11/4/2024, the Physician's Order indicated to provide gluten free, no lactose, regular texture consistency with thin liquids diet. During a review of Resident 71's Nutritional assessment dated [DATE], the Nutritional Assessment indicated Resident 71 was allergic to gluten and lactose. The assessment indicated Resident 71 should not have gluten due to the diagnosis of gluten enteropathy. During a review of Resident 71's Minimum Data Sheet (MDS -- a standardized assessment and care planning tool), dated 2/25/2025, the MDS indicated Resident 71's understood others and could make himself understood. The MDS indicated the resident required set-up or clean up assistance when eating. During a review of Resident 71's MAR for the month of 4/2025, the MAR indicated Resident 71 was allergic to lactose and gluten. During a review of Resident 71's Physician's Order Summary Report, dated 4/8/2025, the Physician's Order Summary Report indicated Resident 71 had allergy to lactose and gluten. During an interview on 4/8/2025 at 7:37 a.m. with Dietary District Manager 1 (DDM 1) during the tray line in the kitchen, DDM 1 stated the cook prepared for breakfast two hot cereals, oatmeal and cream of wheat. During a review of Resident 71's breakfast meal tray ticket, on 4/8/2025 at 8:10 a.m., Resident 71's meal ticket indicated Resident 71 was on gluten restricted diet, was allergic to gluten and lactose, liked no salt on the tray and small portion entree. During a concurrent observation and interview, on 4/8/2025 at 8:17 a.m., in Resident 71's room, Resident 71 had the breakfast tray on the bedside table. The tray contained a bowl of hot creamy cereal with a smooth texture. Resident 71 stated the hot cereal on his tray looked like oatmeal or cream of wheat and he would not eat it. Resident 71 stated he was allergic to gluten and lactose and could not eat cream of wheat or oatmeal because it caused him to have loose bowel movements and lots of gas. Resident 71 stated he has been given oatmeal and regular bread, despite having informed the nursing staff about his allergies. Resident 71 stated he had requested that someone from the kitchen came to talk to him, but nobody came. During an interview with [NAME] 1, on 4/8/2025 at 8:26 a.m., [NAME] 1 stated she prepared oatmeal and cream of wheat for breakfast. [NAME] 1 stated the hot cereal bowl on Resident 71's tray was cream of wheat. During an interview with the RD, on 4/8/2025 at 8:28 a.m., the RD stated cream of wheat had gluten and the software (programs used to operate computers and execute specific tasks) the facility use for their menus should have adjusted Resident 71's meal ticket to indicate cream of rice was the choice instead of oatmeal or cream of wheat but it did not. The RD stated Resident 71 had a gluten allergy diagnosis and should not receive cream of wheat or oatmeal because of his possible allergic reaction such as having diarrhea, loose bowel movement, shortness of breath, and swallowing problems. The RD stated she needed to find out the reason Resident 71's meal ticket did not indicate No Wheat. During an interview with the DS, on 4/8/2025 at 8:35 a.m., the DS stated she told [NAME] 1 to serve cream of rice (instead of oatmeal or cream of wheat) and that she saw [NAME] 1 preparing it earlier that morning. During an interview with [NAME] 1, on 4/8/2025 at 8:40 a.m., [NAME] 1 stated she only cooked oatmeal and cream of wheat for breakfast and did not cook cream of rice because it was not available in stock in the facility. During an interview the RD, on 4/8/2025 at 8:44 a.m., the RD confirmed the cream of rice was out of stock. During a concurrent observation inside the dry storeroom (a designated area used for storing food that do not require temperature control or refrigeration) and interview with Dietary Aide 1 (DA 1), on 4/8/2025 at 10:22 a.m., there was no cream of rice observed available in the facility. DA 1 stated the last time he placed an order for cream of rice was in 3/2025. During a review of the facility's purchase order dated 1/28/2025, the purchase order indicated that the most recent order for cream of rice was placed on 1/28/2025. During an interview with DA 2, on 4/8/2025 at 10:31 a.m., DA 2 stated she was responsible for checking the accuracy of the tray for breakfast by making sure the food on the tray matched the food listed on the meal ticket. DA 2 stated she checked for allergies, likes, dislikes and other special request of each resident in the tray line. DA 2 stated she also checked for gluten-free diet to provide gluten-free bread and other foods that were safe to give to residents with gluten free diet. DA 2 stated Resident 71 had water, orange juice, lactose free milk, and cream of wheat in his tray that morning. DA 2 stated a previous DS told her cream of wheat was okay to give to residents with gluten-free diet. DA 2 stated they served cream of wheat to residents on gluten free diet every day. During an interview with the DS, on 4/8/2025 at 10:47 a.m., the DS stated there were three staff assigned on the tray line. The first was the starter, responsible for setting up the trays and tray tickets. The second staff placed the drinks, desserts, salads, and breakfast cereals. The third staff was the caller, whose role involved calling residents' diet texture, allergens, diets and any missing items on the tray, as well as ensuring the accuracy of each tray. The DS stated she expected DA 1 to remove cream of wheat from trays for residents with allergies to gluten. The DS stated no training on gluten free diets had been provided to the kitchen staff since she assumed the position in 3/ 2025. During an interview with LVN 3, on 4/8/2025 at 10:57 a.m., LVN 3 stated that earlier in the morning during the breakfast meal, she checked Nursing Station 3 tray for any allergies, intolerances, diet texture and verified that what had been served on the resident's tray matched the information in the diet report. LVN 3 stated it was important to have accurate trays especially for residents with allergies to prevent complications. LVN 3 stated she checked Residents 71's breakfast meal trays but could not remember what was on Resident 71's tray. LVN 3 stated she lifted the lid of Resident 71's hot cereal and it appeared to be cream of rice. LVN 3 stated since the ticket indicated hot or cold cereals, LVN 3 felt it was appropriate to serve the cream of wheat to Resident 71. LVN 3 stated if she knew the hot cereal was cream of wheat, she would not have allowed it to be served to Resident 71. During an interview with the ADM, on 4/8/2025 at 11:41 a.m., the ADM stated Resident 71's physician informed them that Resident 71 had gluten intolerance because if his symptoms of diarrhea and gas upon gluten consumption. During an interview with the DON, on 4/8/2025 at 11:45 a.m., the DON stated the licensed nurse checks the meal trays for allergies before giving it to the residents but would not know if the product was or not gluten-free. The DON stated it was the kitchen staff's responsibility to provide the correct food on the resident's tray as it could potentially cause diarrhea, dehydration and weight loss to Resident 71. During an interview with the RD, on 4/8/2025 at 2:17 p.m., the RD stated she spoke and conducted a nutritional assessment with Resident 71 on 10/14/2024 but did not talk to Resident 71 on 2/7/2025 as there were no reports from nursing and kitchen staff indicating any dietary issues. During a revie of the facility's P&P titled Nutritional Assessment, dated 1/16/2025, the P&P indicated, (6) The dietitian will determine whether food allergies or intolerances are interfering with the resident's overall nutrition status and make recommendations regarding appropriate food substitutions and/or dietary supplements. During a review of the facility's P&P titled, Food Allergies and Intolerances, dated 1/16/2025, the P&P indicated Residents with food allergies and/or intolerances are identified upon admission and offered food substitutions of similar appeal and nutritional value. Steps are taken to prevent resident exposure to the allergen(s). Policy and Interpretation: (1) Food allergies are immune system responses to allergens (foods). Immunoglobulin E ([[NAME]] antibodies produced by immune system) attach to mast cells (a type of white blood cells that is found in connective tissue all through the body) in the body tissue (e.g. skin, nose, throat, lungs and gastrointestinal tract) and basophils (white blood cells in the immune system) in blood. When allergens are eaten, the [NAME] antibodies attach to mast cells and basophils in certain sites and those cells produce histamine, an inflammatory compound. (2) Food intolerances are unpleasant reactions to specific foods that are not life threatening it can necessitate avoidance of the triggering foods. Assessment and interventions: o Resident are assessed for a history of food allergies and intolerances upon admission and as part of the comprehensive assessment. o All resident reported food allergies and intolerances are documented in the assessment notes and incorporated into the resident's care plan. o Meals for resident with severe food allergies are specially prepared so that cross-contamination with allergens does not occur. o Residents with food intolerances and allergies are offered appropriate substitutions or food that they cannot eat. During a review of the facility's P&P titled, Diet Manual dated 1/16/2025, the P&P indicated, the diet manual has been developed to provide explanation of the diets used in the development of the menu program. The diets have been developed using current scientific research, information from best practices, and recommendations from Position Papers of Professional Associations. The menu is developed to meet the Recommended Daily Allowances (RDAs) of the National Academies for persons 51 and over. Diet should be adjusted to meet the needs and preferences of the individual resident. The diet manual is intended as a guide for the physician or other qualified healthcare professional to use in prescribing modified diets and for the healthcare personnel in following the diet orders. During a review of the facility's diet manual titled, Gluten Restricted Diet dated 2/2025, the diet manual indicated Intended Use: This diet is used in the treatment of gluten-induced enteropathy (non-tropical sprue, celiac disease). The diet aims to eliminate symptoms, such as flatulence, diarrhea, steatorrhea, weight loss, indigestion and bloating, caused by sensitivity to gluten and gluten-containing products. The tropical sprue is not responsive to a gluten restricted diet. Adequacy: The Gluten restricted diet eliminates all foods containing wheat, rye, and barley. Grains not allowed on a gluten restricted diet: wheat, einkorn, [NAME], wheat starch, wheat bran, wheat germ, cracked wheat, barley, rye, graham flour, plain flour, white flour. Gluten free foods are made from the recommended grains listed above. There are many gluten-free substitutions to wheat-containing foods. You must read labels, as many products contain wheat ingredients where it is not obvious. During a review of the facility's P&P titled, Tray Identification dated 1/16/2025, the P&P indicated, The food service manager or supervisor will check trays for correct diets before the food carts are transported to their designated areas. Nursing staff shall check each food tray for the correct diet before serving the residents. If there is an error, the nurse supervisor will notify the dietary department immediately by phone so that the appropriate food tray can be served. During a review of the facility's P&P titled, Resident Food Preferences dated 1/16/2025, the P&P indicated, The dietary manager will complete a dietary profile for residents to reflect current food preferences and nutritional needs upon admission, readmission, quarterly, annually or as needed. The dietary manager will complete the dietary profile for residents to capture and update the information regarding nutritional needs and food preferences (b) allergies.

Based on interview and record review, the facility failed to ensure that one of three sampled residents (Resident 147) was not given food containing allergens (a substance that causes an allergic [a condition that causes illness when someone eats certain foods or touches or breathes in certain substances] reaction) when: 1. Certified Nursing Assistant 2 (CNA 2) did not inform a licensed nurse (a Licensed Vocational Nurse [LVN] or Registered Nurse [RN]) of Resident 147's request for a snack on 4/14/2024 which would then require a licensed nurse to complete a Diet Order and Communication Form (DOCF- a form designed to ensure clear communication between residents, nurses and dietary staff that indicates dietary preferences and restrictions to promote safe food distribution) prior to providing food to Resident 147. 2. Dietary Staff 1 (DS 1) did not first obtain from CNA 2 a DOCF to ensure the provided peanut butter and jelly sandwich did not violate Resident 147's dietary restrictions, prior to providing CNA 2 with a peanut butter and jelly sandwich which was then given to Resident 147. This deficient practice resulted in Resident 147 being given a peanut butter and jelly sandwich causing Resident 147 to experience shortness of breath, requiring Resident 147 to be transferred to the General Acute Care Hospital (GACH); and had the potential to resulted in life-threatening conditions such as anaphylactic shock (severe allergic reaction including closure of airways), and or death for Resident 147. On 5/1/2024 at 2:12 p.m., the State Survey Agency (SSA) called an Immediate Jeopardy (IJ- a situation in which the facility's non-compliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death of a resident) situation for the facility's failure to ensure that facility staff did not provide food containing a known allergen to Resident 147 in the presences of the Administrator (ADM) and the Director of Nursing (DON). On 5/2/2024 at 3:44 p.m., the ADM provided an IJ Removal Plan (a plan that identifies all actions the facility will take to immediately address the noncompliance that has resulted in the IJ situation) which included the following summarized actions: 1. On 4/14/2024, Resident 147 was placed on supplemental oxygen (a treatment that provides residents with extra oxygen to breathe in) at two (2) liters (L- unit of measure) via nasal cannula (a device used to deliver supplemental oxygen or increased airflow to a resident in need of respiratory help). Resident 147 was then transferred to the GACH for evaluation. 2. On 4/15/2024, the Direct of Staff Development (DSD) provided a one to one (1:1- when one trainer works with one learner) in-service (training) to CNA 2 regarding the use of the Diet Order Communication Form when requesting food from the kitchen. 3. On 4/15/2024, the Dietary Supervisor (DS) provided 1:1 in-service to DS 1, who provided the peanut butter and jelly sandwich to CNA 2, the importance of obtaining a DOCF to verify the resident's diet and allergies prior to providing the requested food. 4. On 5/1/2024, the DON reviewed all current resident's medical records residing in the facility with noted food allergies and there were no issues found. 5. On 5/2/2024, the Social Service Director and Social Service Assistant completed interviews with all residents and or responsible parties to ascertain and confirm current and or new food allergies. 6. All Change in Condition (COC - when there is a sudden change in a resident's health or condition) Forms from the dates of 4/14/2024 to 5/1/2024 were reviewed through a chart review by the DON. 7. On 5/1/2024, the DON and or designee initiated an in-service training to staff which included: a. Identification of food allergies using the daily Allergy Report provided by Director of Nursing and/or Designee. i. The daily Allergy Report can be found in a special needs binder located at each nursing station. b. Process of requesting food from the kitchen using the Diet Order & Communication Form (DOFC) is as follows: i. Any Staff who request food on behalf of a resident will provide all food requests to the licensed nurse. ii. The licensed nurse will then check the Allergy Report prior to completing the Diet Order & Communication Form. iii. The licensed nurse will complete the Diet Order & Communication Form. iv. The Staff requesting the food item will provide the completed Diet Order & Communication Form to the dietary staff. v. Dietary staff will then review the completed Diet Order & Communication Form prior to providing food to the requesting staff. vi. The requesting staff will visually check that the food is labeled and matches the Diet Order & Communication Form. 8. The DON and/ or designee will update the Allergy report daily at the clinical meeting and ensure it is available at each nursing station and dining room. 9.For new admissions, and during weekends (Saturday and Sunday) the Registered Nurse Supervisor and or Designee will update the Allergy Report and special needs binders at each nursing station, and dining room. 10. If any resident is identified to have a new food allergy, the Registered Nurse Supervisor will update the Allergy Report and special needs binders at each nursing station, and dining room. 11. The DON and or Designee will review the change of conditions daily related to food allergies. 12. The DON and or Designee will complete a random daily visual observation of meals trays for residents with identified food allergies using the Daily Food Allergy Audit Form. 13. The DON and or Designee will complete a Monthly Food Allergy Interview Audit Tool to ensure that each residents allergies are current, and up to date. On 5/3/2024 at 4:14 p.m., while onsite and after verifying the facility's full implementation of the IJ removal plan, the SSA accepted the IJ Removal Plan and removed the IJ in the presence of the ADM and DON. Findings: A review of Resident 147's Admission Record indicated the facility originally admitted Resident 147 on 4/8/2024 with diagnoses that included hemiplegia (inability to move one side of the body) and hemiparesis (partial weakness on one side of the body) following a cerebral infarction (disruption of blood flow to the brain due to the lack of blood supply and oxygen to the brain) affecting the left dominant side, atrial fibrillation (an irregular and often very rapid heart rhythm), and difficulty in walking. The Admission Record further indicated that Resident 147 had an allergy to nuts. A review of Resident 147's Minimum Data Set (MDS - a standardized assessment and care planning tool) dated 4/11/2024 indicated Resident 147's cognition (ability to think and make decisions) was intact. The MDS further indicated that Resident 147 needed supervision when eating. A review of Resident 147's Allergy Reported dated 4/8/2024 indicated that Resident 147 is allergic to nuts. A Review of Resident 147's Nutritional assessment dated [DATE] timed at 11:06 a.m. indicated Resident 147 is allergic to nuts. A review of Resident 147's Change in Condition Form dated 4/14/2024 timed at 10:55 a.m., indicated that Resident (Resident 147) has allergy to peanut, ate peanut butter sandwich and complaining of shortness of breath now. Further review of the COC form indicated Resident 147 requested for a tuna sandwich, but mistakenly received a peanut butter and jelly sandwich. The COC form indicated that Resident 147 then complained of difficulty with breathing after Resident 147 had taken a bite of the peanut butter and jelly sandwich. Resident 147 was placed on two (2) L of oxygen via nasal cannula and was given STAT (an immediate order) Benadryl (a medication used to treat allergies, itching and the common cold [an illness affecting a person's nose and throat]) 25 milligrams (mg- unit of measure), Claritin (a medication that treats allergies and hives [raised red bumps on the skin]) 10 mg and Pepcid (a medication that can be used to treat an allergic reaction) 40 mg by mouth. Resident 147 was monitored and transferred to the GACH at 12:40 p.m. A review of Resident 147's Physician Orders dated 4/14/2024 at 11:30 a.m. indicated the following orders: 1. STAT Benadryl 25mg one time for allergy to peanut; route not specified. 2. STAT Claritin 10 mg one time for allergy to peanut; route not specified. 3. STAT Pepcid 40 mg one time for allergy to peanut; route not specified. A review of Resident 147's GACH Emergency Department (ED- area in a hospital that provides 24-hour emergency care to patients in need of urgent medical attention) Provider Notes dated 4/14/2024 at 2:15 p.m. indicated that Resident 147 experienced a sudden onset of throat tightening after being given a peanut butter sandwich which Resident 147 was told was a tuna sandwich. The ED Provider note further indicated that Resident 147 is allergic to nuts [peanuts] and peanut butter and has had anaphylaxis (life threatening allergic reaction) in the past. A review of Resident 147's GACH After Visit Summary dated 4/14/2024 indicated Resident 147 is allergic to nut (peanuts) and peanut butter (all nuts) both of which have been identified since 5/23/2016. During an interview on 5/1/2024 at 10:13 a.m. with CNA 2, CNA 2 stated that it is the facility's process that when a resident requests for a snack, a DOCF must be filled out and signed by a licensed nurse before the kitchen staff can provide the requested food. CNA 2 stated that on the morning of 4/14/2024 (unable to recall specific time), Resident 147 asked CNA 2 for a sandwich. CNA 2 stated that CNA 2 then went to the kitchen and asked DS 1 for a tuna sandwich. When CNA 2 was asked if CNA 2 provided a DOCF to DS 1 on 4/14/2024, CNA 2 stated CNA 2 forgot. CNA 2 stated that CNA 2 was not aware that DS 1 provided a peanut butter and jelly sandwich instead of the requested tuna sandwich. CNA 2 stated that CNA 2 forgot to inform Registered Nurse 1 (RN 1) of Resident 147's request for a tuna sandwich so that RN 1 could complete a DOCF for Resident 147. CNA 2 stated that after giving Resident 147 the peanut butter and jelly sandwich, which CNA 2 believed to be a tuna sandwich at the time, Resident 147 took a bite of the peanut butter and jelly sandwich. CNA 2 stated that Resident 147 threw the sandwich in the trash after taking a bite and informed CNA 2 that the sandwich was a peanut butter sandwich which was bad for him (Resident 147). CNA 2 stated that DS 1 provided CNA 2 with the wrong sandwich. CNA 2 stated it is important that staff completed a DOCF when a resident requests food because the form acts as a safety check for a resident's allergies. During a concurrent interview and record review on 5/1/2024 at 10:30 a.m. with the DS, the DS reviewed the facility's Food & Nutrition Services: Diet Order & Communication Form (DOCF) last revised on 12/6/2019. The DOCF indicated an area for resident allergies to be filled out and documented by the licensed nurse. DS stated that it is the process of the facility that when a food request is made by a resident to a Certified Nursing Assistant (CNA), the CNA is then responsible for informing a licensed nurse (LVN or RN) of the resident's request. DS stated that the LVN or RN will then complete the DOCF after first confirming (though chart review) the resident's dietary restrictions. DS stated that upon completion of the DOCF by a licensed nurse, the licensed nurse can then provide the DOCF to a CNA who in turn can provide the DOCF to a kitchen staff. The DS stated that kitchen staff will then have to review the DOCF before providing the CNA with the requested food. The DS stated it is important to follow the facility protocol and complete a DOCF because it is a safety check for the resident and the DOCF is used to identify potential food concerns such as food allergies. The DS stated that on 4/14/2024 (unable to recall exact time) CNA 2 requested a sandwich from DS 1. DS stated that DS 1 believed the sandwich request was intended for CNA 2 which is why DS 1 provided CNA 2 with a sandwich without a DOCF. DS stated that the incident that took place on 4/14/2024 where Resident 147 was provided a peanut butter sandwich that Resident 147 was allergic to, could have been prevented if facility staff had followed protocol and completed a DOCF. The DS stated that providing a resident with foods they are allergic can possibly result in the death of a resident. During an interview on 5/1/2024 at 1:48 p.m. with Resident 147, Resident 147 stated, on 4/14/2024 (unable to recall specific time), Resident 147 requested a snack from CNA 2 and was given a sandwich that CNA 2 stated was a tuna fish sandwich. Resident 147 stated that after taking two bites of the sandwich, Resident 147 immediately had labored (difficult or impaired) breathing. Resident 147 stated that CNA 2 had given him a peanut butter and jelly sandwich which caused severe itching to the roof of Resident 147's mouth and made Resident 147's throat start to swell (increase in size) up. Resident 147 further stated I was having extreme difficulty breathing and I was actually panicking, wondering if that was going to be it (death) for me. During an interview on 5/1/2024 at 3:08 p.m. with RN 1, RN 1 stated that on 4/14/2024 (unable to recall specific time), CNA 2 did not inform RN 1 of Resident 147's request for a sandwich or snack. RN 1 stated that if a resident makes a food request from a CNA, the CNA is supposed to inform a licensed nurse so that the licensed nurse can fill out a DOCF. RN 1 stated that on 4/14/2024, CNA 2 went directly to the kitchen and asked DS 1 for a sandwich intended for Resident 147. RN 1 stated that CNA 2 then gave the obtained sandwich to Resident 147 believing the sandwich was a tuna sandwich. RN 1 stated that CNA 2 informed RN 1 that Resident 147 took one bite of the sandwich and stated that the sandwich was a peanut butter sandwich. RN 1 stated that RN 1 reviewed Resident 147's chart for the resident's allergy list and noted nuts listed. RN 1 stated that upon realizing Resident 147's allergy to nuts, RN 1 informed Resident 147's attending physician. During a follow-up interview on 5/2/2024 at 9:21 a.m. with Resident 147, Resident 147 stated that upon admission to the facility on [DATE], Resident 147 was asked by facility staff (unable to recall exact staff member) about Resident 147's allergies. Resident 147 stated that Resident 147 had a nut allergy, specifically mentioning a peanut allergy. During an interview on 5/3/2024 at 2:10 p.m. with the DON, DON stated that it is the facility process that if and when a resident request for a snack or food, that request must be relayed to a licensed nurse. The DON stated the licensed nurse must then fill out a DOCF only after the licensed nurse has verified the resident's dietary restrictions. DON stated that on 4/14/2024, CNA 2 did not follow the facility protocol for requesting food on behalf of Resident 147. The DON stated that CNA 2 went directly to the kitchen without a completed DOCF to request a sandwich for Resident 147. The DON stated that DS 1 provide a peanut butter and jelly sandwich to CNA 2 without first obtaining a completed DOCF. The DON stated that as a result of CNA 2 and DS 1 failure to follow facility protocol related to a resident's request for food, Resident 147 experienced shortness of breath after taking a bite of the peanut butter and jelly sandwich provided to Resident 147 on 4/14/2024. The DON stated it is important for staff to be aware of a resident's allergies when providing food to a resident. The DON stated a resident can go into anaphylactic shock if given food a resident is allergic to. A review of the facility's policy and procedure (P&P) titled, Food Allergies and Intolerances, last reviewed 1/11/2024, indicated, Residents with food allergies and or intolerances are identified and offered food substitutions of similar appeal and nutritional value. Steps are taken to prevent resident exposure to the allergen(s). The policy further indicates that Residents with food intolerances and allergies are offered appropriate substitutions for foods that they cannot eat.

Based on observation, interview and record review, the facility failed to provide necessary care and services in accordance with professional standards of practice to adequately manage and control blood glucose (also called blood sugar) levels for one of 51 sampled residents (Resident 24) by failing to: 1. Notify the physician when Resident 24's blood sugar (BS) levels were over 400 milligrams per deciliter (reference range ,[DATE] mg/dl) as directed by the physician and as indicated in the facility's policy and procedure on Diabetic Care Control. 2. Monitor Resident 24's BS level on (MONTH) 2, (YEAR), when the BS was outside the physician parameter (a limit or boundary) range and after administration of insulin (a medication that keeps blood sugar levels from getting too high). 3. Ensure Residents 24 received meals within 5 to 15 minutes of [MEDICATION NAME] (rapid acting insulin) administration, as indicated in the manufacturer's instruction. 4. Clarify with the physician the time of administration of diabetes medications when Resident 24 was outside of the facility receiving [MEDICAL TREATMENT] (a medical procedure to remove fluid and waste products from the blood and to correct electrolyte imbalances) treatment. 5. Notify the Registered Dietitian (RD) of Resident 24's elevated BS levels. As a result, Resident 24's blood sugar levels were insufficiently managed and the resident required transfer to the general acute care hospital (GACH) emergency department on (MONTH) 2, (YEAR). The resident received insulin therapy in the Emergency Department due to [DIAGNOSES REDACTED].) and can happen when your blood sugar is too high for too long. Resident 24 was placed on comfort care per Resident Representative's request and ultimately expired on (MONTH) 3, (YEAR), at 4:50 a.m. (This was 13 hours after the resident was transferred from the Skilled Nursing Facility to the GACH emergency room ). Findings: According to the admission record, Resident 24 was admitted to the facility on (MONTH) 15, (YEAR), with [DIAGNOSES REDACTED]. A review of Resident 24's History and Physical report completed by the resident's physician dated (MONTH) 21, (YEAR), indicated Resident 24 was alert. A review of Resident 24's Minimum Data Set (MDS- a comprehensive assessment and care screening tool) dated (MONTH) 27, (YEAR), indicated the resident usually understood and sometimes made herself understood. Resident 24 required extensive one person physical assistance with eating. The MDS indicated Resident 24 was receiving insulin injections. A review of the laboratory results indicated Resident 24's hemoglobin A1C (a blood test that provides information about your average levels of blood sugar, over the past 3 months) level increased from 7.1 percent to 8.2 percent in four months as follow: 1. Hemoglobin A1C = 7.3 percent (reference range 4.0 to 6.0 percent), dated (MONTH) 29, (YEAR). 2. Hemoglobin A1C = 8.1 percent, dated (MONTH) 12, (YEAR). 3. Hemoglobin A1C = 8.2 percent, dated (MONTH) 11, (YEAR). On (MONTH) 31, (YEAR) at 8:24 a.m., during an observation, Resident 24 was lying in bed, awake, alert, and oriented to person only. A review of Resident 24's physician orders [REDACTED]. 1. [MEDICATION NAME] (diabetes medicine that helps control blood sugar levels) tablet 25 milligrams, give one tablet by mouth one time a day for DM, dated (MONTH) 18, (YEAR). 2. [MEDICATION NAME] solution (Insulin [MEDICATION NAME]) inject subcutaneously (SQ- applied under the skin) before meals and at bedtime as per sliding scale (refers to the progressive increase in pre-meal or nighttime insulin doses and is based on fingerstick blood sugar test levels done at set intervals) if blood sugar 150 to 200 milligrams per deciliter (mg/dl) = 2 units, blood sugar (BS) 201 to 250 mg/dl = 4 units, BS- 251 to 300 mg/dl = 6 units, BS- 301 to 350 mg/dl = 8 units, BS- 351 to 400 mg/dl = 10 units, and if BS greater than 401 mg/dl = 12 units; Call physician for BS less than 70 or greater than 400, dated (MONTH) 7, (YEAR). (According to the American Diabetic Association, [MEDICATION NAME] is a rapid acting insulin that starts to lower blood glucose within 5 to 10 minutes after injection.) 3. Basaglar solution (Insulin [MEDICATION NAME]- long acting) pen injector 100 units per milliliter (ml), inject 18 unit SQ every 12 hours for DM, dated (MONTH) 17, (YEAR), and discontinued on (MONTH) 27, (YEAR). 4. Basaglar solution pen injector 100 units per milliliter (ml), inject 20 unit SQ every 12 hours for DM, dated (MONTH) 27, (YEAR), and discontinued (MONTH) 22, (YEAR). 5. [MEDICATION NAME] solution (insulin [MEDICATION NAME]-used to treat diabetes) inject 10 units subcutaneously in the morning for DM with [MEDICAL CONDITION] (elevated BS), dated (MONTH) 29, (YEAR). A review of Resident 24's care plan initiated on (MONTH) 21, (YEAR), and revised on (MONTH) 1, (YEAR), indicated the resident had a [DIAGNOSES REDACTED]. The care plan goal indicated Resident 24 will be free of all signs and symptoms of [DIAGNOSES REDACTED] (low BS)/[MEDICAL CONDITION] (high BS) such as sweating, thirst, fatigue, weakness, blurred vision for 90 days. The care plan interventions included: access and record blood glucose levels in the morning and as needed, monitor for signs and symptoms of hyper/[DIAGNOSES REDACTED] and report abnormal findings to the physician, and inject (subcutaneously) [MEDICATION NAME] solution (Insulin [MEDICATION NAME]) before meals and at bedtime as per sliding scale; if blood sugar 150 to 200 mg/dl = 2 units, blood sugar (BS) 201 to 250 mg/dl = 4 units, BS- 251 to 300 mg/dl = 6 units, BS- 301 to 350 mg/dl = 8 units, BS- 351 to 400 mg/dl = 10 units, and if BS greater than 401 mg/dl = 12 units; Call physician for BS less than 70 or greater than 400. A review of Resident 24's Medication Administration Record [REDACTED]. The MAR indicated [REDACTED] 1. On Thursday, (MONTH) 16, (YEAR), at 5:48 p.m., Resident 24's BS level was 426 mg/dl. The licensed nurses did not notify the physician, as directed in the physician order. 2. On Tuesday, (MONTH) 21, (YEAR), at 8:44 p.m., Resident 24's BS level was 500 mg/dl. The licensed nurses did not notify the physician, as directed in the physician order. 3. On Tuesday, (MONTH) 4, (YEAR), at 5:05 p.m., Resident 24's BS level was 441 mg/dl. The licensed nurses did not notify the physician, as directed in the physician order. 4. On Wednesday, (MONTH) 19, (YEAR), at 9:26 p.m., Resident 24's BS level was 425 mg/dl. The licensed nurses did not notify the physician, as directed in the physician order. 5. On Thursday, (MONTH) 20, (YEAR), at 4:48 p.m. and 9:06 p.m., Resident 24's BS levels were 488 mg/dl and 422 mg/dl respectively. The licensed nurses did not notify the physician, as directed in the physician order. 6. On Thursday, (MONTH) 27, (YEAR), at 8:25 p.m., Resident 24's BS level was 476 mg/dl. The licensed nurses did not notify the physician, as directed in the physician order. 7. On Sunday, (MONTH) 30, (YEAR), at 5:12 p.m., Resident 24's BS level was 484 mg/dl. The licensed nurses did not notify the physician, as directed in the physician order. 8. On Monday, (MONTH) 1, (YEAR), at 8:17 p.m., Resident 24's BS level was 421 mg/dl. The licensed nurses did not notify the physician, as directed in the physician order. 9. On Saturday, (MONTH) 6, (YEAR), at 5:09 p.m., Resident 24's BS level was 403 mg/dl. The licensed nurses did not notify the physician, as directed in the physician order. 10. On Sunday, (MONTH) 28, (YEAR), at 12:46 p.m. and 4:40 p.m., Resident 24's BS levels were 403 mg/dl and 402 mg/dl respectively. The licensed nurses did not notify the physician, as directed in the physician order. 11. On Friday, (MONTH) 2, (YEAR), at 6:16 a.m., Resident 24's BS level was 405 mg/dl. The licensed nurses did not notify the physician, as directed in the physician order On (MONTH) 2, (YEAR) at 8:12 a.m., during an observation, Resident 24 was lying in bed and sleeping. On (MONTH) 2, (YEAR), at 8:45 a.m., during an observation, a Certified Nursing Assistant was sitting on a chair next to Resident 24's bed and was getting ready to assist the resident with her meal (breakfast). On (MONTH) 2, (YEAR), at 8:48 a.m., during an observation, Resident 24 ate 100 percent of her meal. On (MONTH) 2, (YEAR), at 11:02 a.m., during an observation in the presence of the Director of Staff Development (DSD) and Registered Nurse 2 (RN 2), Resident 24 was lying in bed, unresponsive, with an abnormal breathing pattern. During a concurrent interview, the DSD stated that Resident 24 was found unresponsive by Certified Nursing Assistant 12 (CNA 12), and that the resident had fever (temperature 102.1 degree Fahrenheit), low blood pressure, and elevated BS (the BS machine indicated high). At 11:10 a.m., the paramedics arrived and entered Resident 24's room. On (MONTH) 2, (YEAR), at 11:25 a.m., during an interview, RN 2 stated that the nursing staff, who was assigned to Resident 24 during the 11 p.m. to 7 a.m. shift did not notify her of the resident's elevated BS (of (MONTH) 2, (YEAR), at 6:16 a.m.) A review of Resident 24's Medication Administration Record [REDACTED] LVN 5 administered 12 units of [MEDICATION NAME] SQ to Resident 24 on (MONTH) 2, (YEAR) at 6:16 a.m. There was no documented evidence LVN 5 rechecked Resident 24's BS to determine if the insulin was effective in lowering the resident's blood sugar. On (MONTH) 2, (YEAR) at 11:29 a.m., during an interview, Licensed Vocational Nurse 6 (LVN 6) stated that [MEDICATION NAME] was a fast acting insulin and that Resident 24's meal should have been provided within 15 to 30 minutes of [MEDICATION NAME] administration. On (MONTH) 2, (YEAR) at 11:30 a.m., during an interview, RN 1 (Unit manager) stated she was not notified that Resident 24's BS was greater than 400 earlier in the morning ([DATE], (YEAR), at 6 a.m.). RN 1 stated that if she had been notified of the resident's elevated BS, she would have followed up and assessed the resident more frequently. RN 1 stated that if a resident's BS was outside the physician's parameter range, the nurse should have rechecked the resident's BS after 30 minutes of [MEDICATION NAME] administration. On (MONTH) 2, (YEAR), at 4:50 p.m., during a phone interview, Licensed Vocational Nurse 5 (LVN 5) stated Resident 24's BS was greater than 400 earlier in the morning ([DATE], (YEAR).) LVN 5 stated that she did not notify the physician of Resident 24's elevated BS because she did not see the instruction to notify the physician when the BS was greater than 400. LVN 5 stated that she did not notify the unit manager of the resident's elevated BS and she did not communicate the BS level to the licensed nurse working 7 a.m. to 3 p.m. (on (MONTH) 2, (YEAR).) A review of the GACH's emergency room Documentation dated (MONTH) 2, (YEAR), indicated Resident 24 presented to the Emergency Department at 11:44 a.m. with altered mental status, [MEDICAL CONDITION] (elevated BS). Resident 24's laboratory test results indicated a critical BS level of 1,066 mg/dl (reference range: less than 126 mg/dl), a critical potassium level of 6.8 millimoles (mMol) per liter (reference range: 3.6 to 5.2 mMol/l). Resident 24's [DIAGNOSES REDACTED]. A review of the GACH's History and Physical report dated (MONTH) 2, (YEAR), indicated that Resident 24 presented to the GACH with [MEDICAL CONDITION], severe acidosis (buildup of acid in the body), and evidence of DKA. A review of the GACH's Discharge Summary dated (MONTH) 3, (YEAR), indicated Resident 24 expired on (MONTH) 3, (YEAR), at 4:50 a.m. (13 hours after the resident presented to the emergency room Department). The Discharge Summary indicated that the cause of death was likely [MEDICAL CONDITION] (a medical condition in which a person's kidneys cease functioning on a permanent basis) in the setting of type 2 diabetes mellitus. On (MONTH) 5, (YEAR), at 8:55 a.m., during an interview, the RD stated that Resident 24's BS was controlled with medications. The RD stated that she was not notified of Resident 24's elevated BS (greater than 400). RD stated that she should have been notified if Resident 24's BS fell outside parameter range, so she could adjust the resident's diet. On (MONTH) 6, (YEAR) at 11:39 a.m., during an interview, the Director of Nursing (DON) stated that the nursing staff should have notified the physician when Resident 24's was greater than 400 as directed in the physician order [REDACTED]. The DON stated the facility did not identify that Resident 24 was not receiving her meals within 5 to 15 minutes of [MEDICATION NAME] administration, as indicated in the manufacturer's instruction. The DON stated that the nursing staff should have notified the RD if Resident 24's BS was uncontrolled for possible change of the resident's diet. On (MONTH) 7, (YEAR), at 10:06 a.m., during an interview, the Nurse Practice Educator (DSD) stated that he was unable to provide documented evidence the licensed nursing staff notified Resident 24's physician that the resident was not receiving scheduled diabetes medications (Basaglar and [MEDICATION NAME]) on [MEDICAL TREATMENT] days (Tuesdays, Thursdays, and Saturdays). The DSD stated that Resident 24's care plan did not identify an alternate time of administration during the days the resident was away from the facility and receiving [MEDICAL TREATMENT] treatment. On (MONTH) 7, (YEAR) at 11:05 a.m., during an interview, the DSD stated he reviewed Resident 24's nurses notes, physician orders, and MAR, and was unable to provide documented evidence the nurses staff notified the physician of Resident 24's elevated BS (greater than 400) on (MONTH) 16 and 21, (YEAR), (MONTH) 4, 19, 20, 27, and 30, (YEAR), and (MONTH) 1, 6, and 28, (YEAR). The DSD stated that the licensed nurses should have notified the physician as ordered, and rechecked Resident 24's BS (standards of nursing practice) after [MEDICATION NAME] was administered for a BS greater than 400. On (MONTH) 15, (YEAR) at 1:43 p.m., during a phone interview, Resident 24's primary physician (MD 1) stated that Resident 24's BS levels had been challenging to manage due to the resident's labile (often swings quickly from high to low and from low to high) BS levels. MD 1 stated that he did not recall the nursing staff notifying him that the resident was not receiving long acting insulin and [MEDICATION NAME] at the scheduled time (9 a.m.) on Tuesdays, Thursdays, and Saturdays, when the resident was outside the facility receiving HD treatment. MD 1 stated that he was not aware that the resident was receiving her meal (breakfast) between 8:30 a.m. and 9 a.m. MD 1 stated that if Resident 24 received [MEDICATION NAME] (rapid acting insulin) at 6 a.m., theoretically, it could have affected the resident's blood glucose management. MD 1 stated that the RD should have been involved in the resident's blood glucose management. MD 1 stated that if the nursing staff had notified him of Resident 24's BS of 405 on (MONTH) 2, (YEAR), he would have cautiously ordered additional doses of insulin, monitored the resident closely, investigate why the resident was having high blood sugar (resident possibly having an infection), and most probably adjusted the resident's blood glucose management. MD 1 stated that it would have been best practice for the nursing staff to recheck the BS within 30 minutes to an hour after insulin administration if the resident's BS was outside the ordered parameter range. MD 1 also stated that he reviewed Resident 24's H&P from the GACH and concurred that resident presented to the emergency room department with DKA. A review of [MEDICATION NAME]'s Package Insert revised in (YEAR), (provided by the facility), indicated [MEDICATION NAME] is a rapid human insulin analog indicated to improve glycemic control in adults and children with diabetes mellitus. [MEDICATION NAME] starts acting fast; you should eat a meal within 5 to 10 minutes after you take the dose of [MEDICATION NAME]. [MEDICATION NAME] should generally be used in regimens with an intermediate or long acting insulin. The duration of action for [MEDICATION NAME] is three to five hours. A review of the facility revised policy dated (MONTH) 2, 2014, titled Diabetic Care Protocol indicated to perform fingerstick blood glucose monitoring as ordered, administer insulin/oral hypoglycemic medication as ordered, evaluate for and respond to any change of condition, and report blood glucose results to the physician/mid-level provider according to ordered parameters. Report the following to the physician: 1. Urgent: Notify immediately if blood glucose is greater than 400 or less than 70 (and not corrected with interventions according to [DIAGNOSES REDACTED] protocol.) 2. Routine: Notify as soon as possible during normal business hours if blood glucose greater than 350 or greater than 300 on two consecutive readings. A review of the facility's undated Guidelines for Physician Notification indicates it is urgent to notify the physician immediately once evaluation is complete when a resident's blood sugar is greater than 400 or less than 70.

Based on observation, interview, and record review, the facility failed to ensure safe medication dispensing, administration, and provision of pharmaceutical services to meet the needs of each resident for a total facility census of 130 residents, by failing to: 1. Maintain a system of medication records that enables periodic accurate reconciliation and accounting of all controlled medications in the automated dispensing unit (ADU - computerized drug storage device or cabinet, allowing medications to be stored and dispensed while controlling and tracking drug distribution) in order to identify potential loss or diversion of controlled medications. 2. Ensure the medication being dispensed from the ADU bin was the correct medication as indicated to be dispensed on the computer screen, to minimize the chance of medication errors. 3. Ensure licensed nurses followed proper procedures in reporting medication discrepancies found during the use of the ADU. 4. Ensure the change of shift narcotics reconciliation records were properly filled and signed, for four (4) of eight (8) medication carts located at two (2) out of three (3) nursing stations. 5. Maintain proper temperature controls for refrigerated medications (36 to 46 degrees Fahrenheit) for one of three nursing stations (Station 1), and to provide a room temperatur monitoring record for proper temperature controls in the medication room at the Station 1. These deficient practices resulted in system failures placing the residents at a high risk of harm by potentially administering wrong medication and a system failure of the inability of the facility to readily identify loss and diversion of controlled medications. These deficient practices also resulted in the potential for loss of potency of refrigerated medications that were stored below the normal refrigerator temperature range, and potentially affected the residents at the Station 1. On (MONTH) 1, (YEAR), at 5:55 p.m., the facility Administrator (ADM) and the Director of Nursing (DON), were notified of the Immediate Jeopardy (IJ) situation regarding the failure to have control of all medications in the ADU in a manner that allows for monitoring of medication supply available to the resident, monitoring medication to readily identify loss, and diversion of controlled medications. The facility provided an acceptable immediate plan of action and the IJ was abated on (MONTH) 2, (YEAR), at 3:50 p.m., in the presence of the ADM and the DON. The remedies for the abatement of the IJ were verified onsite on (MONTH) 2, (YEAR), and included: 1. Disabling access to the ADU by all users 2. Removal of all medications in the ADU by the Pharmacist 3. Emergency Kits (E-Kit) to replace the ADU Findings: a1. On (MONTH) 29, (YEAR), at 3:30 p.m. during an observation of a cycle count (an inventory procedure, where a small subset of inventory is counted on a specified day) for controlled II medications (a category of drugs considered to have a strong potential for abuse or addiction but that have legitimate medical use) at the facility's ADU performed by Registered Nurse 1 (RN 1) and Registered Nurse 2 (RN 2) the following discrepancies were noted: 1. Drawer 1 Bin 60 - The computer indicated that the bin should contain oxycodone acetaminophen (a combination medicine used to relieve moderate to severe pain), 5 - 325 milligrams (mg) per tablet. However, the actual medication present in the bin was one (1) tablet of morphine immediate release (IR- a medication used in treating moderate to severe pain),15 mg. 2. Drawer 1 Bin 70 - The computer indicated that the bin should contain oxycodone extended release (ER) 10 mg/tablet. However, the actual medication present in the bin was one (1) tablet of amlodipine (a medication used to treat chest pain and high blood pressure) 2.5 mg. 3. Drawer 3 Bin 75 - The computer indicated that the bin should contain morphine IR 10 mg/tablet. However, the actual medication present in the bin was one (1) tablet of simvastatin (a lipid or fat lowering medication), 20 mg. 4. Drawer 3 Bin 78 - The computer indicated that the bin should contain hydromorphone (pain medication), 2 mg/tablet. However, the actual medication present in the bin was one (1) tablet of oxycodone hydrochloride (used to treat moderate to severe pain), 5 mg. 5. Drawer 5 Bin 10 - The computer indicated that the bin should contain morphine ER 15 mg/tablet. However, the actual medication present in the bin was one (1) vial of morphine 10 mg per millimeter (ml). On (MONTH) 29, (YEAR), at 4:10 p.m. during the interview with RN 1, she stated that she was not aware of any discrepancy of the controlled medications in the ADU. RN 1 also added although the facility had problem with the ADU earlier in the month of November, the said problem was already resolved. On (MONTH) 29, (YEAR), at approximately 4:15 p.m., during the interview, RN 2 denied any experience regarding discrepancy of mismatched medications in the ADU cycle count of controlled medication in the past. A record review of facility's policy titled Automated Medication Dispensing Systems (AMDS) dated (MONTH) 17, (YEAR), indicated that the AMDS is used for emergency medications and to provide pharmacy services required before the facility's next scheduled delivery from the dispensing pharmacy. During an interview with the Director of Nursing (DON) on (MONTH) 29, (YEAR) at 4:50 p.m., she stated she was not aware of any ongoing problem with the ADU. The DON stated that the ADU had a problem earlier in the month of (MONTH) (YEAR), and because of that, the facility did not use the ADU from (MONTH) 7, (YEAR) to (MONTH) 23, (YEAR), as advised by the pharmacist (P1). On (MONTH) 24, (YEAR), P1 gave the facility a clearance to use the ADU. The facility currently uses the ADU. During the same interview, the DON stated the controlled II emergency medications listed in supply, were not placed in the storage bins accurately, but the licensed nurses continued to dispense and administer medications to the residents from the ADU. The DON stated the facility completes a cycle count of controlled medications in the ADU once a day at 11:00 p.m. The DON added that two RNs are responsible for doing the cycle count and these RNs are the outgoing (3 p.m. to 11:00 p.m. shift) RN and the incoming (11:00 p.m. to 7:00 a.m. shift) RN. Any discrepancy is reported to the DON the following day. On (MONTH) 29, (YEAR) at 4:55 p.m., in addition to the descrepancies already noted during the narcotic count, in a complete medication physical inventory of the ADU with RN 1 and RN 2, the following were observed: 1. Drawer 1 Bin 57, of the ADU indicated there was one tablet of Lanoxin (digoxin- used to treat heart failure) 125 microgram, but there was none found in the bin. 2. Drawer 1 Bin 64, of the ADU indicated there was one tablet of Ambien (zolpidem- used to help you fall asleep), 5 mg, but there was none found in the bin. 3. Drawer 2 Bin 45, of the ADU indicated there were two doxycycline hyclate (used to treat many different bacterial infections), 100 mg capsules. However, there was one (1) capsule of doxycycline 100 mg and one (1) capsule of phenytoin sodium ER (medication used to reduce the spread of seizure activity in the brain), 100 mg found in the bin. 4. Drawer 3 Bin 74, of the ADU indicated there was one tablet of alprazolam (Xanax- used in the treatment of [REDACTED]. 5. Drawer 3 Bin 76, of the ADU indicated there was one tablet Depakote DR (delayed-release, used to treat certain types of seizures) 250 mg. However, there were two tablets of amoxicillin (used to treat infections), 250 mg found in the bin. 6. Drawer 3 Bin 79, of the ADU indicated there was one tablet ketoconazole (used to treat fungal infections), 200 mg. However, there was none found in the bin. 7. Drawer 3 Bin 80, of the ADU indicated there was one tablet ketoconazole 200 mg. However, there was none found in the bin. 8. Drawer 4 Bin 57, of the ADU indicated there was one tablet divalproex sodium (a medication used to treat bipolar disorder), 1 25 mg. However, there was none found in the bin. 9. Drawer 4 Bin 59, of the ADU indicated there was one tablet levofloxacin (used to treat infections), 500 mg. However, there was none found in the bin. 10. Drawer 4 Bin 62, of the ADU indicated there was one tablet acetaminophen with codeine (used to relieve moderate to severe pain), However, there was none found in the bin. 11. Drawer 4 Bin 64, of the ADU indicated there was one tablet acetaminophen with codeine. However, there was none found in the bin. 12. Drawer 4 Bin 66, of the ADU indicated there was one tablet quetiapine fumarate (used to treat schizophrenia, a severe mental illness) 25 mg. However, there was none found in the bin. 13. Drawer 4 Bin 73, of the ADU indicated there was one tablet warfarin sodium (helps prevent the formation of blood clots), 2 mg. However, there was none found in the bin. 14. Drawer 4 Bin 75, of the ADU indicated there was one tablet clonazepam (used to prevent and treat seizures), 0.5 mg. However, there was none found in the bin. 15. Drawer 6 Bin 1, of the ADU indicated there was one injectable Lovenox (helps prevent the formation of blood clots), 40 mg per 0.4 ml. However, there was none found in the bin. 16. Drawer 6 Bin 3, of the ADU indicated there was one injectable Lovenox 40 mg per 0.4 ml. However, there was none found in the bin. 17. Drawer 6 Bin 9, of the ADU indicated there was one tablet metoprolol tartrate (used to treat chest pain and high blood pressure), 50 mg. However, there was none found in the bin. 18. Drawer 6 Bin 9, of the ADU indicated there were two tablets of fluconazole (used to treat infections caused by fungus), 100 mg. However, there was one fluconazole tablet found in the bin. 19. Drawer 6 Bin 14, of the ADU indicated for one tablet of moxifloxacin (used to treat infections) 400 mg. However, there were two moxifloxacin tablets found in the bin. 20. Drawer 6 Bin 15, of the ADU indicated there were four vials of Compazine (used to treat disorders such as schizophrenia), 5 mg per ml. However, there was none found in the bin. 21. Drawer 6 Bin 16, of the ADU indicated there was one tablet zolpidem tartrate (used for treatment of [REDACTED]. However, there was none found in the bin. 22. Drawer 6 Bin 19, of the ADU indicated there were four vials of Tigan (used to prevent nausea and vomiting) 100 mg. However, there was none found in the bin. 23. Drawer 6 Bin 25, of the ADU indicated there was one ampule of promethazine (used to treat the symptoms of allergies and motion sickness), 50 mg. However, there was none found in the bin. 24. Drawer 6 Bin 27, of the ADU indicated there were four ampule of tobramycin (used to treat infections), 40 mg per ml. However, there was none found in the bin. 25. Drawer 6 Bin 30, of the ADU indicated there was one tablet of amlodipine besylate (used to treat chest pain and high blood pressure), 10 mg. However, there was none found in the bin. 26. Drawer 6 Bin 33, of the ADU indicated there were four vials of Haldol (used to treat schizophrenia), 5 mg per ml vial. However, there was none found in the bin. 27. Drawer 6 Bin 34, of the ADU indicated there was one tablet of risperidone (used to treat schizophrenia), 0.25 mg. However, there was none found in the bin. 28. Drawer 6 Bin of 41, the ADU indicated there were four ampule of lidocaine HCl (a local anesthetic agent), one percent ampule. However, there was none found in the bin. 29. Drawer 6 Bin 43, of the ADU indicated there were four vials of dexamethasone (an anti-inflammatory agent), four mg per ml vial. However, there was none found in the bin. 30. Drawer 6 Bin 46, of the ADU indicated there was one tablet of metronidazole (used to treat infections), 500 mg. However, there was none found in the bin. 31. Drawer 6 Bin 47, of the ADU indicated there were two injectables of enoxaparin (Lovenox - a blood thinner) 30 mg per 0.3 ml. However, there was none found in the bin. 32. Drawer 6 Bin 48, of the ADU indicated there was one tablet of donepezil HCl 10 mg. However, there was none found in the bin. 33. Drawer 7 Bin 18, of the ADU indicated there was one solution of Kayexalate (use to treat potassium level in the blood)15 gm per 60 ml. However, there was none found in the bin. 34. Drawer 7 Bin 21, of the ADU indicated there was one solution of Kayexalate 15 gm per 60 ml. However, there was none found in the bin. 35. Drawer 7 Bin 22, of the ADU indicated there was one solution of Kayexalate 15 gm per 60 ml. However, there was none found in the bin. During an interview with RN 2, during the physical inventory count, she stated only the night shift (11:00 p.m. - 7:00 a.m.) does the cycle count every night and it should be done with a RN and a Licensed Vocational Nurse (LVN). When asked if RN 2 had experienced a discrepancy where a different medication was found instead of the ordered medication, such as, the bin was supposed to have Percocet and morphine was found, or oxycodone and Norvasc was found instead, RN 2 stated no. On (MONTH) 29, (YEAR), at 5:48 p.m., during an interview with the P1, he stated he is in charge of the ADU in the facility regarding inventory of medications, restocking of the medications, and checking that the ADU is working properly. P1 stated he does a monthly physical inspection and inventory of the medications in the ADU and re-stocks the ADU on an average of 2 times a week. According to P1, during the physical inspection of the medications in the ADU, he checked that the medications were correct, medications were in the correct bins, and the medications were not expired. P1 also explained that there was a problem identified with the ADU on (MONTH) 7, (YEAR). The ADU was not communicating with the dispensing pharmacy and he attributed this problem to the failed plan upgrade to a new network server. P1 verbally instructed the facility not to use the ADU from (MONTH) 7, (YEAR), to (MONTH) 23, (YEAR). Since it was taking too long to fix the new network server, P1 decided to reconnect the ADU to the old network server so that the facility could resume use of their ADU. P1 stated that he did a spot check on the facility's ADU on (MONTH) 23, (YEAR), and he found the system was working properly. P1 verbally told the facility that they could begin using the ADU starting (MONTH) 24, (YEAR). On (MONTH) 29, (YEAR), at 5:48 p.m., during the same interview, P1 stated that he was not aware of any communication from the facility that the ADU had a problem until (MONTH) 29, (YEAR), regarding mismatched medications of the ADU. P1 explained the problem could have been a computer glitch related to the network server. On (MONTH) 29, (YEAR), at approximately 6:10 p.m., during an interview with the DON, she clarified that the facility does a cycle count of the controlled II medications by two licensed nurses (one RN and one LVN) from 11:00 p.m. to 7:00 a.m. shift and not as previously stated. The two licensed nurses who do the cycle counts of the controlled II medications will sign their names in the Daily Cycle Count Log. In case of a discrepancy, the ADU automatically prints a receipt and the receipt is attached to the log. The discrepancy should be resolved at the time of discovery. Regardless of whether the medication discrepancy was resolved or not, the DON will still investigate. The DON stated again she was not aware of any problem with the ADU until (MONTH) 29, (YEAR) after the RN 1 and RN 2 did a random cycle count. A record review of the facility's Daily Cycle Count Log for the month of (MONTH) (YEAR), indicated that it is the responsibility of the facility to reconcile controlled II substances on a daily basis with the cycle count. The count required one nurse and a second nurse as witness. The Daily Cycle Count Log form indicated fillable fields for Month and Year, Date, Registered Nurse's signature, and Licensed Vocational Nurse's Signature. The Daily Cycle Count Log indicated the following entries: 1. (MONTH) 7, (YEAR) to (MONTH) 23, (YEAR) - No entries 2. (MONTH) 29, (YEAR), only one signature was noted. The LVN signature was blank. During an interview with RN 1 on (MONTH) 29, (YEAR) at 8:00 p.m., RN 1 stated there was no entry in the Daily Cycle Count Log from (MONTH) 7, (YEAR), to (MONTH) 23, (YEAR), because the ADU was not in use at that time. The facility resumed the use of ADU on (MONTH) 24, (YEAR). On (MONTH) 29, (YEAR), at 8:20 p.m., during an interview, RN 2 stated she usually works the 11:00 p.m. to 7:00 a.m. shift and when she is on duty she does the cycle count for controlled II drugs in the ADU with the LVN on duty. During same interview, RN 2 explained the facility's procedure of a cycle count done by licensed nurses as follows: 1. One RN and one LVN do the cycle count for controlled II medications in the ADU. 2. Each Licensed Nurse enters their user name and password in the facility's ADU. 3. The ADU opens by drawer and by bin one at a time. 4. One Licensed Nurse will do the physical check and counts the medication, while the other nurse will double check it. 5. Licensed Nurses check the correct medication (name, form, and strength) indicated on the computer screen and compare it to the actual medication in the bin. 6. Licensed Nurses check for expiration date of the medication. 7. Licensed Nurses enter the actual count found in the bin. 8. The ADU automatically prints a receipt for any discrepancy in the count. 9. Receipts are attached to the log book for follow up by the DON. RN 2 stated that she did the cycle count last on (MONTH) 24, (YEAR), and (MONTH) 25, (YEAR). When asked if she followed the process when she did the cycle count on the said dates, RN 2 did not answer the question directly, but stated that she noticed mismatched medication on (MONTH) 24, (YEAR), and again on (MONTH) 25, (YEAR). She stated she did not report the discrepancies to anyone. RN 2 stated the LVN who did the cycle count with her on the said dates, also knew about the discrepancies. RN 2 stated that she should have reported the discrepancies to the DON, the first time she discovered them. On (MONTH) 29, (YEAR), at approximately 8:45 p.m., the facility provided the current computer inventory of medications for the ADU. On (MONTH) 30, (YEAR) at 8:00 a.m. during an interview with RN 4, she stated she works the 11:00 p.m. to 7:00 a.m. shift and she performed the cycle count of controlled II medications in the ADU. RN 4 stated from (MONTH) 26, (YEAR), to (MONTH) 29, (YEAR), she did the cycle count with a LVN. RN 4 stated that on (MONTH) 26, (YEAR), there were discrepancies between what was indicated on the ADU computer and what was in the ADU medication bins. RN 4 stated a simvastatin tablet (a non-narcotic medication) was found in a bin instead of a narcotic medication. RN 4 could not recall how many medications were mismatched during their cycle count. RN 4 stated the same medication discrepancies were noted for four days. However, she did not report these discrepancies to the DON or Pharmacist. RN 4 stated that she should have reported the discrepancies as soon as she discovered them. On (MONTH) 30, (YEAR) at 3:37 p.m., during a phone interview with LVN 1, she stated that within the last two weeks there was a medication discrepancy (an instance when the medication type or medication count of the ADU does not match the physical count inside the drug bin container) when she conducted a narcotic medication count on the ADU. The medication, oxycodone (a narcotic pain medication), was one of the medication discrepancies she remembers, in which the number of tablets indicated on the ADU computer screen did not match the actual physical count of tablets. LVN 1 stated this event occurred when she conducted a narcotics medication count on the 11 p.m. to 7 a.m. night shift with RN 4. LVN 1 could not recall the exact date of the incident but she remembers the event occurred within the last two weeks. LVN 1 stated there was another medication discrepancy for the medication, morphine sulfate (a narcotic pain medication) but could not remember the type of discrepancy. LVN 1 stated she was unsure of the procedure to follow in case of finding medication discrepancies. LVN 1 stated she witnessed RN 4 writing down the medication name and actual count on a piece of paper. LVN 1 stated RN 4 told her she would report the discrepancy to the Director of Nurses (DON). LVN 1 stated the ADU did not produce a medication discrepancy printout. LVN 1 stated the ADU use to produce a medication discrepancy computer printout, but currently does not produce a printout. A record review of the actual inventory performed by RN 1 and RN 2 on (MONTH) 29, (YEAR), and the inventory print out in the computer on (MONTH) 29, (YEAR), indicated the following discrepancies: Medication - aprazolam 0.25mg tablet Actual Inventory - 7 Computer Inventory - 8 Medication - amlodipine besylate 10 mg tablet Actual Inventory - 0 Computer Inventory - 1 Medication - amlodipine besylate 2.5 mg tablet Actual Inventory - 0 Computer Inventory - 1 Medication - benztropine (used in the treatment of [REDACTED]. Actual Inventory - 0 Computer Inventory - 4 Medication - chlorpromazine (used as a tranquilizer), 25mg/ml Actual Inventory - 0 Computer Inventory - 2 Medication - clonazepam (used to treat seizures and panic disorder) 0.5mg tablet Actual Inventory - 0 Computer Inventory - 3 Medication - dexamethasone ( used to treat inflammatory condition) 4mg/ml vial Actual Inventory - 0 Computer Inventory - 4 Medication - enalapril maleate (used to treat high blood pressure) 5 mg tablet Actual Inventory - 0 Computer Inventory - 1 Medication - enoxaparin 30 mg/0.3ml syringe Actual Inventory - 0 Computer Inventory - 2 Medication - enoxaparin 40 mg/0.4ml syringe Actual Inventory - 4 Computer Inventory - 8 Medication - epinephrine 1mg/ml ampule Actual Inventory - 0 Computer Inventory - 4 Medication - furosemide (water pill) 20 mg/tab Actual Inventory - 0 Computer Inventory - 1 Medication - haloperidol lac (used to treat nervous, emotional and mental condition) 5 mg/ml vial Actual Inventory - 0 Computer Inventory - 4 Medication - ipratropium Br (used to treat non allergenic and allergenic condition) 0.02% sol 2.5 ml Actual Inventory - 0 Computer Inventory - 4 Medication - isosorbide MN ER (used to prevent chest pain and reduce strain of the heart) 30mg Actual Inventory - 0 Computer Inventory - 2 Medication - ketoconazole 200mg tablet Actual Inventory - 2 Computer Inventory - 4 Medication - levofloxacin 500mg tablet Actual Inventory - 0 Computer Inventory - 1 Medication - lidocaine hcl 1% 2 ml ampule Actual Inventory - 0 Computer Inventory - 4 Medication - lorazepam (used to treat anxiety) 0.5 mg tablet Actual Inventory - 10 Computer Inventory - 11 Medication - mephyton (used to treat thin blood) 5 mg tablet Actual Inventory - 0 Computer Inventory - 1 Medication - metformin HCl (use to improve blood sugar control) 500 mg tablet Actual Inventory - 4 Computer Inventory - 6 Medication - metoprolol tartrate 25 mg tablet Actual Inventory - 0 Computer Inventory - 2 Medication - metronidazole 500 mg tablet Actual Inventory - 0 Computer Inventory - 1 Medication - morphine sulfate ER 15 mg tablet Actual Inventory - 6 Computer Inventory - 7 Medication - naloxone (used to reverse the effects of narcotic drugs) 0.4mg/ml vial Actual Inventory - 0 Computer Inventory - 4 Medication - ondansetron HCl (use to treat or prevent nausea and vomiting)4 mg tablet Actual Inventory - 12 Computer Inventory - 17 Medication - ondansetron HCl 4 mg/2ml vial Actual Inventory - 0 Computer Inventory - 7 Medication - potassium Cl ER (used to treat low potassium level) 230 milliequivalent tablet Actual Inventory - 10 Computer Inventory - 15 Medication - prochlorperazine (use to treat or prevent nausea and vomiting) 10 mg/2ml vial Actual Inventory - 0 Computer Inventory - 4 Medication - prochlorperazine 25 mg suppository Actual Inventory - 0 Computer Inventory - 4 Medication - promethazine 50 mg/ml ampule Actual Inventory - 0 Computer Inventory - 1 Medication - quetiapine Fumarate 25 mg tablet Actual Inventory - 0 Computer Inventory - 1 Medication - ranitidine (use to promote healing in the stomach by controlling stomach acid production)) 150 mg tablet Actual Inventory - 1 Computer Inventory - 2 Medication - zolpidem ( sleeping pill)5 mg tablet Actual Inventory - 10 Computer Inventory - 11 On (MONTH) 30, (YEAR), at 3:30 p.m., during an interview with the pharmacist (P1), he stated there were discrepancies between the actual count and the printed inventory from the computer on (MONTH) 29, (YEAR). P1 stated that he did not do an actual physical inventory of the medications in the ADU prior to giving clearance to use the ADU on (MONTH) 24, (YEAR). P1 stated that he should have done one complete cycle count before allowing the facility use the ADU on (MONTH) 24, (YEAR). During same interview, P1 stated he did complete a physical inventory of all the medications in the ADU on (MONTH) 30, (YEAR), early in the morning, but had not yet restocked the medications. A review of the medication use log indicated no medications were added to or taken out of the ADU between (MONTH) 29, (YEAR) at 4:55 p.m. and (MONTH) 30, (YEAR) at 6:00 p.m. During a record review of the actual physical inventory done on (MONTH) 29, (YEAR) at 4:55 p.m. performed by RN 1 and RN 2, and compared with the inventory prints out of the computer listed inventory on (MONTH) 30, (YEAR) at 6:00 p.m., (after P 1 stated an actual physical inventory and correction of the discrepancies of the ADU were completed), discrepancies were still noted as follows: 1. Medication: clonazepam 5 mg tablet [DATE] Actual physical inventory - 0 [DATE] Computer print out inventory - 3 2. Medication: hydromorphone 2mg tablet [DATE] Actual physical inventory - 19 [DATE] Computer print out inventory - 17 3. Medication: oxycontin 10 mg tablet [DATE] Actual physical inventory - 11 [DATE] Computer print out inventory - 0 4. Medication: rifampin 150 mg capsule [DATE] Actual physical inventory - 2 [DATE] Computer print out inventory - 1 On (MONTH) 30, (YEAR) at 4:20 p.m., during observation of the ADU in the presence of RN 3, the facility's ADU was still operational and there was no visible sign indicating that it should not be used. RN 3 confirmed that she still had access to the facility's ADU and that it still contained medications. On (MONTH) 1, (YEAR) at 9:10 a.m., during observation and interview with RN 1, she stated the facility's ADU was still on and could be accessed by the licensed nurses. A record review of the OmniSupplier User Access dated (MONTH) 29, (YEAR), indicated that there were 29 active users of the facility's ADU. A review of the facility's policy and procedure titled, Automated Medication Dispensing Systems, revised (MONTH) 17, (YEAR), indicated, the facility determines the content of the AMDS in conjunction with the Pharmacy and in accordance with applicable law. The pharmacy tracks use of the automated medication delivery system and makes a complete and accurate record of all transactions. A pharmacist reviews medication contained within, and the operation and maintenance of the automated drug delivery system. The review is to be conducted on a monthly basis by a pharmacist and shall include a physical inspection of the drugs in the automated drug delivery system, a review of all transaction records in order to verify the security and accountability of the system. The Pharmacist and Facility will document and report unresolved controlled substances discrepancies to the pharmacy and pursuant to Facility policy and applicable law. In the event of a system malfunction or failure, facility will contact Pharmacy during Pharmacy's hours of operation and if the system failure occurs after regular pharmacy hours contact the on call pharmacist. A review of a California Health and Safety Code Section 1261.6 titled, Automated Drug Delivery Systems, provided by the facility, included but was not limited to the following: (d)(1) Policies and procedures shall define access to the automated drug delivery system and limits to access to equipment and drugs. (g)(3) Review of the drugs contained within, and the operation and maintenance of, the automated drug delivery system shall be done in accordance with law and shall be the responsibility of the pharmacy. The review shall be conducted on a monthly basis by a pharmacist and shall include a physical inspection of the drugs in the automated drug delivery system, an inspection of the automated drug delivery system machine for cleanliness, and a review of all transaction records in order to verify the security and accountability of the system. a 2. During an observation of the cycle count with the registered nurse (RN 2), on (MONTH) 29, (YEAR), that started at 4:55 p.m., in the presence of Pharmacist 1 (P1), there were two ADU bins that did not close fully or lock to ensure that the bins were secured and could not be accessed by other staff members. P1 asked RN 2 to push the drawers in to see if the bins would lock. When RN 2 pushed the drawer, the bins did not fully close and did not lock. The drawers had a flashing light indicator. P1 was unable to explain why the flashing light was occurring. On (MONTH) 29, (YEAR), at 9:05 p.m., during interviews with RN 1 and RN 2 regarding medication reconciliation and discrepancies, they stated only narcotic medications were counted at the cycle count at night. There was also an automatic print out when a discrepancy occurs. However, when RN 1 and RN 2 found discrepancies during the cycle count, there was no automatic print out of discrepancies from the ADU, as observed. RN 1 and RN 2 stated the automatic print out of discrepancies reports were placed in a binder kept at Station 1. When RN 1 and RN 2 were asked how they resolve the discrepancy before the end of the shift, they stated they only place the automated print out discrepancy report in the binder. During the same interview on (MONTH) 29, (YEAR) at 9:05 p.m., with RN 1 and RN 2 regarding the process of how to obtain medications from the ADU, they stated, if it is a narcotic medication, it needs to be electronically cosigned or witnessed electronically by another licensed nurse. If the licensed staff is obtaining a non-narcotic medication, there is no need for a witness. During the interview on (MONTH) 29, (YEAR) at 9:05 p.m., that included the Director of Nursing (DON), when asked how she knows if there was any discrepancy with the ADU, she stated the licensed nurses from the night shift place the discrepancy report inside the binder. The DON demonstrated where the discrepancy reports were kept in the binder. The DON also received the discrepancy report through electronic mail (email) from the pharmacy every day. When asked how she resolves the discrepancy, the DON stated she gives the discrepancy printouts to RN 1. When the DON was asked how she handles unresolved discrepancies if the licensed nurses cannot resolve the discrepancy, she was not able to provide an explanation. On (MONTH) 29, (YEAR), at 9:15 p.m., interview with RN 1, when asked how she resolves the pharmacy discrepancy reports, she stated the night shift nurses do the cycle count, place the discrepancy reports (TRUNCATED)

Based on interview and record review, the licensed nursing staff failed to provide necessary care and services to one Random Sample Resident (RSR 25) and for 1 of 24 sample residents (Resident 19) by failing to: 1. Provide initial and continued assessments and document the findings after RSR 25 had a fall incident during the night shift resulting in a head injury. RSR 25 was severely impaired in cognitive skills; the fall incident was not communicated verbally and/or in writing to the incoming day shift licensed nursing staff until day shift called the off-duty night shift nurse at home when a head injury to the right eyebrow was discovered the next morning. 2. Ensure Resident 19 had pre-[MEDICAL TREATMENT] and post-[MEDICAL TREATMENT] assessments that included the AV (arteriovenous shunt/graft site- passageway, artificial or natural, that allows blood to flow from an artery to a vein without going through a capillary network) post [MEDICAL TREATMENT] weight were completed. These deficient practices placed RSR 25 at risk for undetected head injury, and Resident 19 at risk for complications associated with [MEDICAL TREATMENT] treatment. Findings: a. A review of the admission record indicated RSR 25 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. ranging from slight confusion to total disorientation) and difficulty in walking. A review of the Minimum Data Set (MDS - a comprehensive assessment and screening tool), dated July 23, 2016, indicated RSR 25 was severely impaired in cognitive skills for daily decision making. RSR 25 required two person extensive assistance in transfer and walking, and one person assistance in dressing and toileting. RSR 25 had a fall since admission and was indicated as injury (except major) (skin tears, abrasions or injury that does not include a bone fracture or loss of consciousness). A review of RSR 25's Change in Condition Note, dated July 18, 2016 at 9:00 a.m. indicated the following: Found lying on the floor. Upon investigation, per 11 p.m. - 7 a.m. charge nurse, resident was found on the floor. 8 a.m. charge nurse was giving morning medications, noticed a bump on the right eyebrow. Resident is noted with right eyebrow laceration measure 2 x 0.5 centimeter (cm) - a unit of measure and a bump measuring 4 x 0.5 cm. RN Supervisor and charge nurse reassessed resident. A review of RSR 25's General Nursing Note, written by LVN 12, dated July 18, 2016 3:59 a.m., indicated the following: Received patient in bed, alert and oriented times three (alert to their own name, today's date, and where they are located), breathing is even and unlabored, no shortness of breath noted, no complaints of pain at this time., antibiotic therapy for urinary tract infection, will continue to monitor. However, there is no nursing note or assessment information entered to the clinical record by LVN 12 regarding RSR 25's fall during the night shift. On December 8, 2016 at 9:30 a.m., during an interview with RN 1, she stated the facility was unaware of RSR 25's fall that occurred during the night shift on July 18, 2016 at an unknown time, because the night shift nurse, LVN 12 did not notify the day shift licensed nurse (LVN 13) until the facility called the staff member on the phone to investigate the incident. LVN 12 did not notify the day shift nurses of RSR 25's fall during the change of shift report. On December 8, 2016 at 10:00 a.m., during an interview with the Director of Nurses (DON), she stated she did not know the exact time RSR 25 fell on the morning of July 18, 2016, because there was no assessment record or any documentation of the time, or any circumstances of the fall including what occurred, witnesses involved if any, and why RSR 25 fell . None of the answers to these questions could be provided by the DON. On December 8, 2016 at 10:05 a.m., during a concurrent record review and interview the DON, presented LVN 12's Employee File which contained a written warning that not notifying staff of RSR 25's fall during the night shift on July 18, 2016 was unacceptable. No other disciplinary action was taken at that time. LVN 12 was unable to be interviewed. LVN 12 is no longer employed at the facility. On December 8, 2016 at 10:15 a.m., during an interview with LVN 13, she stated she could not remember when she found RSR 25 the first time after his fall or if she was the staff member who spoke to the night shift nurse, LVN 12. A review of the policy and procedure, Fall Response Protocol, revised May 2013, indicated if a fall occurs on the 11 p.m. to 7 a.m. shift, staff are to notify the charge nurse the following morning. b. According to the admission record, Resident 19 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the Minimum Data Set (MDS - a comprehensive assessment and screening tool) dated November 27, 2016, indicated Resident 19 was cognitively intact, required extensive assistance with activities of daily living, and was always continent with bowel and bladder. There was a plan of care for resident at risk for impaired renal function and is at risk for complications related to [MEDICAL TREATMENT] was initiated on November 28, 2016 and revised on December 6, 2016, the goals included to avoid fluid overload and [MEDICAL TREATMENT] (a treatment to filter wastes and water from your blood) access will remain patent for 90 days. The interventions included to monitor the access site for signs and symptoms of infection, swelling, bleeding and upon return from [MEDICAL TREATMENT], monitor the access site for bruit and thrills (the nurse could palpate (feel with fingers) the thrill and hear the bruit (with a stethoscope) in every shift. A review of the Physician order [REDACTED]. A review of the [MEDICAL TREATMENT] Communication Record indicated the following: 1. On December 6, 2016, the post [MEDICAL TREATMENT] weight was not documented from the [MEDICAL TREATMENT] center, upon returning from the [MEDICAL TREATMENT] center, the date and time of return, the access site assessment to include redness, swelling, drainage, pain, bruit, thrill, new orders from [MEDICAL TREATMENT] center, signature of the receiving nurse were not assessed and completed as indicated on the plan of care and the boxes on the assessment form were blank. 2. On December 8, 2016, the post [MEDICAL TREATMENT] the date and time of return were not completed when resident returned from [MEDICAL TREATMENT] center. On December 9, 2016 at 2:00 p.m., during an interview, Licensed Vocational Nurse 4 (LVN 4) stated the receiving nurse should have assessed the access site and documented in the [MEDICAL TREATMENT] Communication Record when resident returned from the [MEDICAL TREATMENT] center. According to the facility's May 1, 2016 policy and procedure titled, [MEDICAL TREATMENT] Communication and Documentation, indicated the [MEDICAL TREATMENT] Communication Record will be completed upon return of the patient from the [MEDICAL TREATMENT] center. Upon return, the licensed nurse will review the [MEDICAL TREATMENT] center communication, evaluate/observe the patient, and document the evaluation/observation on the [MEDICAL TREATMENT] Communication Record form.

Based on observation, interview, and record review, the facility failed to ensure the resident environment was free from accident hazards, and failed to provide supervision and follow facility policies to prevent fall accidents, for two of 24 sample residents (Resident 7 and Resident 11), by failing to: 1. Develop, review, revise and implement Resident 7's plan of care and interventions for the resident's identified high risk for falls, and to address continuity of care and prevention of falls after Resident 7 returned to the facility from dialysis treatment. 2. Provide close supervision to Resident 7, who was identified as a high risk of falls and required supervision, when left unsupervised after dialysis (mechanical filtering of waste products from the blood, when the kidneys no longer work adequately) treatment. 3. Implement the facility policy for continuity of care of a resident returning from dialysis. 4. Ensure Resident 11, who was assessed as a high risk for falls, had safety devices (floor pads) to prevent injury due to a fall, as ordered by the physician. 5. Prevent unauthorized access to the roof by leaving a ladder propped against the facility exterior. The facility exterior was accessible to residents in three rooms. These deficient practices resulted in Resident 7 fracturing her arm after a second fall, and receiving a bump to her forehead after a third fall; and for the potential for injury to Resident 11, other residents and visitors. Findings: a. According to the admission record, Resident 7 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of Resident 7's medical record indicated she had three fall incidents. The first fall was an unwitnessed fall from bed on September 15, 2015. The second fall was an unwitnessed fall from bed on October 9, 2015, where Resident 7 sustained a fracture of the right arm. The third fall was an unwitnessed fall from her wheel chair on May 7, 2016, where Resident 7 sustained a bump on her right forehead. A review of Resident 7's Risk Management System Report dated September 18, 2015, indicated Resident 7 had an unwitnessed fall with no injury on September 15, 2015, at 8:15 p.m. Resident 7 was trying to get up from her bed and fell . She was found by a licensed nurse while doing her rounds. A review of Resident 7's post fall assessment dated [DATE], indicated interventions to be implemented to prevent further falls included providing a low bed, and applying an alarm (alerts staff when attempting to get up unassisted) when in bed and in the chair. A review of Resident 7's fall risk assessment dated [DATE], indicated Resident 7 was a high risk for falls. A care plan was initiated on September 16, 2015, for at risk for falls due to cognitive impairment, poor safety awareness, right sided weakness, dialysis, and on psychotropic medication. The goal was Resident 7 would have no falls with injury during the next 90 days. The care plan interventions included to utilize a low bed, to place the call light within reach at all times, to assist the resident getting in and out of bed with one person assistance, to apply a bed alarm and a chair alarm to alert staff members of the resident's needs. According to interdisciplinary team (IDT) notes, dated September 17, 2015, Resident 7 was alert and oriented with periods of confusion. Resident 7 was also assessed to be a high risk of falls for the following reasons: poor safety awareness, right-sided weakness, poor standing balance, and being prescribed psychotropic medications. The IDT team agreed to continue the current plan of care and to monitor Resident 7. A review of Resident 7's admission Minimum Data Set (MDS), an assessment and care screening tool, dated September 24, 2015, indicated Resident 7 was alert and required extensive assistance for bed mobility, transferring, dressing, and toileting. A review of Resident's 7 Post Fall Neurological Evaluation Flow sheet, dated September 15, 2015, to September 17, 2015, indicated to monitor the resident for 72 hours with the following schedules: every hour for 4 hours, then every 4 hours for 4 instances, then every shift. The space intended for monitoring on the September 17, 2015, 7 a.m. to 3 p.m. shift, was blank. A review of Resident 7's Nurses Notes for the 11 p.m. to 7 a.m. shift, dated September 16, 2015, indicated Resident 7 constantly attempted to get up from bed. On December 2, 2016, at 5:20 p.m., during an interview, Licensed Vocational Nurse 4 (LVN 4) stated Resident 7's neurological evaluation was not performed on September 17, 2015, 7 a.m. to 3 p.m. shift. LVN 4 stated the nurse and the CNA who were on duty at the time of Resident 7's fall incident were no longer working in the facility. A review of Resident 7's Risk Management System Report, dated October 13, 2015, indicated Resident 7 had an unwitnessed (second) fall with injury October 9, 2015, at 7:30 p.m. Resident 7 had just returned from her dialysis treatment when she fell . A review of Resident 7's Post Fall Assessment, dated October 9, 2015, indicated Resident 7's pain level was 8 out of 10 (on a rating scale of 0 to 10, with 0 as no pain and 10 as the most severe pain). A review of Resident 7's Physician Order, dated October 9, 2015, indicated an order for [REDACTED]. The X-ray results dated October 9, 2015, indicated Resident 7 had a fracture (broken) of the right proximal humerus (long bone of the arm). On December 6, 2016, at 3:43 p.m., during an interview, LVN 14 stated on October 9, 2015, he was accepting a report from the transportation staff, when he was called by one of the CNAs who informed him that Resident 7 fell from her bed. LVN 14 stated he did not see Resident 7 personally after she had returned from dialysis and before getting the report from the transport staff. LVN 14 stated one of the transport staff brought the resident directly to her room. LVN 14 stated he didn't recall what time Resident 7 arrived at the facility, or how long she was in her room alone, before her fall. On the same interview, LVN 14 stated when he accepts a resident coming from an outside appointment, he usually ensures that he or one of the facility staff would personally check the resident first before receiving a report. However, on that day, LVN 14 did not check Resident 7 first or tell any staff to check the resident. LVN 14 stated Resident 7's dialysis schedule was fixed and he knows the time range when Resident 7 comes back to the facility. LVN 14 did not give a reason why no staff from the facility supervised Resident 7 when she came back to the facility, even though she was a high risk for falls. LVN 14 stated if he would have checked the resident when she first arrived, as required, the fall could have been prevented. A review of the facility's revised policy, dated May 1, 2016, titled Hemodialysis Communication and Documentation, indicated upon return of the patient to the center, a licensed nurse will review the dialysis center communication, evaluate/observe the patient and document the evaluation. A review of Resident's 7 Post Fall Neurological Evaluation Flow sheet, dated October 10, 2015, to October 14, 2015, indicated a neurological assessment was not done on October 10, 2015 at 2:30 p.m. A review of Resident 7's care plan that was in place prior to her fall on October 9, 2015, indicated interventions that included utilization of low bed, placing the call light within reach at all times, assisting the resident with getting in and out of bed with one person assist, and utilization of a bed alarm and chair alarm to alert staff members of the resident's needs. The plan of care did not include interventions for staff to anticipate Resident 7's needs after dialysis, and in accordance with the policy, to prevent the fall on October 9, 2015. A review of Resident 7's SBAR (situation, background, assessment, recommendation) communication form, dated October 10, 2015, indicated there was a physician order [REDACTED]. A review of Resident 7's Nurses Notes, dated October 10, 2015, indicated Resident 7 came back from the GACH on October 10, 2015, at 7:30 p.m. with a splint on her right arm. A review of Resident 7's IDT notes, dated October 12, 2015, indicated Resident 7 just returned from her dialysis treatment. While the LVN 14 was accepting report from the transportation staff in the Nursing Station, one of the Certified Nursing Assistants (CNA) discovered Resident 7 in her room crying and lying on her right side on the floor near her bed. When the CNA entered Resident 7's room, the resident's bed was in a high position and the bed alarm was not clipped to the resident. The IDT team agreed licensed nurses required inservice to not receive report from the ambulance staff until the resident is checked, and making sure the bed alarm is connected and the bed is in the lowest position. On December 2, 2016, at 5:20 p.m., during an interview, LVN 4 stated if the receiving nurse or one of the facility staff had checked the resident first and connected the bed alarm as indicated in the care plan, the fall might have been prevented. On December 9, 2016, at 9:00 a.m., during an interview, Resident 7 stated that she cannot fully recall what happened when she fell last October 9, 2015. But she remembered that when she fell , she sustained a broken bone on her left arm. A review of Resident 7's Risk Management System, dated May 11, 2016, indicated Resident 7 had an unwitnessed (third) fall with injury on May 7, 2016, at 1:00 p.m. Resident 7 returned from her dialysis treatment and was left in front of the nurses station, unattended, and sitting in the wheel chair. A review of Resident 7's change in condition report, dated May 7, 2016, indicated she had fallen from her wheel chair sustaining a 2 by 2 centimeter bump on the right side of her forehead. Interventions included conducting a neurological assessment for 72 hours, pain assessment, and frequent visual monitoring. A review of Resident 7's care plan interventions that were in place on May 7, 2016, included the low bed, placing the call light within reach at all times, and assisting the resident getting in and out of bed with one person assist. The care plan had not been updated to include interventions for the continuity of care after Resident 7 returned from dialysis treatment, for the prevention of falls. A review of Resident's 7 Neurological Evaluation Flow sheet, dated May 7, 2016, to May 10, 2016, indicated the neurological assessment was to be conducted for 72 hours. The following dates and times for neurological assessment were not done: 1. May 7, 2016, at 8:00 p.m. 2. May 8, 2016, at 8:00 a.m. 3. May 8, 2016, at 3 - 11 p.m. shift 4. May 9, 2016, at 3 - 11 p.m. shift 5. May 10, 2016, at 7 - 3 p.m. shift 6. May 10, 2016, at 3 - 11 p.m. shift A review of the facility's policy titled Neurological Assessment, revised October 1, 2010, indicated a neurological assessment will be performed when a patient sustains an injury to the head and or has an unwitnessed fall. Neurological assessments will be performed every 30 minutes for 2 hours, then every one hour for 4 hours, then every 4 hours for 24 hours, then every shift. On December 2, 2016 at 5:20 p.m., during an interview, LVN 4 stated that the Licensed Nurses on duty are responsible for performing the neurological assessment. LVN 4 stated the blank in the Neurological Evaluation Flow sheet indicated that a licensed nurse did not do the assessment as required. On December 5, 2016, at 8:55 a.m., during an interview, CNA 5 stated CNAs who are assigned to residents who have appointments or dialysis schedules are aware of the time the resident is to be picked up and a rough estimate when the resident is coming back to the facility. CNA 5 stated that the CNAs see to it that they inform the charge nurse when the resident has returned from dialysis. On December 7, 2016, at 7:25 a.m., during an interview, LVN 13 stated that she was called by one of the CNAs informing her that Resident 7 fell from the wheel chair in front of Nursing Station 2. LVN 13 stated that she was working as a desk nurse at that time. LVN 13 was not aware the exact time Resident 7 returned to the facility because the transport staff did not give a report. LVN 13 stated that the transport staff should bring the resident to the nursing station and inform the charge nurse on duty. LVN 13 stated that CNAs will bring the resident back to his/her room and check the vital signs. On December 7, 2016, at 8:10 a.m., during an interview, the registered nurse (RN 7) stated that any facility nursing staff can receive a resident returning from an outside appointment. The CNAs are also responsible for checking on their assigned resident. RN 7 did not know why no staff from the facility received or knew when Resident 7 came back from her dialysis treatment. On December 8, 2016, at 7:20 a.m., during an interview, LVN 9 stated she was the charge nurse on duty on May 7, 2016. She stated she was expecting Resident 7 to be back at approximately 1 p.m. that day. However, she was busy giving medications to other residents when Resident 7 came back to the facility. LVN 9 was only made aware that Resident 7 came back from dialysis after a CNA reported finding the resident lying on the floor in front of the nurses station. On December 8, 2016, at 9:00 a.m., during an interview, the Director of Nursing (DON) stated Resident 7 was identified as being at a high risk for falls, and had three fall incidents. The DON stated Resident 7's care plan was not updated to reflect the current transportation group. The DON stated the current plan of care did not include Resident 7's continuity of care from the dialysis center to the facility, for the prevention of falls. On December 9, 2016, at 9:00 a.m., during an interview, Resident 7 stated on the day she fell (May 7, 2016), she was left alone in the hallway after she returned from the dialysis appointment. Resident 7 stated she did not know how long she was left alone in the hallway, but was feeling weak and hungry at that time. She stated she was calling for help; and the next thing she remembered was being on the floor and being helped by nurses. On December 9, 2016, at 8:30 a.m., during an interview, the Administrator (ADM) stated the facility had no contract with the transportation services. The ADM stated that the resident's insurance company was responsible for the arrangement of transportation for Resident 7. A review of facility policy titled Patient transportation and escort revised September 1, 2013, indicated that the purpose of the policy is to assure patient safety. The facility will contract for ambulance and other appropriate transportation services to provide transportation of patients for scheduled appointments as well as emergency. A review of the facility's revised Fall Management policy dated March 15, 2016, indicated to identify the patient's fall risk and communicate the fall risk status to care givers, develop an individualized plan of care, review and revise the care plan regularly, update the care plan to reflect new interventions, perform neurological assessment for all unwitnessed falls and witnessed falls with head injury. b. A review of the admission record indicated Resident 11 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of Resident 11's Fall Risk Review forms, from April 3, 2015, through December 9, 2015, indicated Resident 11 was at risk for falls. A review of Resident 11's Risk for Fall Care Plan, dated July 12, 2015, indicated a goal that the resident will minimize fall with injury for ninety days, implemented the same date. One of the interventions indicated was to utilize a low bed with landing pads (rubber mat placed by the bedside to minimize injury in the event of a fall). A review of Resident 11's Minimum Data Set, a comprehensive assessment and screening tool, dated November 3, 2016, indicated Resident 11 had severe impairment in cognitive skills for daily decision making; and required one person extensive assistance in transfers. During a room observation with the registered nurse (RN 5) during the initial tour on November 28, 2016, at 10:30 a.m., Resident 11 was lying in bed with one bed landing pad observed to the left side or the bed. There was no landing pad to the resident's right side of the bed. At that time, RN 5 stated she did not know why Resident 11 did not have a second landing pad, but should have landing pads on both sides of the bed. A review of the facility's undated Recommendations for Restraint Alternatives indicated to place bed at its lowest level and surround the bed with a soft mat. c. During a general observation of the facility with the Maintenance Supervisor, on December 1, 2016, at 9:30 a.m., an unsecured ladder was propped up against the roof in the small courtyard near the back kitchen door. There were three resident rooms that had sliding glass exit doors leading to the courtyard. When questioned the Maintenance Supervisor said the ladder should not be left against the building with no staff nearby who are using the ladder for roof access.

Based on observation, interview, and record review, the facility failed to ensure a resident, who had dysphagia (difficulty swallowing) and dementia (decline in memory), maintained acceptable parameters of body weight and [MEDICATION NAME] levels for one out of 24 sample residents (Resident 5), by failing to: 1. Continuously assess, monitor, and evaluate Resident 5's weight record, and inform the physician and/or Registered Dietitian (RD) for timely medical interventions when the resident experienced slow progressive weight loss. 2. Ensure Resident 5's plan of care was evaluated and revised to include interventions useful to prevent weight loss when the resident's intake did not meet the required caloric and protein needs. 3. Ensure Resident 5, who had meal intake of less than 75 percent (%), was offered and/or provided meal substitutes when she began to have a slow progressive weight loss, that led to a significant weight loss. 4. Ensure Resident 5, who had low [MEDICATION NAME] (main protein in blood plasma) levels, received high protein nourishment (HPN) as ordered by the physician, and the percentage consumed was monitored. 5. Ensure Resident 5 received all food items to meet her caloric and protein intake requirements as ordered by the physician. These deficient practices resulted in Resident 5's significant weight loss of 19 pounds (12.4 %) in six months. Findings: According to the admission record, Resident 5 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the Minimum Data Set (MDS - an assessment and care screening tool) dated July 4, 2016, indicated Resident 5 had severely impaired cognition, required extensive assistance with eating, was always incontinent of bowel and bladder, and had a height and weight of 59 inches and 150 pounds, respectively. A review of Resident 5's care plan goals for nutritional risk due to depression, [MEDICAL CONDITIONS] disorder (a mental illness), and difficulty swallowing, initiated on July 9, 2015, and revised on November 15, 2016, indicated the resident will consume greater than 75 percent of meals for 90 days, and will maintain a stabilized weight of 146 pounds to 156 pounds during the next 90 days. The interventions included to weigh monthly or as ordered, and alert the registered dietitian (RD) and physician to any significant weight loss or gain; monitor intake at all meals, offer alternate choices as needed, alert RD and physician to any decline in intake, provide a dysphagia pureed texture (for persons who have chewing or swallowing problems and may not safely handle a ground texture), consistent carbohydrate (aids in the preservation of the best possible blood glucose and lipid levels) nectar thick liquids (coats a spoon and falls in small droplets) diet, and house supplement of high protein nourishment (HPN) daily as ordered. A review of the RD's Nutritional assessment dated [DATE], indicated Resident 5 had no significant weight loss in the past six months. The assessment also indicated the resident consumed an average of 70 percent of meals which equal to approximately 1540 calories, and 63 grams of protein per day. Resident 5's estimated caloric needs were 1304 calories, 79 grams protein, and 1980 cubic centimeters (cc) fluids per day. The RD recommended increasing HPN to three times a day with meals to increase oral intake. On December 6, 2016 at 8:45 a.m., Certified Nursing Assistant 1 (CNA 1) was observed feeding Resident 5 at the bedside. CNA 1 stated the resident was able to self-feed but would make a mess on herself; that's why the resident was being fed. CNA 1 stated the resident consumed 60 percent of her breakfast tray. The resident's breakfast tray included puree pancake (consumed 30 %), puree sausage (consumed 100 %), oatmeal (consumed 20 %), four ounces of orange juice (consumed 100 %), and four ounces of High Protein Nourishment (consumed 0 %), eight ounces of milk (consumed 100 %), eight ounces of water (consumed 10 %) and another eight ounces of water from yesterday's evening snack (consumed 0 %). CNA 1 was not observed offering the HPN drink to the resident even though the meal consumption was less than 75 %. On December 6, 2016 at 9:30 a.m., during an interview, CNA 1 stated she did not offer the HPN because Resident 5 had pushed her hand away when she was giving her the milk. A review of the Medication Administration Record [REDACTED]. On December 6, 2016 at 3:45 p.m., during an interview, LVN 5 was asked if she verified with CNA 1 if Resident 5 consumed the HPN. LVN 5 stated she didn't, but she knew the HPN was on the tray. LVN 5 stated she should have verified with CNA 1 if Resident 5 consumed the HPN or not, and then documented in the progress note. A review of Resident 5's MAR for the month of October, November, and December 2016, indicated the volume of the HPN consumed by Resident 5 was not recorded. There were signatures of the staff members indicating they provided the HPN, but there was no entry to indicate how much of the HPN the resident actually consumed. On December 6, 2016 at 4:15 p.m., during an interview, LVN 4 stated that staff are not monitoring the percentage of HPN intake. On December 6, 2016 at 3:10 p.m., during an interview, the RD stated she should have updated Resident 5's care plan regarding the goals, and the interventions for the resident should be specific. The RD stated the stable goal weight should have been adjusted and the interventions such as the HPN should be changed to three times a day instead of daily, and the diet changed to dysphagia puree texture with nectar thick liquid without the consistent carbohydrate. A review of Resident 5's weight log indicated the following: 1. April 4, 2016 - 153 pounds (lbs.) 2. May 8, 2016 - 153 lbs. 3. June 6, 2016 - 150 lbs. 4. July 5, 2016 - 148 lbs 5. July 8, 2016 - 146 lbs. 6. July 15, 2016 - 144 lbs. 7. July 22, 2016 - 143 lbs. 8. July 29, 2016 - 144 lbs. 9. August 8, 2016 - 145 lbs. 10. September 8, 2016 - 142 lbs. 11. October 6, 2016 - 137 lbs. 12. October 12, 2016 - 137 lbs. 13. October 19, 2016 - 136 lbs. 14. October 26, 2016 - 135 lbs. 15. November 2, 2016 - 134 lbs. 16. November 9, 2016 - 137 lbs. 17. November 26, 2016 - 135 lbs. 18. December 3, 2016 - 134 lbs. Resident 5 had a 16 pound weight loss from 153 lbs. on April 4, 2016, to 137 lbs. on October 6, 2016, which is equivalent to a 10.4 % significant weight loss in the last six months. Resident 5 continued to lose an additional three pounds that resulted in further significant weight loss in November 2016. Resident 5 had a 19 pound weight loss from 153 lbs. on May 8, 2016, to 134 lbs. on November 2, 2016, which is equivalent to a 12.4 % significant weight loss in the last six months. According to the Centers for Medicare and Medicaid Services, suggested parameters for evaluating significance of unplanned and undesired weight loss are: Interval Significant Loss Severe Loss 1 month 5% Greater than 5% 3 months 7.5% Greater than 7.5% 6 months 10% Greater than 10% A review of the physician's orders [REDACTED]. The resident went from 148 lbs. on July 5, 2016, to 144 lbs. on July 29, 2016. There was no documented evidence the progressive weight loss was reported to the RD and to the physician as indicated in the care plans and the facility policies. On December 8, 2016 at 9:45 a.m., during interviews with the RD and Licensed Vocational Nurse 4 (LVN 4), LVN 4 stated he was aware of the order for weekly weights. LVN 4 stated he did not notify the RD or the physician of the progressive weight loss at the end of the four-week period. The RD stated she was not aware of the order for weekly weights. She stated she is the one who usually recommends the weekly weights to be done. Resident 5 had a physician's orders [REDACTED]. This was not ordered until 21 days after the RD's recommendation was made, and while Resident 5 had a slow progressive weight loss. On December 7, 2016 at 9:00 a.m., during an interview, the RD stated she would make recommendations and then licensed nurses would call the physician to get the order. On December 7, 2016 at 9:05 a.m., during an interview, LVN 4 was asked why it took so long to get a physician order [REDACTED]. A review of the RD's Nutritional assessment dated [DATE], indicated Resident 5 had a significant weight loss of 10.4 % in the last six months. The RD recommended liberalizing the diet to promote oral intake and to gain weight, and snacks twice a day at 2:00 p.m. and 8:00 p.m. The assessment indicated the resident had a low [MEDICATION NAME] level of 2.5, and was receiving HPN. The resident's estimated caloric needs were 1251 calories, 77 grams protein, and fluid of 1860 cc per day. A review of Resident 5's physician's orders [REDACTED]. A review of the Diagnostic Laboratories and Radiology report indicate the following: 1. On October 4, 2016, a low [MEDICATION NAME] level of 2.5 gram per deciliter (g/dl) (reference range 3.5-5.7 g/dl) and a low total protein level of 5.4 g/dl (reference range 6.4-8.9 g/dl) 2. On November 9, 2016, a low [MEDICATION NAME] level of 2.9 g/dl and a low total protein level of 5.9 g/dl. 3. On December 8, 2016, a low [MEDICATION NAME] level of 2.8 g/dl. A review of the Activity of Daily Living (ADL) Record for October, 2016, indicated the following: 1. The ADL Record did not indicate snacks were provided at 2:00 p.m. 2. On October 12-17, 27, 2016, the resident refused bedtime snacks. 3. On October 19, 20, 26, 2016, the resident accepted the bedtime snacks but consumed less than 75 percent (50 percent, 50 percent, and 70 percent, respectively). 4. On October 18, 21-25, 28, 31, 2016, were documented with a dash. 5. On October 29, 2016, the resident accepted the bedtime snack but there was no documentation of how much was consumed. A review of the ADL Record for November, 2016, indicated the following: 1. Resident accepted the bedtime snack on November 2, 2016 and consumed 30 percent. 2. On November 1, 3-6, 14, 2016, the resident refused the bedtime snack. 3. On November 7-13 and 15-30 were documented with a dash. A review of the ADL Record for December, 2016, indicated the following: 1. On December 1-4, 6, 7, 2016 were documented with a dash. 2. On December 5, 2016, the resident refused bedtime snack. 3. On December 8, 2016, the resident accepted the bedtime snack and consumed 100 percent. On December 9, 2016 at 9:15 a.m., during an interview, LVN 4 stated he did not know what the dash in the documentation meant. The code to document the bedtime snack did not include a dash. LVN 4 stated if it was not documented, then it was not done. The bedtime snacks should have been given to the resident and documented accordingly. On December 9, 2016 at 9:20 a.m., during an interview, the RD stated one bedtime snack of pudding, had approximately six grams of protein. When the bedtime snacks were not given, Resident 5's protein intake of the recommended 77 grams per day, were not met. A review of the Interdisciplinary Team (IDT) notes for weight variance dated October 7, 2016, indicated Resident 5 had an actual weight loss of 16 pounds for the last six months, a 10.5% significant weight loss. The IDT recommendations included to follow up with the RD and Dietary Supervisor (DS) for room visits regarding meal preferences. On December 6, 2016 at 3:30 p.m., during an interview, the DS stated he would generally see a resident on admission and when recommended by the physician, RD, or nursing staffs' request to find out about the resident's food preferences. When asked about Resident 5, the DS stated he was not aware the resident was having slow progressive weight loss, and could not recall when he had last seen Resident 5. On December 8, 2016 at 9:50 a.m., during an interview regarding how staff get information from the weight variance committee regarding Resident 5's significant weight loss, LVN 4 stated he would inform the assigned charge nurse and the assigned certified nursing assistant regarding the weight changes. A review of Resident 5's progress notes from May 6, 2016 through December 5, 2016, indicated there was no documented evidence that the LVNs were aware of Resident 5's significant weight loss. On December 8, 2016 at 10:05 a.m., during a follow-up interview, LVN 4 stated he was unable to locate documented evidence that the LVNs were aware of Resident 5's significant weight loss. On December 8, 2016 at 11:00 a.m., during an interview, LVN 5 stated she could not recall if LVN 4 or the RD had informed her of Resident 5's significant weight loss. On December 8, 2016 at 12:20 p.m., during a lunch observation, the Restorative Nursing Assistant 1 (RNA 1) was feeding Resident 5 in the dining room. The lunch tray included puree carrot, puree tuna sandwich, four ounces of juice, four ounces of milk, and eight ounces of water. A review of Resident 5's meal card dated December 8, 2016, indicated she was to receive one cup of milk, one HPN drink, half cup of juice, and one cup of water. When RNA 1 was asked about the half cup of milk received instead of the one cup of milk that was indicated on the meal card, RNA 1 stated the milk should have been eight ounces which would be one cup. RNA 1, and RNA 2 who was also in the dining room, both stated they did not know what HPN drink was. RNA 1 was asked if the lunch tray was checked prior to serving to resident, RNA 1 stated she did check and thought the tray was complete; RNA 1 stated the licensed nurses usually checked the lunch cart before it got distributed. On December 8, 2016, at 12:35 p.m., during an interview, the RD stated RNAs should have known what HPN drink was and the difference between half a cup and one cup beverages. On December 8, 2016 at 12:40 p.m., during an interview, Dietary Aid stated that she checked all the trays in the cart before it comes out of the kitchen; she stated she missed the HPN, and the milk should have been eight ounces. On December 8, 2016 at 12:45 p.m., during an interview, LVN 6, one of the licensed nurses responsible for checking the trays prior to sending the cart out to be distributed, stated he checked the trays but could not remember if Resident 5's tray was missing the HPN, or had the wrong cup size of milk or not. On December 8, 2016 at 1:00 p.m., during an interview the Administrator stated Resident 5's tray should have been checked prior to serving to make sure every item on the meal card is on the tray. The Administrator stated the RNAs should have known what HPN was and the differences in the sizes of the cups and how much volume it contains. On December 8, 2016 at 2:00 p.m., during an interview of another treatment nurse that checked the trays, RN 6 stated he checked each tray on the cart, but did not recall if the trays were missing any items. A review of Resident 5's care plan for nutritional risk, initiated on July 9, 2015, and revised on November 15, 2016, indicated it was not revised to include the HPN three times a day on July 13, 2016, to meet the resident's protein needs. The care plan also was not revised to include the resident's actual weight loss on October 6, 2016, or November 2, 2016. A review of the facility's revised November 30, 2015, policy and procedure titled, Weights and Heights, indicated the licensed nurse will notify the physician and dietitian of significant weight changes and document notification of physician and dietitian in the Weight Change Progress Note. A review of the facility's revised November 28, 2016, policy and procedure titled, Food Preferences, indicated the Director of Dining Services update the food preferences at a minimum of quarterly. A review of the facility's revised January 2, 2014, policy and procedure titled, Care Plans, indicated the comprehensive care plan is reviewed and revised a minimum of quarterly and as needed to reflect response to care and changing needs and goals. The care plan must be customized to each individual patient's needs.