Every finding on record at York Healthcare & Wellness Centre

Based on observation , interview, and record review, the facility failed to provide adequate assistance and supervision to prevent a fall for one of three sampled residents ( Resident 1), who was identified as being at risk for falls and assessed as requiring moderate to maximum assistance with lower- body dressing. This deficient practice resulted in Resident 1 falling and sustaining a right - sided occipital condyle fracture ( right sided break of the bone at the lower right side of skull, connecting to the neck/ spine) and placed other residents with similar assistance needs at risk for falls and injury. FINDINGS: During a review of Resident 1's admission Record (AR), the AR indicated Resident 1 was admitted to facility on 6/15/ 2026 with a diagnosis to include a history of falling, muscle weakness, and fracture (break) of shaft of right tibia (long, middle portion of the right shinbone). During a review of Resident 1's History and Physical (H&P) dated 6/17/2026, the H&P indicated Resident 1 had the capacity to make medical decisions. During a review of Resident 1's Minimum Data Set ( MDS- a resident assessment tool) dated 6/22/2026, the MDS indicated Resident 1 was assessed to be cognitively intact (able to understand information and communicate their needs). The MDS indicated Resident 1 required a walker and wheelchair for mobility. The MDS indicated Resident required lower - body dressing, putting on/ taking off footwear, and sit-to-stand. The MDS indicated that Resident 1 required substantial/ maximal assistance for Activity of daily living (ADL) which involved bending or stooping from a standing position. During a review of Resident 1's care plans titled Resident 1 had activities of Daily Living (ADL) of self - care performance deficit dated 6/15/2026, the care plan indicated Resident 1 required substantial assistance with lower-body dressing, putting on and taking off footwear, and moving from lying to sitting on the side of the bed. The care plan further indicated Resident 1 was unable to pick up objects or negotiate a one-step curb and required substantial assistance with transfers due to weight-bearing limitations. During a review of Resident 1's care plan titled Resident 1 is at Risk for Falls, initiated on 6/15/2026 and revised on 8/18/2026, the care plan indicated Resident 1 was at risk for falls related to impaired mobility and gait, preference for independence with ADL's and medication use. The care plan further indicated that following a fall on 8/14/2026, Resident 1 received a fall risk evaluation score of 18 (10 or greater is considered high risk for potential falls). During a review of Resident 1's emergency department (ED) records dated 8/14/2026 at 12:33PM, the record indicated Resident 1 presented to the ED following a trauma. The ED records indicated that a computed tomography (CT imaging test that uses x-rays and computer technology to create detailed images of the inside of body) scan of the cervical spine (neck portion of spine) without contrast results indicated an acute fracture of the medial right occipital condyle (round bone at the base of the skull where the skull connects to the upper neck) with a 5 - millimeter (mm - unit of measurement) displaced (out of place) bone fragment. The ED records indicated that Resident 1 had an Magnetic Resonance imaging (MRI imaging test that uses a strong magnetic field to create detailed images of the body's internal structures) of the cervical (spine near neck) spine without contrast (substance used for imaging) results indicated a suspected avulsion fracture (a fracture or piece of bone that is pulled away from the main bone) of the right occipital condyle. The ED records further indicated that Resident 1 had a CT scan of the brain which had indicated a left frontal scalp soft - tissue swelling. During a review of Resident 1's Point of Care (POC) Response History for Lower Body Dressing, dated 9/2/2026 through 8/31/2026, the POC indicated that Resident 1 required varying levels of staff assistance with lower-body dressing, including partial/moderate assistance, substantial/maximal assistance, and dependent assistance. During a review of Resident 1's Change in Condition Evaluation (COC - any noticeable shift in a person's physical, mental, or behavioral health compared to their normal baseline), dated 8/14/2026 at 11:20 AM, the COC indicated that restorative nursing assistant (RNA) 1 heard a commotion after RNA 1 left Resident 1 behind a privacy curtain so Resident 1 could change clothes. RNA 1 found Resident 1 seated on the floor with redness and approximately 1-inch (unit of measurement) by 1-inch swelling to the forehead. The COC indicated the physician was notified and ordered Resident 1 to be transferred to the emergency room for further evaluation. During a review of Resident 1's Order Summary Report dated 8/14/2026, the Report indicated an order to transfer Resident 1 to the emergency room for evaluation after the fall on 8/14/2026. During a review of Resident 1's Medication Administration Record (MAR) for August 2026, the MAR indicated an order for Tylenol (over-the-counter pain reliever and fever reducer) 325 milligram (mg - unit of measurement), two tablets by mouth every six hours as needed for pain. The MAR indicated Resident 1 was administered Tylenol 325mg on 8/17/2026, 8/20/2026 for a pain level of 3, 8/21/2026 MAR indicated Not applicable, and 8/25/2026 for a pain level of 4. During a review of Resident 1's Occupation al Therapy (OT) Discharge summary dated [DATE] , the Discharge Summary indicated that Resident 1 required partial/moderate assistance with lower-body dressing, toilet transfers, bathing, toileting hygiene and was identified as a fall risk. During a review of Resident 1's Physical Therapy Discharge summary, dated [DATE], the Discharge Summary indicated that Resident 1 had generalized muscle weaknesses and required partial/moderate assistance with sit-to-stand and chair/bed-to-chair transfers. During a review of Resident 1's PT Discharge summary dated [DATE], the record indicated Resident 1 was non - weight bearing to the left lower extremity and required partial / moderate assistance for sit - to - stand and chair/ bed - to chair transfers. The Summary indicated a restorative transfer program was established for sit - to - stand using a front - wheeled walker. During a review of Resident 1's Fall Risk Evaluation dated 6/15/206, the Evaluation indicated Resident 1 was assessed as high risk for falls. The Evaluation indicated Resident 1 had balance problems while standing and while walking and required the use of an assistive device. The Evaluation indicated a recent hospitalization related to right side weakness. The Evaluation indicated a goal for Resident 1 to remain free from falls and included interventions to assist Resident 1 with ambulation and transfers utilizing therapy recommendations, determine the resident's ability to transfer, and evaluate the resident's fall risk upon admission and as needed. During a review of the facility's Interview Record dated 8/14/2026 , the Record indicated that the reason for the interview was post - fall. The interview was conducted by Registered Nurse (RN1) with Resident 1 regarding the circumstances surrounding her fall. The Record further indicated Resident 1 was transferred to the hospital following the fall. The Record finding indicated that Resident 1 stated she had requested privacy from RNA 1, so RNA 1 left Resident 1 unattended and stepped away behind the curtain. While the RNA 1 was behind the curtain, Resident 1 During a concurrent observation and interview on 8/31/2026 at 10:58 AM with Resident 1 , Resident 1 was observed seated in wheelchair adjacent to her room wearing a cervical collar/ neck brace. Resident 1 was observed with blackish, dark purple discoloration and bruising beneath Resident 1's right eye, upper cheek area and mid forehead above the left eyebrow. Resident 1 stated at the time of fall, she attempted to dress herself which included placing on her adult briefs, sweatpants, and shoes. Resident 1 stated the wheelchair was positioned at the end of the bed. Resident 1 stated she asked RNA 1 to leave while she dressed. Resident 1 stated that while attempting to dress and retrieve her shoes, she stood from the bed, leaned forward, and fell forward. Resident 1 stated she fell headfirst, striking the left upper forehead, and described the pain at the time of the fall as being 8 out of 10 on a pain scale (numbers from 0 (no pain) to 10 (worst possible pain) for patients to rate their discomfort/pain). Resident 1 stated that RNA 1 came from behind the curtain following the fall and , with assistance from another staff member, helped her into the wheelchair. Resident 1 stated prior to fall, staff had instructed her to request and wait for assistance with dressing and putting on her shoes. During an interview on 8/31/2026 at 11:27 AM with RNA 1, RNA 1 stated that he entered Resident 1's room to provide sit - stand exercises. Upon entering, Resident 1 stated that she did not have pants on and asked him to hand her pants so she could dress. Resident 1 asked that RNA 1 remained on the other side of the curtain. RNA 1 stated he did not offer Resident 1 assistance with putting on her brief, pants, or shoes because Resident 1 was alert and had asked him to step behind the curtain. RNA 1 stated approximately one minute later, he heard Resident 1 fall, stating he pulled back the curtain and observed Resident 1 on the floor, on her knees with her head on the floor. RN1 stated he called for assistance. Another staff member responded and assisted him with placing Resident 1 back into the wheelchair. RNA 1 stated shortly after Resident 1 was taken to the emergency room (ER) at the general acute care hospital (GACH). RNA 1 stated that when he is assigned to work with residents, the physical therapist informs him of the resident's level of care. However, RNA 1 stated he knew Resident 1 required assistance because he used a gait belt (a safety device used by caregivers and medical staff to help support, stabilize, and guide people who have trouble walking or moving) when assisting Resident 1. RNA 1 also stated he knew Resident 1 had balance problems and required assistance. During a concurrent interview and record review on 8/31/ 2026 at 11:45 AM with Director of Rehabilitation ( DOR) , Resident 1's Occupational Therapy (OT) Discharge summary dated [DATE]/2026 was reviewed. The OT Discharge summary indicated lower body dressing required partial/ moderate assistance . DOR stated rehabilitation staff instruct RNAs regarding residents 'safety precautions and required levels of assistance. The DOR stated that Resident 1 required assistance with standing and lower - body dressing, including putting on her brief. The DOR stated Resident 1 was not to stand independently and should not dress unsupervised. The DOR further stated Resident 1 required minimum to moderate assistance of one person for sit - to - stand. The DOR stated that Resident 1 was toe - touch weight bearing ( without putting any body weight through that leg) on the right lower extremity, due to residual right - sided weakness and a history of fracture, having balance problems. The DOR stated Resident 1 required assistance while preforming lower - body dressing while in bed and could not put on her pant by self. The DOR stated RNA were trained to perform sit - stand - exercises and should have called a CNA to provide the resident with the required assistance with dressing. The DOR further stated RNAs are educated regarding resident safety precautions and required levels of assistance and are required to perform a return demonstration. During a concurrent interview and record review on 8/31/2026 with Director of Nursing (DON) , Resident 1's fall risk assessment dated [DATE] and MDS dated [DATE] was reviewed. The Fall Risk Assessment indicated Resident 1 was assessed as high risk for potential fall and prevention protocol should be initiated immediately and documented on the care plan. The MDS indicated Resident 1 required maximum assist with lower body dressing. DON stated Resident 1 required assistance and utilized a wheelchair and sliding board for mobility, transfers and further stated according to MDS walking was not attempted due to the resident's right - sided weakness. The DON stated although the resident requested privacy, Resident 1 was at risk for falls and required assistance based on Resident 1's assessed needs and care plan. During an interview on 8/31/2026 at 1:34 PM with Resident 1, Resident 1 stated she continued to experience pain and was taking Tylenol approximately once or twice daily for pain relief. During an interview on 8/31/2026 at 2 PM with DON, DON stated RNA 1 should have helped Resident 1 with dressing since Resident 1 required maximum assistance. The DON stated Resident 1 should not have been dressing herself without assistance. During an interview on 8/31/2026 at 2:12 PM with the Administrator ( ADM) , ADM stated that Resident 1's fall occurred on 8/14/2026 at approximately 11:20 AM. The ADM stated that the facility's investigation included interview with Resident 1 and RNA1 . ADM stated the facility determined the fall was unavoidable because Resident 1 was alert and oriented. ADM acknowledged that Resident 1 was identified as a high fall risk due to a previous fall at home and had an ADLs deficit . The ADM stated that while Resident 1 had a right to privacy because she was alert, she should have been offered assistance with dressing. During a review of the facility's policy and procedure (P&P) titled, Activities of Daily living, dated 6/9/2026, indicated that ADL care would be provided based on the resident's needs. The policy identified dressing as an activity of daily living and identified levels of assistance, Partial/ moderate assistance, substantial maximal assistance, and dependent assistance. The policy further indicated that assistance would be provided based on the resident needs, staff would encourage residents to perform ADLs to the highest level of their ability, and ADL assistance would be documented.

Based on interviews and record reviews, the facility failed to follow its policy and procedure titled, Resident Rights by not honoring Resident 1's right to an overnight out-on-pass (OOP, a resident is temporarily permitted to leave a healthcare facility for a short, approved period of time) request for 7/7/2026 and 7/8/2026 to grieve the loss of a family member and attend the funeral and burial. The facility failed to:Based on interviews and record reviews, the facility failed to promote Resident Rights for one for two sampled residents (Resident 10) by not honoring Resident 1's right to an overnight out-on-pass (OOP, a resident is temporarily permitted to leave a healthcare facility for a short, approved period of time) request from 7/7/2026 to 7/8/2026 to grieve the loss of a family member and attend the funeral and burial in accordance with facility Polocy and Procedure (P&P) titled, Resident Rights, by failing to: Ensure the Director of Nursing (DON) investigated and obtained clinical evidence to verify the alleged fall and claimed drug overdose during Resident 1's OOP in 2025 before refusing the resident's overnight OOP request. 2. Ensure Resident 1's physician, the DON and the interdisciplinary team (IDT, a collaborative gathering where professionals from different departments or specialties meet to coordinate care) assessed Resident 1, identified, and informed Resident 1 about safety risks and alternative measures before refusing the resident's overnight OOP request. 3. Ensure Resident 1's physician, the Administrator (ADM), and the DON did not impose personal opinions related to liability or control over where the resident should stay, overriding the resident's expressed wishes to grieve overnight with her family. These deficient practices resulted in Resident 1 not being able to exercise her rights, unable to attend her family members' burial and prevented her from spending the night with her family grieving with her loved ones as she had requested.Findings: During a review of Resident 1's admission Record (AR), the AR indicated the facility originally admitted Resident 1 on 4/12/2025 and readmitted her on 11/23/2025 with diagnoses that included acquired absence of right leg below knee (surgically remove a leg below the knee) and type II diabetes mellitus (a condition that happens when your blood sugar is too high). During a review of Resident 1's Physician History & Physical (H&P), the H&P indicated Resident 1 can participate in plan of care. During a review of Resident 1's admission package titled, California Standard admission Agreement for Skilled Nursing Facilities and Intermediate Care Facilities, dated 4/12/2025, the record indicated the following information:a. The California Standard admission Agreement is an admission contract that the facility is required to use by state law and regulation. It is a legally binding agreement that defines the rights and obligations of each person (or party) signing the contract.b. Residents of the facility keep all their basic rights and liberties as a citizen or resident of the United States when, and after, they admitted . Because these rights are so important, both federal and state laws and regulations describe them in detail, and state law requires that a comprehensive Resident [NAME] of Rights be attached to this agreement.c. Attachment F, entitled Resident [NAME] of Rights, lists the resident's rights, as set forth in State and Federal law.d. Violations of state laws and regulations identified above may subject the facility and the staff to civil or criminal proceedings.e. Attachment F Resident [NAME] of Rights was provided to Resident 1 on 4/12/2025. During a review of the facility's Attachment F Resident [NAME] of Rights, the attachment indicated Patients have the rights enumerated in this section and the facility shall ensure that these rights are not violated. Patients shall have the right: a. to be transferred or discharged only for medical reasons, or the patient's welfare or that of other patients or for nonpayment for his or her stay and to be given reasonable advance notice to ensure orderly transfer or discharge. Such actions shall be documented in the patient's health record. b. to be treated with consideration, respect and full recognition of dignity and individuality, including privacy in treatment and in care for personal needs. c. to meet with others and participate in activities of social, religious and community groups.The Resident [NAME] of Rights indicated patient's rights, as set forth above, may only be denied or limited if such denial or limitation is otherwise authorized by law. Reasons for denial or limitation of such rights shall be documented in the patient's health record. During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 4/13/2026, the MDS indicated Resident 1 had intact memory and cognition (ability to think and reason). The MDS indicated Resident 1 was independent with eating, oral hygiene and personal hygiene, and required setup or clean-up assistance with toileting hygiene, shower/bathe self and chair/bed-to-chair transfer. During a review of Resident 1's Progress Notes (PN), dated 7/4/2026, the PN indicated on 7/4/2026, Resident 1 requested for an overnight OOP from 7/7/2026 to 7/8/2026 to attend her niece's viewing and funeral. The PN indicated the request was reported to Resident 1's physician with response that Resident 1 may go OOP if the ADM approved. During a review of Resident 1' PN, dated from 7/4/2026 to 7/8/2026, the PN indicated there was no documented evidence from Resident 1's physician indicating that the resident had been assessed and found medically unstable or unable to be OOP overnight. There was no documentation providing any clinical reason for denying Resident 1 an overnight pass. During an interview on 7/21/2026 at 9:50 AM in Resident 1's room, Resident 1 stated that she requested an overnight pass from 7/7/2026 to 7/8/2026 so she could stay with her son and attend her niece's funeral and burial. Resident 1 stated, the Administrator (ADM) denied her request, citing a fall she had during an OOP last year and that she had overdosed on fentanyl (powerful opioid [pain medication]), which Resident 1 stated she had only received the medication in the hospital. Resident 1 stated that when she asked for proof of the alleged fentanyl misuse, the ADM changed the reason to her Medi-Cal coverage, saying that Medi-Cal would not pay for an overnight leave. Resident 1 stated that after she filed a complaint, the Ombudsman (OMB) came and informed the ADM that Resident 1 had the right to leave the facility for a few days, but the ADM then threatened to discharge Resident 1 if Resident 1 stayed overnight during her OOP. The ADM stated that Resident 1 would not be allowed to return. Resident 1 stated, she attended the funeral but was unable to attend the burial. Resident 1 stated she was emotionally distressed, and unable to grieve fully with her loved ones overnight. During a concurrent interview and record review on 7/21/2026 at 11 AM with the MDS Nurse (MSDN), Resident 1's medical record from 7/4/2026 to 7/8/2026 was reviewed. The MSDN stated according to Resident 1's medical record, Resident 1 requested an overnight pass from 7/7/2026 to 7/8/2026 on 7/4/2026, but there was no follow up on the request or an IDT meeting conducted to determine whether the pass could be granted until 7/13/2026, which was after the requested dates had already passed. The MSDN added that the delay may have occurred because the team was out during the holiday period and the weekend and confirmed that the request should have been addressed earlier. During an interview on 7/21/2026 at 11:15 AM with the DON, the DON stated that Resident 1 had requested an overnight pass, but the facility only issued a daily 4 hour pass since Resident 1 previously experienced a fall during an OOP in 2025, along with a possible drug overdose. The DON stated medical records would need to be requested from the General Acute Care Hospital (GACH) when asked for documented evidence of Resident 1's alleged drug overdose. During an interview on 7/21/2026 at 11:30 AM with Registered Nurse (RN) 1, RN 1 stated Resident 1 has always been independent and very compliant while OOP. During an interview on 7/21/2026 at 12 PM with Licensed Vocational Nurse (LVN) 2, LVN 2 stated Resident 1 came to LVN 2 to request an overnight OOP, so LVN 2 reported the request to the RN supervisor and was told that Resident 1's physician was ok with overnight pass but only if the ADM approved it. During a telephone interview on 7/21/2026 at 12:15 PM, the ADM stated she denied Resident 1's overnight pass because she believed it was not safe for the resident to stay outside the facility overnight. The ADM stated she did not need to contact Medi-Cal for approval and stated that granting an overnight pass was a 'liability.' The ADM stated when the OMB came and informed her that Resident 1 had the right to leave the facility overnight, the ADM told the OMB that she would discharge Resident 1 and not allow Resident 1 to return to the facility if Resident 1 chose to stay overnight from 7/7/2026 to 7/8/2026. During an interview on 7/21/2026 at 2:45 PM with Resident 1's physician, the physician stated he does not allow his patients to be out overnight in general because they would be away from the facility for too many hours. The physician stated he felt he would be responsible if anything happened to the resident. The physician stated he preferred to maintain control over his patients, and he was concerned about liability. Resident 1's physician further stated, Resident 1 was medically stable and that the physician's decision was based not on Resident 1's condition but on his own legal and moral concerns. During a telephone interview on 7/21/2026 at 3:45 PM with the ADM, the ADM stated the facility granted Resident 1 only daily OOP on 7/7/2026 and 7/8/2026 because she was just following the doctor's orders. The ADM stated she did not speak with the physician to clarify why the overnight OOP was denied and stated, the doctor just didn't want to do it, so we cannot grant her an overnight pass. During an interview on 7/21/2026 at 4:15 PM, the DON stated she had no evidence to support concerns of a fentanyl overdose and could not locate any hospital records or laboratory result to confirm an incident that Resident 1 sustained during an OOP last year. The DON stated, she did not know why Resident 1 fell during her OOP in 2025. The DON stated that although Resident 1 requested to stay overnight with her son on 7/7/2026 so she could grieve with her family, the DON believed that Resident 1 did not need to stay overnight because the son lived close to the facility. During a review of the facility's policy and procedures (P&P) titled, Resident Rights, revised 2012, the P&P indicated Residents of skilled nursing facilities have a number of rights under state and federal law. The facility will promote and protect those rights. Residents have freedom of choice, as much as possible, about how they wish to live their everyday lives and receive care, subject to the facility's rules and regulations and applicable state and federal laws governing the protection of resident health and safety. Employees are to treat all residents with kindness, respect, and dignity and honor the exercise of resident's rights. The P&P indicated State and federal laws guarantee certain basic rights to all residents of the facility. These rights include, but are not limited to, a resident's right to a. Be informed about what rights and responsibilities he or she has, b. Visit and be visited by others from outside the facility.

Based on observation, interview and record review, the facility failed to implement a resident centered care plan for one of three sampled residents (Resident 1) who sustained a fall while out of the facility during an out on pass (OOP an admitted patient has official, temporary permission from their doctor to leave a hospital or care facility for a short period) on 11/21/2025, and failed to ensure an Interdisciplinary Team (IDT) meeting was held to identify and investigate the reason for Resident 1's fall, in order to provide adequate care and services to Resident 1. This deficient practice resulted in Resident 1 not being assessed appropriately after sustaining a fall on 11/21/2025 while out of the facility and prevented Resident 1 from being permitted to obtain an OOP for two days, 7/7/2026 to 7/8/2026 to attend a funeral. Findings:During a review of Resident 1's Face Sheet (FS), the FS indicated the facility originally admitted Resident 1 on 4/12/2025 and readmitted her on 11/23/2025 with diagnoses that included acquired absence of right leg below knee (surgically remove a leg below the knee) and type II diabetes mellitus (a condition that happens when your blood sugar is too high). During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 4/13/2026, indicated Resident 1 had intact memory and cognition (ability to think and reason). The MDS indicated Resident 1 was independent with eating, oral hygiene and personal hygiene, and required setup or clean-up assistance with toileting hygiene, shower/bathe self and chair/bed-to-chair transfer. During a review of Resident 1's Physician Telephone Orders, dated 7/7/2026, the order indicated physician ordered Resident 1 may go OOP on 7/7/2026 and 7/8/2026. During a review of Resident 1's Quarterly Multidisciplinary Care Conference (IDT meeting), dated 7/9/2026, the IDT note indicated Resident 1 must request an OOP order, since Resident 1 sustained a fall during her last OOP, which caused increased pain and decline in function for Resident 1. The Note indicated no overnight or multiple night passes given at this time. During a telephone interview on 7/10/2026 at 5:12 PM with Resident 1, Resident 1 stated she requested a daytime and an overnight OOP for 7/7/2026 and 7/8/2026 on 7/4/2026 to attend a two-day funeral service for a family member. Resident 1 stated she did not have transportation on 7/8/2026 from the facility to the funeral service location, so she requested the overnight OOP to stay over at a family member's house. Resident 1 stated she spoke to the Administrator (ADM) on 7/6/2026 and the ADM told her she could not go on an overnight OOP because her insurance would not pay for it. The ADM then stated to Resident 1 could not be granted an overnight stay since Resident 1 sustained a fall during OOP last 11/2025. Resident 1 stated the ADM told Resident 1 that Resident 1 could go on a daytime OOP on 7/7/2026 and 7/8/2026 but could not stay outside of the facility overnight. Resident 1 stated the ADM said if she did not return to the facility before midnight on 7/7/2026, the facility would discharge Resident 1 as against medical advice (AMA a situation where a patient chooses to leave a hospital or decline a recommended treatment before their healthcare provider officially sanctions it). Resident 1 stated she contacted her insurance company, and the insurance representative said the insurance would cover her one overnight OOP. Resident 1 stated the facility did not ask or investigate how she fell during her OOP last November. Resident 1 stated she did not think the fall during her OOP last November was the reason for the facility not approving her request for the overnight OOP because she had been approved for the daytime OOP since 1/2026 and Resident 1 did not have any accident for the past 6 months. Resident 1 stated she felt she was forced to agree to return to the facility on 7/7/2026 because the facility would discharge her and she did not have a place to go. Resident 1 stated she could not attend the funeral service on 7/8/2026, which made her sad. During an interview on 7/10/2026 at 3:04 PM with the Director of Nursing (DON), the DON stated she was aware that Resident 1 and the ADM had a meeting on 7/6/2026 to discuss the overnight OOP, but the DON was not part of the meeting and she was not sure if Resident 1 agreed with the result that she could not get the overnight OOP for 7/7/2026. During an interview on 7/10/2026 at 3:45 PM with ADM, ADM stated she had a conversation with Resident 1 but did not conduct an IDT meeting regarding her request for the overnight OOP prior to the event. The ADM stated she informed Resident 1 that there was a risk that her insurance would not cover her overnight OOP, therefore the physician ordered only the daytime OOP on 7/7/2026 and 7/8/2026. The ADM stated Resident 1 was at risk for fall due to her alleged fall during Resident 1's last OOP last 11/2025. The ADM stated the facility would discharge Resident 1 AMA if Resident 1 did not return on 7/7/2026. because she left the facility AMA. The ADM stated Resident 1 verbally agreed with the daytime OOP on 7/7/2026 and 7/8/2026 during the 7/6/2026 after the conversation. The ADM stated she did not document this conversation in Resident 1's Medical Record. During a concurrent interview and record review on 7/10/2026 at 4:17 PM with the DON, Resident 1's medical records were reviewed. The DON stated Resident 1's Interdisciplinary Team (IDT) Note in the Progress Notes, dated 11/24/2025 time 10:13 AM, indicated the facility received a report from a General Acute Care Hospital (GACH) that Resident 1 was admitted to the GACH from 11/20/2025 to 11/21/2025 with a complaint of back pain due to a fall backward from the wheelchair at home. The DON stated there was no other documentation that indicated any details of how Resident 1 fell during her daytime OOP at that time. The DON stated she did not know how Resident 1 fell during her OOP and the facility staff did not investigate the fall. During a concurrent observation and interview on 7/13/2026 at 11:53 AM with Resident 1, Resident 1 was sitting on a wheelchair in her room with a prosthesis at right leg. Resident 1 stated it was hard for her to find transportation to attend the second day service and the ADM kept telling her different reasons that she could not get the overnight OOP, but there was no document or evidence to reject her request. During a concurrent interview and record review on 7/13/2026 at 2:45 PM with the ADM, Resident 1's medical record was reviewed. The AMD stated Resident 1 was not approved for the one night overnight OOP on 7/7/2026, due to the fall Resident 1 sustained 11/2025 while on OOP. The ADM did not know the details of how Resident 1 fell an there was not documentation of the facility investigating the cause of Resident 1's fall during her OOP. The ADM stated the facility did not conduct an IDT meeting to address Resident 1's request for the overnight OOP before the event. During a review of the facility's policy and procedure (P&P) titled, Person-Centered Care Planning, dated 5/22/2025, the P&P indicated the facility focuses on the resident as the center of control and supports each resident in making his or her own choices. The P&P indicated Person-centered care includes making an effort to understand what is important to each resident with regard to daily routines and preferred activities and having an understanding of the resident's life before coming to reside in nursing facility. The P&P indicated care planning was prepared by IDT and the care planning meeting will be documented in the resident's clinical record.

Based on observations, interviews, and record review, the facility failed to maintain safe food storage by keeping multiple expired food items (use-by date) in the dry storage and the refrigerator. The deficient practices increased the risk of residents being served unsafe or spoiled food.During a concurrent observation and interview on 7/21/2026 at 4:30 PM with the Dietary Supervisor (DS), the following items were observed in the dry storage area and the refrigerator:Four bags of assorted citrus Jello's labeled with a use by date of 7/10/2026 in the storage room.One bottle of rice vinegar labeled with an opened date of 2/12/2026 and with the manufacture use by date of 7/9/2026 in the storage room.One bottle of rice vinegar labeled with an opened date of 5/15/2026 and with use by date of 7/15/2026 in the storage room.One bottle of light amber honey labeled with an opened date of 1/19/2026 and with a use by date of 7/19/2026.One container of leftover ham labeled as Turkey Breast dated 7/18/2026 with a use by date of 7/20/2026 in the refrigerator.The DS stated that all food items should be discarded by the end of their use by date and should already have been removed from storage, since they were no longer safe for residents to consume. During a review of the facility's policy and procedures (P&P) titled, Refrigerated Storage Guidelines, Produce Storage Guidelines, and Dry Storage Guidelines, undated, the P&P indicated: Prepared items should include the day the item is prepared as Day 1; Discard within 48 hours unless otherwise specified; Always label with date opened and expiration.

Based on observations, interviews, and record review, the facility failed to maintain an effective pest control program to ensure the environment was free of pests (including flies, gnats, rodents, and other insects) by failing to: Ensure the kitchen exterior door was kept always closed and equipped with an intact door sweep to prevent pest intrusion into the kitchen. 2. Ensure residents' meal trays were free of gnats. These deficient practices had potential for pests to enter the food service area, leading to food contamination, spoilage, and increased risk of foodborne illness. As a result, residents were at increased risk of losing their appetite, refusing meals, and experiencing emotional distress when observing pests near their food. Findings: a. During a review of Resident 1's admission Record (AR), the AR indicated the facility originally admitted Resident 1 on 4/12/2025 and readmitted her on 11/23/2025 with diagnoses that included acquired absence of right leg below knee (surgically remove a leg below the knee) and type II diabetes mellitus (a condition that happens when your blood sugar is too high). During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 4/13/2026, indicated Resident 1's cognition (ability to think and reason) was intact. The MDS indicated Resident 1 was independent with eating. b. During a review of Resident 7's admission Record (AR), the AR indicated the facility originally admitted Resident 7 on 3/13/2021 and readmitted her on 5/12/2023 with diagnoses that included metabolic encephalopathy (a temporary, generalized malfunction of the brain caused by a chemical imbalance in the body), respiratory disorders (health conditions that affect the lungs), and protein-calorie malnutrition (a serious health condition caused by not eating enough food, calories, or protein). During a review of Resident 7's MDS, dated [DATE], the MDS indicated Resident 7's cognition was moderately impaired. The MDS indicated Resident 7 required set up or clean-up assistance in eating. During a concurrent observation and interview on 7/21/2026 at 4:52 PM with the Dietary Supervisor (DS), the exterior door connecting the kitchen to the outside area was observed opened and not latched. The bottom door sweep (a flat strip of metal, plastic, or wood fitted with a flexible insert like rubber, vinyl, or nylon bristles that attaches to the bottom edge of a door to seal the gap above the floor or threshold) was severely worn, with the rubber casing completely deteriorated and frayed metal mesh exposed along more than one third of its length. The DS stated the kitchen door should always remain closed to prevent pests, insects, and flies from entering. The DS demonstrated that the damaged sweep could be easily pushed through and confirmed that uneven floor tiles created a gap of approximately 1 cm. The DS stated these conditions significantly increased the risk of pest intrusion into the kitchen. During a concurrent observation and interview on 7/22/2026 at 10 AM with the Maintenance Supervisor (MS), the exterior kitchen door and surrounding floor area were observed. The MS stated the DS notified him the previous day regarding the door sweep, and MS replaced the door sweep and filled the uneven tile gap immediately. The MS stated that the prior sweep was a brush type material intended to make opening and closing easier for staff, but it had worn out over time and should have been replaced sooner. During an interview on 7/22/2026 at 11 AM, Resident 1 stated that gnats had been flying around, especially near her meal trays. Resident 1 stated that it made her lose her appetite and felt that the food was no longer good or safe to eat. During an interview on 7/22/2026 at 11:35 AM with the MS, the MS stated that any gap in the door sweep can serve as a point of entry for pests and flies and confirmed that there should be no gaps to effectively prevent pest intrusion. During an interview on 7/22/2026 at 11:45 AM, Resident 7 stated she frequently observed flies around the food trays, especially during lunchtime. She reported that the flies appeared to come from the kitchen and stated she last saw flies the day before. Resident 7 stated this ongoing issue made her lose her appetite. During a concurrent observation and interview on 7/22/2026 at 12 PM in the kitchen, the exterior door was observed open. Dietary Aide (DA) 3 stated that staff sometimes leave the door open to let air in because it becomes too hot during the day. During an interview on 7/22/2026 at 12:48 PM with the Dietary Supervisor Covering (DSC), the DSC stated that all kitchen doors must be tightly closed and that there should be no gaps under the door to prevent pests, including rats and flies, from entering. The DSC stated that if pests enter the kitchen, the food can become contaminated or spoiled, posing potential harm to any resident who consumes it. During a review of the facility's pest control report, dated 7/9/2026, the report indicated the technician strongly recommended follow up treatment for flies in previously infested areas, continued monitoring, keeping all exterior doors closed when not in use to prevent flying insects, and installing door sweeps on all exterior doors to prevent fly intrusion. During a review of the facility's policy and procedure (P&P) titled, Pest Control, dated 2012, the P&P indicated the facility's Pest Control ensure the facility is free of insects, rodents, and other pests that could compromise the health, safety, and comfort of residents, facility staff, and visitors. The administrator arranges for a pest control company to visit and inspect the facility at least once a year. The company will perform services and submit a site-specific work plan for each are/department with recommendations on how to keep the facility pest-free. Department and area staff are responsible for carrying out these recommendations to prevent pest in their respective areas and keeping documentation in accordance with Department and Facility policies.

Based on interview and record review, the facility failed to ensure that one of three certified nurse assistants (CNA 1) maintained a valid certification while providing resident care. CNA 1's certification expired on [DATE], and the facility did not identify the expired status until [DATE]. As a result, CNA 1 provided resident care for 2 years, 6 months, and 4 days without a valid CNA certificate. This deficient practice had the potential to place residents at risk for harm, including inadequate care, neglect, and possible abuse due to the CNA 1 providing care without a valid certification.Findings: During a review of the facility's Monthly Schedule CNA Department from 1/2026 to 4/2026, the monthly schedule indicated that CNA 1 was scheduled to work at the facility five days weekly in 1/2026 and 2/2026. The schedule indicated CNA 1's last day of work was [DATE]. During a review of an untitled facility-provided document provided by the Payroll, the document indicated CNA 1's Employee Status was recorded as Active from [DATE] to [DATE]. The Document further indicated Change of Status on [DATE] with the reason listed as Non-Nursing, and a termination date of [DATE] with the reason indicated as Return to school. During a review of the L&C Verification (L&C) Detail Page (VDP-1) from California Department of Public Health (CDPH) dated [DATE] located in CNA 1's employee education and personnel file (EEPF), the VDP-1 indicated a CNA's nursing assistant certificate was expired on [DATE], however the VDP-1 was misplaced into CNA 1's EEPF and did not belong to CNA 1. During a review of CNA 1's L&C Verification Detail Page (VDP-2) from CDPH dated [DATE], located in CNA 1's EEPF, the VDP-2 indicated CNA 1's nursing assistant certificate was expired on [DATE]. During a concurrent interview and record review on [DATE] at 11:43 AM with the Director of Staff Development (DSD), CNA 1's EEPF was reviewed. The DSD stated that CNA 1's certificate expired on [DATE]; however, CNA 1 continued working as a CNA at the facility until [DATE]. The DSD stated he discovered the issue on [DATE] while preparing to assist CNA 1 with her renewal, because the VDP 1 form in the EEPF indicated an expiration date of [DATE]. The DSD stated the certificate number listed on the first verification did not match CNA 1's original certificate. The DSD stated he was not the DSD at the time CNA 1's certificate expired in 2023 and, when he assumed the role in [DATE], he did not compare the certificate numbers on the VDP 1 with CNA 1's actual certificate during the EEPF review. The DSD stated he relied on the VDP 1 because the name appeared similar to CNA 1's and he did not review the VDP 2 or notice that CNA 1's actual certificate included a middle initial. The DSD stated VDP-1 with someone else's information was misplaced in CNAs 1's EEPF. The DSD further stated he did not know whether the previous DSD assisted CNA 1 with renewal or ensured she verified the completion of her renewal, since CNA 1 was responsible for maintaining her own certification. During an interview on [DATE] at 4 PM with the Director of Nursing (DON), the DON stated it was illegal to provide care to a resident as a CNA when the CNA's certificate was expired. The DON stated the care provided by CNA 1 to residents may not be adequate since CNA 1's certificate was expired and training hours and competency was not provided. During an interview on [DATE] at 4:29 PM with the Administrator (ADM), the ADM stated that she did not know that CNA 1's CNA certificate was expired. The ADM stated the DSD was supposed to compare and verify each CNA's initial certificate number and name upon certificate verification on the L&C Verification website to avoid confusion and mistakes. The ADM also stated since CNA 1 was working with an expired certificate, this posed a risk in resident care since CNA 1 was not up to date with proficiency and competency. During a review of the facility's policy and procedures (P&P) titled Hiring and Employment Verification revised on [DATE], the P&P indicated that for ongoing monitoring, all licenses and certifications will be verified prior to expiration. And the Director of Staff will maintain a tracking system to alert for renewals.

Based on interview, and record review, the facility failed to implement its policy and procedure titled, Abuse Prevention and Management for one of three sampled residents (Resident 1) by, Failing to report to the State Agency (SA where state law provides for jurisdiction in long-term care facilities), ombudsman (advocates for residents of nursing homes, board and care homes and assisted living facilities) and local enforcement within 2 hours after Resident 1 reported an allegation of physical abuse to the facility. 2. Failing to thoroughly investigate, protect and prevent the possibilities of further abuse happening to Resident 1 and other residents in the facility. These deficient practices lead to Resident 1 feeling unsafe, frustrated for not being taken seriously. Potentially result in recurrences of abuse that could affect Resident 1 and other residents in the facility's health, mental and emotional wellbeing and safety.Findings: During a review of Resident 1's admission record indicated the resident was admitted to the facility on [DATE] with diagnoses including but not limited to hemiplegia (complete or partial paralysis) and hemiparesis (weakness or partial paralysis) following cerebral infarction (ischemic stroke - occurs when blood flow to an area of the brain is blocked or significantly reduced) affecting right dominant side, abnormalities of gait and mobility, and muscle weakness. During a review of Minimum Data Set (MDS, a resident assessment tool), dated 5/16/2026, indicated Resident 1's cognitive skills (ability to make daily decisions) was intact. The MDS indicated Resident 1 required setup and clean-up assistance (helper sets up and cleans up; resident completes activity) with eating, oral hygiene and toileting and partial/moderate assistance (helper does less than half the effort) with bathing dressing and personal hygiene. During a review of Resident 1's Progress Notes (PN) dated 5/22/2026 timed at 1:29 PM, the PN indicated approximately around 10:00 AM, Resident 1 reported to the Police Officers (PO), who came to see the Resident in the facility, Resident 1 complained that someone came to the room, went over his things and hit him in the head. During a review of Resident 1's PN dated 5/26/2026 timed at 10:30 AM, the PN indicated, Los Angeles Fire Department Captain (LAFD) called the facility stated that Resident 1 called and complaining of a man hitting him on the head. PN also indicated when Registered Nurse (RN) 3 ask Resident 1 which part of his head got hit and resident kept pointing to the left side of his aggressively. During a concurrent interview and record review on 6/3/2026 at 1:35 PM with the Director of Nurses (DON), email sent by the Administrator (ADM) to the Sales and Marketing Staff (SMS) dated 5/28/2026 timed at 4:41 PM was provided by the DON to the Surveyor was reviewed. The email indicated interviews conducted by the ADM regarding Resident 1's abuse allegations incident. The email indicated, on 5/22/2026, ADM's response to Resident 1's abuse allegation was by conducting an interview with Resident 1, and on 5/26/26, interviewed RN 3 there were no other actions, measures, and investigations carried out for Resident 1's abuse allegation. DON stated, the interviews of Resident 1 and RN 3 conducted by the ADM on 5/22/2026 and 5/26/2026 was not enough to be considered a thorough investigation. During a phone interview on 6/3/2026 at 12:30 PM with Resident 1, Resident 1 stated, although he does not remember who and when, he did report to everyone in the facility that someone hit him on the head. He did not think facility took his complaint seriously and it was not investigated, that made him very frustrated. During an interview on 6/4/2026 at 8:30 AM with RN 2 (RN 2 worked on 5/22/2026 from 7 AM to 3 PM shift), RN 2 stated, on 5/22/2026, a PO came in around 10:00 AM and stated, Resident 1 complained that someone at night hit him on the head. RN 2 stated, he did tell ADM about the abuse allegation around 12:00 PM on 5/22/2026. RN 2 stated, since the ADM was the abuse coordinator he thought the abuse protocol would be initiated. RN 2 stated, he was not aware if it was reported to appropriate agencies and/or thoroughly investigated. RN 2 stated, the least the facility could have done was to report and thoroughly investigate any abuse allegation. During an interview on 6/4/2026 at 9:15 AM with RN 3 (RN worked on 5/26/2026 from 7 AM to 3 PM), RN 3 stated, on 5/26/2026 LAFD called around 10:30 AM stating, Resident 1 called them complaining someone hit him on the head. RN 3 stated, when she asks Resident 1 where he was hit Resident 1 pointed at the left side of the head. RN 3 stated, she did not see any abnormalities on Resident 1's head. RN 3 stated, she reported it to ADM right away because it was an allegation of abuse. RN 3 stated, abuse allegation needs to be thoroughly investigated, and needs to be reported to the Police Department, Ombudsman and CDPH immediately. RN 3 stated, she thought ADM followed the abuse process/protocol. RN 3 stated, as mandated reporter, she should have followed up with the ADM if the abuse protocol of investigating and reporting was initiated. During an interview on 6/4/2026 at 2:30 PM with the DON, DON stated, on 5/22/2026 and on 5/26/2026, Resident abuse allegation was reported to the ADM but was not thoroughly investigated and was not reported to the ombudsman and CDPH as per policy. DON stated, facility did not follow policy of Abuse by not reporting and not conducting a thorough investigation which potentially can result in recurrence of abuse allegations and that can affect Resident 1 and other residents in the facility. A review of the facility's policy and procedure (P&P) titled Abuse Prevention and Management dated 6/12/2024, indicated, a) allegation of abuse or reasonable suspicion of a crime are to be reported to the Administrator or designated representative, b) when the Administrator receives a report of an allegation of resident abuse, the Administrator or designated representative will initiate an investigation immediately, c) immediate actions include the Administrator or designated representative conducting the investigation will interview individuals who may have information relevant to the allegation, witnesses include but are not limited to the resident, witnesses to the incident, roommates, visitors, etc. and the Administrator or designated representative will notify law enforcement by telephone immediately but no longer than 2 hours, and send the written SOC 341 report to the ombudsman, law enforcement, and CDPH licensing and certification within (2) hours.

Based on observation, interview, and record review, the facility failed to prepare food by methods that conserved flavor and temperature for three (3) of 3 sampled residents (Resident 9, 77 and 78) in accordance with the facility's policy and procedure titled Food Temperatures These failures had the potential to result in decreased meal consumption and negatively affect the health and well-being of residents receiving meals in the facility. Findings: During a review of the admission Record (AR), the AR indicated Resident 78 was originally admitted to the facility on [DATE], with diagnosis myocardial infarction ( heart attack) , hemiplegia (loss of movement on one side of body) and hemiparesis ( weakness on one side of the body) following cerebral infarction ( Stroke) , and multiple sclerosis ( chronic neurological disease where the immune system attacks the protective covering of nerves in the brain and spinal cord). During a review of Resident 78's Dietary profile - V7 dated 3/3/26, the profile indicated Resident 78 was on a regular texture, thin liquid diet (consists only of see-through fluids and foods that melt into clear liquids at room temperature) and identified as vegetarian (someone who does not eat meat, poultry, or seafood), with documented food preferences of fresh fruits, salads, muffins with cheese, and soups. During a review of Resident 78's care plan titled Nutritional status dated 12/4/2025, the care plan indicated resident 78's nutritional status care plan included a consistent carbohydrate diet with standard portions and regular texture. The care plan indicated Resident 78 was a vegetarian and had a dietary preference of fresh fruits, salads, muffins with cheese, and soups. During a review of Resident 78 Minimum Data Set ( MDS a resident assessment tool) dated 5/2/2026, the MDS indicated the resident has moderate impaired cognition ( some memory problems, with forgetfulness) and is independent with eating tasks such as able to use utensils and bring food and or liquids to mouth and swallow food and or liquids once the meal is placed before the resident. During a review of Resident 9's AR, the AR indicated Resident 9 was originally admitted to the facility on [DATE], with a diagnosis including aftercare following a surgical amputation ( removal of body part) , and diabetes ( chronic medical condition in which the body is unable to regulate blood sugar levels ) . During a review of Resident 9's History and Physical (H&P) dated 12/4/2025, the H&P indicated Resident 9 is capable of participating in plan of care. During a review of Resident 9's MDS, dated [DATE], the MDS indicated the resident is cognitively intact ( can understand and answer questions, express preferences and concerns and provide reliable information during interviews) and is independent ( resident completes activities by themselves with no assistance from helper ) for most activities of life ( ADL's ) such as eating and hygiene tasks. During a review of the AR, the AR indicated Resident 77 was originally admitted to the facility on [DATE], with a diagnosis to include Diverticulosis ( small pouches develop in the wall of the intestines causing abdominal discomfort) of the intestine, diabetes ( chronic condition in which the body has difficulty regulating blood sugar) , and atrial fibrillation ( an irregular and often rapid heart rhythm ). During a review of Resident 77's MDS, dated [DATE], the MDS indicated the resident has severe impaired cognition (memory problems, trouble with decision making). During an interview on 5/18/2026 at 9:15AM, with Resident 78, Resident 78 stated she was a vegetarian and reported concerns regarding the quality of the vegetables served. Resident 78 stated the vegetables were mushy and overcooked and that food served was not hot and was unpalatable (unpleasant taste). During an interview on 5/18/2026 at 9:59AM, in the presence of certified nurse assistant (CNA) 1 to assist in language translation Resident 77 stated she did not like her food and that the food was cold and mushy. During an interview on 5/18/2026 at 10:35 AM, with Resident 9, stated she is dissatisfied with the meal quality and stated that vegetables were frequently mushy, and she did not like the texture. Resident 9 further stated breakfast and afternoon meals were often served cold. During a concurrent observation and interview on 5/19/2026 at 12:32 PM with Dietary Supervisor (DS) and Certified Dietary Manager (CDM), a test tray (a process of tasting, temping, and evaluating the quality of the food) was observed being prepared. The DS was observed obtaining the temperature of the food items with the facility's food thermometer. The DS stated meatballs with apple glaze was 124 degrees Fahrenheit ( F, degree of temperature) (hot foods held at 140 degrees Fahrenheit or higher), pasta - 121 F, peas 132 F, 3 bean salad (cold food item [held at 41 degrees Fahrenheit or below] 50 F, mouse (cold food item) 41 F. DS and CDM stated the peas served on a residents' meal tray was overcooked, pale green in color, and lacked consistency in texture and shape, and appeared soft and mushy rather than maintaining their intended form. The CDM stated resident may have an issue with texture, consistency and color of the peas being pale green and soggy, therefore the food would not appeal to the resident. The CDM further stated poor food texture and appearance could potentially impact meal intake and contribute to nutritional concerns. During a review of the facility's policies and procedure (P&P) titled Food Temperatures revised on 10/02/2025, indicated food should be served promptly to maintain safe and palatable temperatures. The policy further indicated acceptable serving temperatures include hot foods held at 140 degrees Fahrenheit or higher on the steam table and cold foods held at 41 degrees Fahrenheit or below at point of service. Additionally dietary staff should minimize the duration food is held on the tray line to maintain food temperature and quality.

Based on observations, interviews, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in accordance with the facility's policies and procedures, titled Food Storage and Handling , Refrigerated Storage Guide, Produce Storage Guideline, and Ice Machine& Ice Storage Chest to prevent the outbreak of foodborne illness (an infection or irritation of the gastrointestinal tract caused by consuming food or beverages contaminated with bacteria, viruses, parasites, or chemical toxins) for 96 of 99 residents receiving food from the kitchen . The facility failed to: Discard 9 cucumbers beyond labeled use-by date 5/16/2026 stored in the refrigerator. Label and store one case of frozen boneless chicken thighs that indicates Received date and use-by-date. Cover the opening of an opened carton of liquid whole egg when stored in the walk-in refrigerator. Keep the ice scoop/bin in a covered container when not in use. These deficient practices posing a risk for bacterial growth and foodborne illness and a potential for food contamination (transfer of harmful bacteria or other germs to food, surfaces, or utensils) had placed residents at risk for foodborne illness and lead to other serious medical complications and hospitalization. Findings: During an initial kitchen tour and a concurrent interview on 5/18/2026 from 8:25 AM to 8:45 AM with the Certified Dietary Manager (CDM), the following were observed in the freezer and the walk-in refrigerator: Nine (9) including three (3) partially peeled cucumbers labeled 5/11/2026 and use-by date 5/16/2026; One carton opened cage-free liquid whole egg with uncovered opening from the top; One case of unopened frozen boneless chicken thighs with no label of received date or use-by-date. During the same observation and a concurrent interview on 5/18/2026 at 8:40 AM, the CDM stated the facility received the chicken thighs around 5/15/2026 but the label was not placed. The CDM stated that storing food in the freezer lacking expiration or use-by-date, or not properly covering opened package of liquid egg that allowed anything to contaminate the food item was considered unsafe for resident's consumption. The CDM stated according to facility policy, the kitchen staff are required to properly label and date foods when storing food and supply and in a safe manner. The kitchen staff and cooks are also responsible for disposing food that is past its use-by-dates. If foods contaminated or past use-by-date are provided to the residents, they could get sick. During a follow-up kitchen tour and a concurrent interview on 5/19/2026 at 11:35 AM with the Certified Dietary Manager (CDM), ice scoop was placed in a plastic container with no cover next to the ice machine. The CDM stated the old one that had a lid to cover was broken and he was supposed to follow the facility policy and replace the broken ice scoop and container with one that had cover to prevent contamination. The CDM stated residents could get sick from the ice if staff served the residents with a contaminated scoop. During a review of the facility's Policy and Procedures titled Produce Storage Guideline dated in 2023, the P&P indicated that cucumbers are stored in the refrigerator four to six days. During a review of the facility's P&P titled Food Storage and Handling dated 2022, the P&P indicated that storing frozen meat, poultry and food should be labeled and dated. During a review of the facility's P&P titled Ice Machine& Ice Storage Chests revised 10/1/2014, the P&P indicated that facility staff should take the following precautions to help prevent contamination of ice machine, ice storage chest/containers or ice: Keep the ice scoop/bin in a covered container when not in use.

Based on observation, interview and record review the facility failed to ensure that the heating, ventilation, and air conditioning (HVAC) system was properly maintained to provide a safe and comfortable environment for 97 residents. The HVAC unit servicing the conference room malfunctioned and emitted a burnt plastic odor and white smoke into the facility. The malfunctioning HVAC unit had the potential to adversely affect resident health and safety by exposing residents to smoke and burnt odors, causing respiratory discomfort, anxiety, and the need for emergency response measures. During a review of the facility Maintenance Log titled Checking HVAC and Coils, changing filters dated 1/2026 to 5/2026, indicated that routine inspections that were documented for HVAC Units 1 through 9 were documented. During a review of the Heating & Air conditioning Invoice dated 5/20/2026, indicated that HVAC #6 had a bad contactor (electrical component) that needed to be replaced. During an observation on 5/21/2026 at 12:39 PM in the facility day room/conference room, surveyors detected a burning plastic odor emanating from the ceiling ventilation vents. [NAME] smoke was observed from the ceiling vent of the conference room for approximately one minute before dissipating. Facility staff were immediately notified of the odor and smoke. Administrator (ADM) was observed initiating the facility's Emergency Operations Plan for an internal fire event. The ADM was observed directing front desk staff to contact 911, instructed staff to close resident room doors and monitor residents for any safety concerns and directed the Maintenance Supervisor (MS) to inspect the HVAC unit located on the roof above the day room area. Facility staff opened the front entrance doors to improve ventilation, and an industrial air scrubber was placed in the day room to assist with air circulation and odor removal. During an interview on 5/21/2026 at 12:42 PM, the MS reported that electrical power to the HVAC unit had been shut off after a burnt plastic odor was detected originating from the unit. The MS stated there were no visible signs of fire, active smoke, or fire damage observed at the HVAC unit. The MS further stated that the HVAC system serviced only the day room and front lobby area. During an observation on 5/21/2026 at 12:45 PM, the local fire department arrived at the facility, including the Fire Chief (FC) and firefighters, in response to the reported burning plastic odor and smoke in the day room/conference room area. The FC was observed discussing the incident and the facility's response actions with the ADM. The Firefighters were observed inspecting the day room ventilation ducts and requested access to the rooftop HVAC unit for further evaluation. During an observation on 5/21/2026 at 1:00 PM, facility staff were observed monitoring residents and maintaining resident room doors closed during the inspection. Residents residing in Rooms 22-24 and 1-4 were interviewed and stated they were doing okay. Residents denied shortness of breath, coughing, respiratory distress, or other related symptoms. During a concurrent record review on 5/21/2026 at 1:20 PM with the MS, Maintenance records for HVAC inspections, coil cleaning, and filter changes from January through May 2026 were reviewed. MS stated that the facility had nine rooftop HVAC units and had received routine inspections, coil cleaning, and filter replacement. The MS identified HVAC Unit #6 as the unit servicing the day room and front lobby and confirmed it did not provide ventilation to resident rooms. During a concurrent record review on 5/21/2026 at 1:30 PM with the MS, Heating & Air conditioning Invoice dated 5/20/2026 was reviewed. MS stated that HVAC #6 had been inspected on 5/20/2026 and the invoice had indicated that the HAVC #6 had a bad electrical component that needed to be replaced. MS stated that this damaged electronic component could have caused the HVAC #6 not to work properly which caused the burnt plastic smell and white smoke to come from the conference room ventilation duct. During an interview on 5/21/2026 at 1:57 PM - Interview with Repairman (RM 1), RM [ROOM NUMBER] stated he inspected the HVAC unit on 5/20/2026 and determined the unit had a defective electrical component requiring replacement. RM [ROOM NUMBER] stated his inspection today 5/21/2026 revealed the HVAC compressor was damaged and required replacement. RM [ROOM NUMBER] stated the burnt plastic odor and white smoke originated from the damaged compressor. RM [ROOM NUMBER] stated there was no evidence of active fire damage upon inspection; however, the electrical components associated with the compressor were damaged. RM [ROOM NUMBER] further stated the damaged electrical component identified during the 5/20/2026 inspection could have contributed to the compressor malfunction and subsequent damage. A review of the facility's P&P titled Maintenance Service revised 1/2012, indicated that the maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times and maintaining the heat/cooling system, plumbing fixtures, wiring, etc., in good working order. The P&P indicated that the director of maintenance is responsible for maintaining the following records/reports: inspection of building; work order requests and maintenance schedules. A review of the facility's P&P titled Resident Rooms and Environment revised 1/2012, indicated that the facility staff aim to create a personalized, homelike atmosphere, paying close attention to the following: cleanliness and order; pleasant, neutral scents; comfortable levels of ventilation and comfortable temperatures.

Based on observation, interview, and record review, the facility failed to initiate a comprehensive care plan for one out of four sampled residents (Resident 4) when the Resident 4's foley catheter (a thin hollow tube that is inserted through the opening of the urinary tract into a person's bladder and is used to drain the bladder into an external collection bag) was changed as a result of a change in condition due to significantly cloudy urine in accordance with the facility's policy and procedure titled Person-Centered Care Planning and Change in Condition. This deficient practice had the potential for Resident 4 to be at risk for complications related to the use of foley catheter such as infection and injury due to accidental removal of the catheter if notFindings: During a review of Resident 4's admission Record (AR), the AR indicated that the resident was admitted on [DATE] with diagnoses that included benign prostatic hyperplasia (enlargement of the prostate gland that commonly leads to difficulty in emptying the bladder), dysphagia (difficulty in swallowing), and muscle weakness. During a review of Resident 4's History and Physical (H&P), dated 4/2/2026, the H&P indicated that the resident has the capacity to understand and make decisions. During a review of Resident 4's Minimum Data Set (MDS, a resident assessment tool), dated 4/9/2026, the MDS indicated that the resident has severely impaired cognition (the ability to process thoughts and emotions). During a review of Resident 4's Change in Condition (CIC), dated 4/24/2026, timed at 1:09 PM, signed by Registered Nurse (RN) 2, the CIC indicated that the resident had significantly cloudy urine. The CIC also indicated that a new foley catheter was being placed by the treatment nurse. During a review of Resident 4's entire care plans, it did not include a care plan to indicate that a new foley catheter was placed on or around 4/24/2026. During a concurrent interview and record review on 5/20/2026 at 11:28 AM with the Treatment nurse (TN) 1, Resident 4's medical records were reviewed, including the care plans. TN 1 stated that there is no care plan or documentation to indicate that a new foley catheter was inserted on 4/24/2026. During an interview on 5/21/2026 at 11:31 AM with the Director of Nursing (DON), the DON stated that care plans are use as the basis on how [the facility] care for the resident. The DON added that the care plan should have a focus or problem, a goal that the facility wants to achieve, and interventions or actions on how to achieve that goal. The DON stated that for Resident 4, if the foley catheter was changed because of the CIC on 4/24/2026, then a new care plan should have been initiated for the insertion of a new foley catheter with interventions such as for the nurses to monitor the resident for signs of infection and to keep the foley catheter bag below the bladder. The DON further stated that if there is no care plan, the facility would not be able to effectively track the resident's care. During a review of the facility's policy and procedure (P&P) titled, Change in Condition, effective 8/25/2022, the P&P indicated that as part of the documentation of a change in condition, the nurse will update the care plan to reflect the resident's current status. During a review of the facility's policy and procedure (P&P) titled, Person-Centered Care Planning, effective 5/22/2025, the care plan indicated that a person-centered care plan means that the facility focuses on the resident as the center of control and supports each resident in making his or her own choices. The P&P also indicated that interventions are actions, treatments, procedures, or activities designed to meet an objective. The P&P also indicated that the care plan must describe services that are to be furnished to attain or maintain the resident's highest practical physical, mental, and psychosocial well-being. The P&P further indicated that care plans must be reviewed and revised by the facility after each assessment.

Based on observation, interview, and record review, the facility failed to update the comprehensive care plan for one out of three sample residents (Resident 39) to address the interventions and goals needed for Resident 39's was ordered to receive prednisone (a medication that suppresses the immune system and reduce inflammation) in accordance with policy and procedure titled Person-Centered Care Planning and Adverse Drug Reactions. This deficient practice placed Resident 39 at risk of not to be monitored and receive immediate care for the potential side effects of the medication, such as the risk of infections. Findings: During a review of Resident 39's admission Record (AR), the AR indicated that the resident was originally admitted on [DATE], and readmitted on [DATE], with diagnoses that included muscle weakness, inflammatory polyarthropathy (clinical term describing inflammation in five or more joints), and hemiparesis (partial weakness, numbness, or reduced control on one entire side of the body). During a review of Resident 39's History and Physical (H&P), dated 9/4/2024, the H&P indicated that the resident does not have the capacity to understand and make decisions. During a review of Resident 39's Minimum Data Set (MDS, a resident assessment tool), dated 4/10/2026, the MDS indicated that the resident has moderately impaired cognition (the ability to process thoughts and emotions). During a review of Resident 39's Change in Condition (CIC) Note, dated 5/11/2026, timed at 3:13 PM, the IC indicated that the resident complained of pain of the left hand near the knuckle. During a review of Resident 39's care plans, it included a care plan for the resident [complaint of] left hand pain, initiated on 5/11/2026. The care plan included an intervention to [follow up] with new orders, initiated on 5/11/2026. The care plan did not have documented evidence to address the interventions and goals needed for Resident 39's who was receiving prednisone. During a review of Resident 39's nurses progress notes, an entry, dated 5/11/2026, timed at 8:48 PM, indicated that a medication order was entered for prednisone oral tablet 20 MG (milligram, a unit of measuring weight) give 1 tablet by mouth one time a day for Rheumatoid Arthritis (a disorder that causes painful swelling, stiffness, and potential deformity of joints). During a review of Resident 39's physician's order, dated 5/11/2026, that indicated for Resident 39 to receive prednisone. During a concurrent interview and record review on 5/21/2026 at 11:31 AM with the Director of Nursing (DON), Resident 39's medical records were reviewed, including the resident's CIC, physician's orders, and care plans. The DON stated that Resident 39's care plan for left hand pain, initiated on 5/11/2026, does not include the medication prednisone. The DON stated that the care plan should have been updated to reflect the medication that was ordered by the physician to manage the resident's left-hand pain. The DON added that updating the care plan was important because some medications, such as prednisone that could have side effects that must be monitored. The DON further added that for prednisone, the nurses should be monitoring for infections, because prednisone can suppress the resident's ability to fight infections. During a review of the facility's policy and procedure (P&P) titled, Person-Centered Care Planning, effective 5/22/2025, the care plan indicated that a person-centered care plan means that the facility focuses on the resident as the center of control and supports each resident in making his or her own choices. The P&P also indicated that interventions are actions, treatments, procedures, or activities designed to meet an objective. The P&P also indicated that the care plan must describe services that are to be furnished to attain or maintain the resident's highest practical physical, mental, and psychosocial well-being. The P&P further indicated that care plans must be reviewed and revised by the facility after each assessment. During a review of the facility's P&P titled, Change in Condition, effective 8/25/2022, the P&P indicated that as part of the documentation of a change in condition, the nurse will update the care plan to reflect the resident's current status. During a review of the facility's P&P titled, Adverse Drug Reactions, effective 8/19/2025, the P&P indicated that the facility will monitor, promptly identify, document, report, and appropriately address adverse drug reactions. The P&P indicated for staff to update the care plan for any new precautions or monitoring requirements.

Based on observation, interview and record review, the facility failed to ensure one of eight sampled residents (Resident 2) who was unable to carry out activities of daily living (ADL) received the necessary services to maintain good oral hygiene as indicated in the facility's policy and procedure titled 'Oral Care. This deficient practice had the potential to result in discomfort, pain, impaired oral health, and a decline in overall well- being. Findings: During a review of Resident 2' s admission Record ( AR), the AR indicated Resident 2 was admitted on [DATE], with a diagnoses that included dysphagia (difficulty swallowing) quadriplegia( unable to move all four limbs and is completely dependent on others for mobility and activities of daily living) , and atherosclerotic heart disease( a form of heart disease caused buildup of plaque or fatty deposits in the arteries that supply blood to the heart). During a review of Resident 2's History and Physical dated 2/27/2026, indicated Resident 2 does not have the capacity the capacity to make medical decisions (decline in memory, thinking, reasoning, judgment, and the ability to perform everyday activities that is severe enough to interfere with daily life). During a review of Resident 2's Minimum Set Data (a resident assessment and care planning tool) dated 3/5/2026, indicated the resident was cognitively intact (minimal or mild difficulty in memory) and dependent on staff for all activities of daily living (ADLs) including oral hygiene. During an observation on 5/18/2026 at 12:46 PM in Resident 2's room, Resident 2 was observed sleeping in bed, breathing with mouth open, and dry lips were with brown scabbed areas present on the lower lip and debris was within the oral cavity. During a concurrent observation and interview with Certified Nursing Assistant (CNA) 1, a regular facility staff assigned to Resident 2 on 5/18/2026 at 1:06 pm the resident was observed lying in bed breathing through his mouth. CNA1 confirmed the resident's lips were dry, cracked, and had brown scabs. CNA 1 stated that he provides oral care, brushing the residents' teeth once daily. During a concurrent observation and interview on 5/18/2026 at 1:11PM, with Director of Nursing (DON) in Resident 2's room, DON stated the resident's lips were dry and cracked with brown scabs. DON stated, the reason Resident 2's lips were dry was because, the resident breaths through his mouth and keeps his mouth open for a long period. The DON further stated staff should be providing oral care as needed. The DON did not indicate if Resident 2's was consistently provided oral care. DON did not identify any additional interventions being implemented to address the residents' dry, cracked lips and oral condition. During an observation on 5/18/2026 at 3:50PM in Resident 2's room, the resident was lying in bed, breathing with mouth open wide. Resident 2's lip was visible with brown scab. During a concurrent observation and interview on 5/18/2026 at 3:55PM with Registered Nurse (RN1) in Resident 2's room, RN1 stated, Resident 2 was breathing through his mouth with dry lips, cracked, and have brown scabbed areas. RN 1 stated that the resident should have lip balm (wax like substance to keep lips moisturized) applied to his lips and receive frequent oral swabbing. RN1 further stated Resident 2 appeared dry and dehydrated. During a concurrent interview and Record review on 5/20/2026 at 9:03AM, Resident 2's care plans were reviewed. DON stated the resident does not have a care plan created for oral care needed related to the resident's mouth breathing. DON further stated he should have a care plan that indicates specific interventions that staff must implement, including frequent swabbing of mouth and provide lip moisturizer. During a concurrent interview and record review on 5/20/2026 at 9:05 AM resident 2's Activities of Daily living (ADL) look back for oral hygiene from 4/1/26 - 4/14/26 was reviewed. DON stated the record indicated Resident 2 received oral care one time during the day shift and one time during the night shift. DON stated he should be receiving oral care as needed. During a review of the facility's policy and procedure titled, 'Oral Care revised on November 2015, indicated all residents receive appropriate oral care daily. The policy stated nursing staff are responsible for ensuring good oral care for each resident, assessing the oral cavity and teeth upon admission and as needed, observing adverse oral conditions such as bleeding , swelling, unusual mouth odor, pain, discomfort, or other abnormalities, and reporting identified concerns to the charge nurse. The policy further indicated oral care should be provided to dependent residents as necessary, measures should be taken to maintain oral hygiene and lip integrity, and oral care and pertinent observations are to be documented in the resident's medical record.

Based on observation, interview, and record review, the facility failed to ensure resident receives care consistent with professional standard of practice to prevent pressure ulcers (a skin breakdown due to unrelieved pressure and friction to the skin) for one of one sampled resident (Resident 22), who was a high risk to develop pressure ulcer, with a waffle mattress (mattress to prevent pressure ulcer) overlay setting at 140 (firmness setting of the mattress 80 [soft] - 280 [firm] ) as per physicians order. This deficient practice had the potential to result in development of pressure ulcer and/or skin breakdown, which could negatively affect Resident 22's quality of life. Findings: During a review of Residents 22's admission Record indicated the resident was originally admitted on [DATE] and readmitted on [DATE] with diagnoses that included Parkinson's disease (brain condition that causes problems with movement), peripheral vascular disease (progressive circulation disorder), and muscle weakness. During a review of Minimum Data Set (MDS, a resident assessment tool), dated 4/1/2026, indicated Resident 22's cognitive skills (ability to make daily decisions) was severely impaired. The MDS indicated Resident 22 was dependent with all activities of daily living (ADLs). During a review of Resident 22's Braden Scale for Predicting Pressure Sore (ulcer) Risk dated 1/8/2026 indicated Resident 22 was completely immobile and high risk for pressure ulcer. During a review of Resident 22's Braden Scale for Predicting Pressure Sore Risk dated 4/2/2026 indicated Resident 22 was completely immobile and high risk for pressure ulcer. During a review of Resident 22's Order Summary report (OSR) (Physician Orders) dated 5/19/2026 indicated use of waffle mattress overlay to prevent pressure injury/ skin breakdown. Settings: 140. During a review of Resident 22's care plan (CP) revised on 5/17/2026, indicated, the resident had a wound management device: Waffle mattress an overlay (pad on top of mattress) to prevent pressure injury and skin breakdown. The intervention included to monitor for accurate settings (setting:140). During a concurrent observation and interview on 5/18/2026 at 9:35 AM with Licensed Vocational Nurse (LVN) 2 in Resident 22's room, Resident 22 was in bed on a waffle mattress with the setting was at 170. LVN 2 stated, the physicians order indicated the waffle mattress setting should be at 140, not 170. LVN 2 stated, the waffle mattress was being used for the prevention of pressure ulcer and/or skin breakdown, and not following the right setting defeats the purpose of the mattress and potentially could result in pressure ulcer and/ or skin breakdown. During an interview on 5/19/2025 at 10:05 AM with Director of Nurses (DON), DON stated, Resident 22 needs the waffle mattress because she's immobile and high risk for pressure ulcer. DON stated, it was the licensed nurse responsibility to follow physicians order, which indicated the waffle mattress setting should be at 140 not 170. DON stated, not following the setting reduces the effectiveness of the mattress, which potentially could result in pressure injury and/or skin breakdown. A review of the facility's policy and procedure (P&P) titled, Mattresses, dated 1/1/2012, indicated, the facility will provide mattresses capable of meeting needs of residents to provide pressure reduction to resident s at risk of skin breakdown, and an air mattress is used under the direction of an attending physician's order. A review of the facility's policy and procedure (P&P) titled, Pressure Injury Prevention, dated 7/31/2024, indicated a) complete a skin risk evaluation, develop a plan of care for the resident's risk factor, and implement intervention identified which include pressure redistributing devices for bed.

Based on observation, interview, and record review, the facility failed to provide a safe and hazard free environment in accordance with the facility's policy and procedure titled Resident Safety and Maintenance Service for one of three sampled residents (Resident 1), who was observed lying in bed under his overhead light fixture with plastic cover sagging and not properly secured. This deficient practice had the potential for the light fixture plastic cover to fall on to Resident 1 and cause injury. Findings: During a review of Resident 1's admission record indicated the resident was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included wedge compression fracture the lumbar vertebra (a broken bone in the lower back), bilateral hip osteoarthritis (the smooth cartilage that cushions the ends of your bones gradually wears away over time, causing bones to rub against each other and resulting in pain, stiffness, and swelling), and generalized muscle weakness. During a review of Minimum Data Set (MDS, a resident assessment tool), dated 4/20/2026, indicated Resident 1's cognitive skills (ability to make daily decisions) moderately impaired. The MDS indicated Resident 1's required supervision or touching assistance (Helper provides verbal cues and or touching steadying) with eating and personal hygiene, and substantial/maximal assistance (helper does more than half the effort) with toileting, bathing and dressing. During a concurrent observation and interview on 5/18/2026 at 9:00 AM with Licensed Vocational Nurse (LVN) 1, In Resident 1's room. Resident 1 was lying in bed under his overhead light fixture with plastic cover sagging and not properly secure. LVN 1 stated, she did not notice it, but the sagging cover of the light fixture potentially could fall on to Resident 1 and cause injury, it should be fixed immediately and secured properly. During an interview on 5/18/2026 at 9:15 AM with the Maintenance Supervisor (MS), In Resident 1's room. MS stated, he not aware that the Resident 1's light fixture cover was not secured properly and sagging. MS stated, the light fixture cover could fall on the patient and cause injury. During an interview on 5/19/2026 at 10:01 AM with the Director of Nurses (DON), DON stated, it is the responsibility of nursing as well as the maintenance supervisor to ensure Resident 1 had a hazard free environment. DON stated, the light fixture cover of Resident 1 should have been secured properly and not sagging, because it potentially could fall on to the Resident 1 and cause injury. A review of the facility's policy and procedure (P&P) titled Resident Safety dated 4/2021, indicated, purpose is to provide a safe and hazard free environment and to observe the safety and wellbeing of the Residents. A review of the facility's policy and procedure (P&P) titled Maintenance Service, dated 1/1/2012, indicated, the maintenance department maintains all areas of the building, and equipment's, and keep the building in good repairs and free from hazards.

Based on observation, interview, and record review, the facility failed to ensure two of two sampled residents (Resident 34 and 4) received appropriate treatment and services for urinary care in accordance with the professional standard of practice and facility's policy and procedures titled Indwelling Catheter, Guideline for Prevention of Catheter-Associated Urinary Tract Infection (2009) (CAUTI, a catheter associated UTI (an infection of the urinary tract that includes urethra, ureters, bladder and kidneys resulting when microorganism gets into the urine and travels to the urinary tract) and Suprapubic Catheter Re-insertion and Management. The facility failing to: 1. For Resident 4, the foley catheter (a thin hollow tube that is inserted through the opening of the urinary tract into a person's bladder and is used to drain the bladder into an external collection bag) was not monitored for use and no date when the catheter was inserted following a change in condition when the resident's urine was observed cloudy. 2. For Resident 34, the suprapubic catheter (SPC-an indwelling urinary catheter inserted surgically through the abdominal wall into the bladder for continuous urinary drainage) was not monitored for signs and symptoms of infection such as cloudiness and sediments (particles such as bacteria, crystals, blood cells and mucus in the urine. This deficient practice had the potential for Resident 4 and 34 to have delayed or not received care and interventions, and/or treatments to prevent catheter-associated urinary tract infection and other catheter associated complications such as dislodgement of the catheter and bladder discomfort from catheter blockage due to sediment buildups. Findings: 1. During a review of Resident 4's admission Record (AR), the AR indicated that the resident was admitted on [DATE] with diagnoses that included benign prostatic hyperplasia (enlargement of the prostate gland that commonly leads to difficulty in emptying the bladder), dysphagia (difficulty in swallowing), and muscle weakness. During a review of Resident 4's History and Physical (H&P), dated 4/2/2026, the H&P indicated that the resident has the capacity to understand and make decisions. During a review of Resident 4's Minimum Data Set (MDS, a resident assessment tool), dated 4/9/2026, the MDS indicated that the resident has severely impaired cognition (the ability to process thoughts and emotions). During a review of Resident 4's Change in Condition (CIC), dated 4/24/2026, timed at 1:09 PM, signed by Registered Nurse (RN) 2, the CIC indicated that the resident had significantly cloudy urine. The CIC also indicated that a new foley catheter was being placed by the treatment nurse. During a review of Resident 4's Treatment Administration Record (TAR) for April 2026, the TAR did not indicate documented evidence that a new foley catheter was inserted on 4/24/2026, as indicated in the CIC, dated 4/24/2026. During a review of Resident 4's entire care plans, the care plan did not include a care plan to indicate documented evidence that a new foley catheter was inserted on or around 4/24/2026. During a review of Resident 4's progress notes for the month of April 2026, the progress notes did not indicate documented evidence that a new foley catheter was inserted on or around 4/24/2026. During a review of Resident 4's Surveillance Data Collection Form (SDC) for Urinary Tract Infections, dated 4/27/2026, signed by the Infection Preventionist Nurse (IPN), the SDC did not indicate documented evidence of when Resident 4's foley catheter was inserted. During a review of Resident 4's Surveillance Data Collection Form (SDC) for Urinary Tract Infections, dated 5/5/2026, signed by IPN, the SDC did not indicate documented evidence of when Resident 4's foley catheter was inserted. During a concurrent interview and record review on 5/20/2026 at 11:28 AM with the Treatment nurse (TN) 1, Resident 4's medical records were reviewed, including the resident's care plans, progress notes, and TAR for April 2026. TN 1 stated that there was no care plan or documentation in the TAR and progress notes to indicate that a new foley catheter was inserted on 4/24/2026. TN 1 stated that he is not certain if he inserted a new foley catheter, but if he did, he stated that he might have forgotten to document it. During an interview on 5/20/2026 at 3:30 PM with RN 2, RN 2 stated that on 4/24/2026, TN 1 inserted a new foley catheter on Resident 4. RN 2 stated that she would expect that TN 1 to document the insertion of the new foley catheter immediately after he finished. RN 2 also stated that it was important to know when the foley catheter was inserted. During a concurrent interview and record review on 5/21/2026 at 11:11 AM with the Infection Preventionist Nurse (IPN), the SDC's, dated 4/27/2026 and 5/5/2026, were reviewed. The IPN stated that the SDC's does not include a date of when the foley catheter was inserted because there is no documented evidence that the foley catheter was inserted at the facility. The IPN also indicated that it was important for the facility to know the insertion date of the foley catheter because it is part of the facility's interventions to prevent the development of catheter-associated urinary tract infections (CAUTI). During a concurrent interview and record review on with the Director of Nursing (DON), the facility's policy and procedure (P&P) titled, Indwelling Catheter, and resource titled, Guideline for Prevention of Catheter-Associated Urinary Tract Infections 2009, were reviewed. The DON stated that the facility's P&P indicate that catheter use and CAUTI's will be monitored. The DON also stated that the facility's resource for the prevention of CAUTI indicated that the date of catheter insertion must be documented. During a review of the facility's P&P titled, Indwelling Catheter- Insertion, Maintenance, and Discontinuation of, effective 8/19/2025, the P&P indicated for staff to document the following after the insertion of a foley catheter: Type and size of catheter inserted. Date and time of catheter insertion. Urine return and characteristics, color, and odor, if any. Any difficulties or discomfort. During a review of the facility's P&P titled, Indwelling Catheter, effective 8/19/2025, the P&P indicated that residents will be periodically assessed for the need for continued catheter use and/or any complications associated with catheter use. The P&P indicated that catheter use and CAUTIs will be included in the facility's monthly infection control surveillance. The P&P further indicated that the facility uses the resource titled, Guideline for Prevention of Catheter-Associated Urinary Tract Infection (2009). During a review of the facility's resource for the prevention of CAUTI titled, Guideline for Prevention of Catheter-Associated Urinary Tract Infection (2009), updated 6/6/2019, the resource indicated that the facility is to consider implementing a system for documenting the indication for catheter insertion, date and time of catheter insertion, individual who inserted catheter, and date and time of catheter removal. The resource also indicated that performance measures in preventing CAUTIs include compliance with documentation of catheter insertion and removal dates 2. During a review of Resident 34's admission record indicated the resident was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included UTI, acquired absence of other parts of the urinary tract (a missing part of urinary system), chronic kidney disease (CKD) (kidneys are damaged and cannot filter blood as well as they should), calculus of kidney (kidney stone) and neuromuscular dysfunction of the bladder/neurogenic bladder (lacks bladder control). During a review of Minimum Data Set (MDS, a resident assessment tool), dated 2/25/2026, indicated Resident 34's cognitive skills (ability to make daily decisions) was intact. The MDS indicated, Resident 34 required setup and clean-up assistance (helper sets up and cleans up; resident completes activity), substantial/maximal assistance (helper does more than half the effort) with bathing and dependent (helper does all the effort) with toileting and dressing. During a review of Resident 34's Order Summary report (OSR) dated 5/19/2026 indicated to a) SPC via gravity drainage for neurogenic bladder, and b) assess urinary drainage for signs and symptoms of infection noting cloudiness and sediments. During a review of Resident 34's CP revised 5/18/2026, indicated Resident 34 had a SPC related to neurogenic bladder at risk for infection/UTI with intervention to assess urinary drainage for sign and symptoms of infection, noting cloudiness, color and sediments, and monitor and report to MD sign and symptoms of UTI including cloudiness. During a concurrent observation and interview on 5/18/2026 at 9 AM with Resident 34, in Resident 34's room. Resident 34 in bed, with SPC tubing and drainage bag cloudy with some sediments. Resident 34 stated, he feels fine, reporting not having any discomfort and no concerns. During a concurrent observation and interview on 5/18/2026 at 2PM (5 hours after first observation of Resident 34's SPC drainage bag) with Licensed Vocational Nurse (LVN) 2, in Resident 34's room. Resident 34 in bed, with SPC tubing and drainage bag cloudy with some sediments. LVN 2 stated, he did not assess the urinary drainage bag earlier, and it is cloudy and had sediments. LVN 2 stated, he though Treatment Nurse (TN) 1 assessed Resident 34's urinary drainage bag this morning. LVN 1 stated, monitoring of Resident 34's urinary drainage bag should be ongoing, because Resident was at risk for infection and/or UTI, not addressing the symptoms earlier had the potential to delay intervention of treatment for possible UTI. During an interview on 5/18/2206 at 3 PM with the TN 1, TN 1 stated, he did not notice the sedimentation and the cloudy urine in Resident 34's SPC tubing and urinary drainage bag at 7 AM this morning, but monitoring should be ongoing. TN 1 stated, it was the responsibility of the LVN and the TN to assess Resident 34's urinary drainage bag and should be ongoing. TN 1 stated, not addressing the sign and symptoms of possible UTI had the potential for delayed of intervention and treatment. During an interview on 5/19/2206 at 10:01 AM with the Director of Nurses (DON), DON stated, assessment of Resident 34's urinary drainage bag should be assessed by both LVN 1 and TN 1 and should be ongoing because of the risk for infection and/or UTI. DON stated, delay reporting of signs and symptoms of infection had the potential to result in delayed of intervention and/or treatment of possible UTI that could negatively affect Resident 34's quality of life. A review of the facility's policy and procedure (P&P) titled, Suprapubic Catheter Re-insertion and Management, dated 1/30/2026, indicated under monitoring and ongoing assessment, nursing staff shall monitor for and promptly report signs of infection (i.e. cloudy or foul-smelling urine). A review of the facility's policy and procedure (P&P) titled, Infection Control – Policies and Procedures, dated 6/21/2022, indicated objective includes to prevent, detect, investigate and control infections in the facility.

Based on observation, interview and record review, the facility failed to insure one out of eight sampled residents (Resident 2) offered and received the sufficient fluid intake to maintain proper hydration as recommended by the Registered Dietitian (RD) baseline daily fluid intake (calculated fluid a resident should consume each day) to ensure proper hydration. This deficient practice had the potential to result in Resident 2's continued dehydration (fluid deficit), impaired oral health, kidney damage, urinary tract infections, hospitalizations, and could result in a decline in the resident's overall condition. Findings: During a review of Resident 2' s admission Record ( AR), the AR indicated Resident 2 was admitted on [DATE], with a diagnoses that included dysphagia (difficulty swallowing) quadriplegia (unable to move all four limbs and is completely dependent on others for mobility and activities of daily living) , and atherosclerotic heart disease (a form of heart disease caused by the buildup of plaque and fatty deposits) in the arteries that supply blood to the heart). During a review of Resident 2's History and Physical dated 2/27/2026, indicated Resident 2 does not have the capacity the capacity to make medical decisions (decline in memory, thinking, reasoning, judgment, and the ability to perform everyday activities that is severe enough to interfere with daily life). During a review of Resident 2's Minimum Set Data (a resident assessment and care planning tool) dated 3/5/2026, indicated the resident was cognitively (thought process) intact and dependent on staff for all activities of daily living (ADLs) including oral hygiene. During an observation on 5/18/2026 at 12:46 PM in Resident 2's room, Resident 2 was observed sleeping in bed, breathing with mouth open with dry observed dry lips and brown scabbed areas present on the lower lip and debris was within the oral cavity. During a review of Resident 2's Change of Condition (COC) report dated 5/18/2026, indicated resident had poor appetite and dry mouth due to mouth breather, physician and resident representative notified. During a review of Resident 2's Order Summary report dated 5/19/2026, indicated Resident 2 was transferred to General Acute Care Hospital (GACH) for further evaluation due to weakness and poor oral intake. During a concurrent interview and record review on 5/20/2026 at 10:05 AM with Director of Nursing (DON) of Resident 2's Nutritional Risk Assessment dated 2/27/2026, the Nutritional Risk Assessment indicated Registered Dietitian (RD) estimated the resident's fluid need was 1,269 ml to 1731 ml (5.3 to 7.2 cups) every day with the goal to have no signs or symptoms of dehydration. During a concurrent interview and record review on 5/20/2026 10:05 AM with Director of Nursing (DON) Resident 2's intake and output record from 5/1/2026 to 5/14/2026 indicated the resident's fluid intake was not consistently maintained within the Registered Dietitian's estimated daily fluid requirement of 1,269ml to 1731ml per day. The intake and output Record indicated the following daily fluid intakes.: 5/01/2026: intake 720ml; Output 1700 ml 5/02/2026: intake 960ml; output1390 ml 5/03/2026: intake 1200 ml; output 1340 ml 5/04/2026: intake 900ml; output 1300 ml 5/5/2026: intake 720 ml; output 750 ml 5/06/2026: intake 1200 ml; output 1640ml 5/07/2026: intake 720 ml; output 1500 ml 5/08/2026: intake 640 ml; output 1400ml 5/09/2026: intake 3120 ml; output 1540ml 5/10/2026: intake 960 ml; output 1120 ml 5/11/ 2026: intake 480 ml; output 1000 ml 5/12/2026: intake 960 ml; output 1640ml 5/13/2026: intake 1200ml; output 1200ml 5/14/2026: intake 1200ml; output 1680ml During a continued interview and record review on 5/20/2026 at 10:05 AM DON further stated the facility has a dashboard for clinical alerts for each resident; however, it did not appear that any alert had been generated regarding Resident 2's inadequate fluid intake. The DON stated there was no specific monitoring process in place. The DON explained the Certified Nursing Assistants (CNAS) were expected to encourage residents to take in fluids, but no specific care plan had been created or Physicians order placed related to Resident 2's dehydration problem. During a concurrent interview and record review on 5/21/2026 at 8:55AM with the DON, stated the physician had not been notified regarding Resident 2's fluid requirements not being met until yesterday 5/20/2026, at which time the physician ordered intravenous fluids ( liquids that are delivered directly into a person's bloodstream through a vein using a small tube inserted into a vein. During a review of the facility's policy and procedure titled, Hydration Program revised November 2015, indicated the facility will provide residents with fluids to minimize episodes of dehydration. The policy further indicated that a Registered Dietitian (RD) will determine a recommended baseline daily fluid need for all residents and that a plan of care will be developed for resident who trigger dehydration or have the potential for fluid imbalance based on diagnosis or medical history. The policy indicated that nursing staff will document fluid intake and notify nursing staff when a resident is not consuming sufficient fluids or exhibits signs and symptoms of dehydration.

Based on observation, interview, and record review, the facility failed to ensure that two out of three medication rooms (MR), did not contain medications that were past the discard by date in accordance with the policy MR 2 contained two bags of Ertapenem (an antibiotic, medication that is used to treat infections) that were past the discard date. MR 3 contained one syringe of Enbrel (a medication used to reduce inflammation and swelling) that was past the discard date. This deficient practice had the potential for residents to be administered expired medications, which could lack the intended efficacy to treat the residents' diseases. Findings: a. During a review of Resident 69's admission Record (AR), the AR indicated that the resident was originally admitted on [DATE], and readmitted on [DATE], with diagnoses that included hypotension (low blood pressure), muscle weakness, and diabetes mellitus (condition characterized by high blood sugar levels). During a review of Resident 69's History and Physical (H&P), dated 4/2/2026, the H&P indicated that the resident has the capacity to understand and make decisions. During a review of Resident 69's Minimum Data Set (MDS, a resident assessment tool), dated 3/6/2026, the MDS indicated that the resident has moderately impaired cognition (the ability to process thoughts and emotions). During a review of Resident 69's physician's orders, dated 4/30/2026, indicated an order for Resident 69 to receive Ertapenem Sodium Infection Solution Reconstituted Use 500 MG (milligram, a unit of measuring weight) intravenously in the evening for [right] hip [hardware infection]. During a medication storage inspection on 5/20/2026 at 2:51 PM with the Assistant Director of Nursing (ADON), the facility's MR 3 was inspected. The MR 3's medication refrigerator was observed containing two bags of Resident 69's Ertapenem with a label that indicated to Discard After 5/17/2026. The ADON stated that the two bags of Ertapenem should not have been in the refrigerator because they are past the discard by date. b. During a review of Resident 43's AR, the AR indicated that the resident was originally admitted on [DATE], and readmitted on [DATE], with diagnoses that included muscle weakness, dysphagia (difficulty in swallowing), and dementia (a decline in mental ability-such as memory loss, impaired judgment, and confused thinking). During a review of Resident 43's H&P, dated 9/15/2026, the H&P indicated that the resident does not have the capacity to understand and make decisions. During a review of Resident 43's MDS, dated [DATE], the MDS indicated that the resident has severely impaired cognition. During a review of Resident 43's physician's orders since the resident's admission from 12/28/2024 to 5/21/2026, indicated no physician order for Resident 43 to receive Enbrel. During a medication storage inspection on 5/20/2026 at 3:09 PM with the ADON, the facility's MR 2 was inspected. The MR 2's medication refrigerator was observed containing one syringe of Resident 43's Enbrel with a label that indicated to Discard After 5/9/2026. The ADON stated that the syringe of Enbrel should not have been in the refrigerator because it is past the discard by date. During a follow up interview on 5/20/2026 at 3:13 PM with the ADON, the ADON stated that it was the responsibility of the nurses to remove expired medications from the medication because the medications could potentially be administered to the residents. The ADON added that the medications could be ineffective or could possibly be contaminated with bacteria if past the discard date. During a concurrent interview and record review on 5/21/2026 at 11:31 AM with the Director of Nursing (DON), Resident 43's medical records were reviewed, including the resident's physician's orders from 12/28/2024 to 5/21/2026. The DON stated that Resident 43 did not have an order for Enbrel. The DON stated she does not know why there was a syringe of Enbrel if the resident never had an order for the medication. The DON further stated that the medication should have been discarded because it was never in the resident's medication regimen. During the same interview on 5/21/2026 at 11:31 AM with the DON, the DON stated that it is the nurses' responsibility to inspect the stocked medications for any medications that are expired. The DON stated that if expired medications are not discarded before their expiration, there is a risk that the nurses might mistakenly administer the expired medication. The DON further added that expired medications could lead to the ineffective treatment of the residents' disease. During a review of the facility's policy and procedure (P&P) titled, Medication Storage in the Facility, revised 1/2018, the P&P indicated that it is the facility's policy that medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The P&P indicated that outdated medications are immediately removed from the inventory, disposed of according to procedures for medication disposal. The P&P further indicated that all expired medications will be removed from the active supply and destroyed in the facility, regardless of amount remaining.

Based on observation, interview, and record review, the facility failed to ensure the accuracy of documentation for two out of four sampled residents (Resident 9 and Resident 94) who were observed during medication administration in accordance with the facility's policy and procedures titled Medication Administration- General Guidelines, by failing to ensure: 1. Licensed Vocational Nurse (LVN) 2 did not document the administration of Resident 94's meclizine (a medication used to treat dizziness) prior to the administration of the medication. 2. LVN 1 did not document the administration of Resident 9's acetaminophen (a medication used to control pain) prior to the administration of the medication. This deficient practice had the potential to cause inaccuracies in the residents' records, which could cause the misadministration of medications. Findings: 1. During a review of Resident 94's admission Record (AR), the AR indicated that the resident was originally admitted on [DATE], and readmitted on [DATE], with diagnoses that included diabetes mellitus (high blood sugar levels), dizziness, and hypertension (high blood pressure levels). During a review of Resident 94's History and Physical (H&P), dated 10/3/2025, the H&P indicated that the resident has fluctuating capacity to understand and make decisions. During a review of Resident 94's Minimum Data Set (MDS, a resident assessment tool), dated 3/26/2026, the MDS indicated that the resident has intact cognition During a review of Resident 94's physician's orders, dated 10/29/2024, indicated for Resident 94 to receive Meclizine HCL oral tablet 25 MG (milligram, a unit of measuring weight) give 25 MG by mouth every 8 hours as needed for dizziness. During a medication administration observation on 5/19/2026 at 9:13 AM inside Resident 94's room, Licensed Vocational Nurse (LVN) 2 was observed preparing Resident 94's meclizine. LVN 2 placed Resident 94's meclizine tablet inside of a medication cup. After placing the meclizine tablet inside of the medication cup, LVN 2 was observed documenting in the MAR that meclizine was administered. During the same medication administration observation on 5/19/2026 at 9:14 AM inside Resident 94's room, LVN 2 administered Resident 94's meclizine. During a follow up interview on 5/19/2026 at 9:18 AM, LVN 2 stated that the correct process of medication administration is to document after the medication has been administered, and not before. LVN 2 further stated that he documented the administration of the medication before the medication was administered because he believed that there is no way that the resident will refuse the medication. 2. During a review of Resident 9's AR, the AR indicated that the resident was originally admitted on [DATE] with diagnoses that included 11/23/2025. During a review of Resident 9's H&P, dated 12/4/2025, the H&P indicated that the resident has the capacity to understand and make decisions. During a review of Resident 9's MDS, dated [DATE], the MDS indicated that the resident has intact cognition (the ability to process thoughts and emotions). During a review of Resident 9's physician's orders, dated 5/14/2026, indicated for Resident 9 to receive acetaminophen oral tablet 500 MG give 2 tablets by mouth every 6 hours as needed for moderate pain. During a medication administration observation on 5/19/2026 at 9:32 AM inside Resident 9's room, LVN 1 was observed preparing Resident 9's acetaminophen. LVN 1 placed Resident 9's acetaminophen tablet inside of a medication cup. After placing the acetaminophen tablet inside of the medication cup, LVN 1 was observed documenting in the MAR that acetaminophen tablet was administered During the same medication administration observation on 5/19/2026 at 9:33 AM inside Resident 9's room, LVN 1 administered Resident 9's acetaminophen. During a follow up interview on 5/19/2026 at 9:45 AM, LVN 1 stated that the correct process of administering medications is for the nurse to document the administration of medication after the medication has been administered. LVN 1 stated that she made a mistake in documenting the administration of medication before she had administered the medication. During an interview on 5/21/2026 at 11:31 AM with the Director of Nursing (DON), the DON stated that the correct process for staff was to document in the MAR the administration of medication after the medication has been administered, and not prior to administration. The DON stated that documenting before the medication has been administered is not accurate because the resident could still refuse the medication. During a review of the facility's policy and procedure (P&P) titled, Medication Administration- General Guidelines, updated 11/2021, the P&P indicated that medications are administered as prescribed in accordance with good nursing principles and practices. The P&P also indicated that the individual who administers the medication dose records the administration on the resident's [Medication Administration Record] after the medication [administration] is completed.

Based on observation, interview and record review, the facility failed to implement the facility's policy and procedure for infection control by failing to ensure a safe and sanitary environment to prevent transmission of diseases and infections for one of three sampled resident (Resident 8), who was observed on 5/20/2026 with a suction cannister (a medical receptacle used with suction machines to collect bodily fluids-such as mucus, and secretion) dated 5/18/2026 half-filled with cloudy secretions. This deficient practice can result in the suction cannister to harbor bacteria and/or virus (microscopic germs that can invade the body and cause infections) which potentially can get Resident 8 and negatively affect her quality of life. Findings: During a review of Resident 8's admission record indicated the resident was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included asthma (a condition that causes airways become swollen, narrow, and clogged with mucus), respiratory failure (a condition where the respiratory system fails to maintain adequate gas exchange), dependence on supplemental oxygen, and on palliative care (medical care for anyone living with a serious illness, focused on providing relief from symptoms). During a review of Minimum Data Set (MDS, a resident assessment tool), dated 4/14/2026, indicated Resident 8's cognitive skills (ability to make daily decisions) was severely impaired. The MDS indicated, Resident8 was dependent with all activities of daily living (ADL's). During a review of Resident 8's care plan (CP) revised 4/6/2026, indicated the resident required oxygen therapy related to respiratory illness. The interventions included to suction resident as needed for excess secretions and at risk for infection, with intervention that included to monitor for sign and symptoms of distress and monitor to Medical Doctor (MD). During a review of Resident 8's Order Summary Report dated 5/21/2026 indicated to administer oxygen at two liters (a metric unit of volume flow rate) via nasal cannula (flexible plastic device used to deliver supplemental oxygen) for respiratory failure and may suction excess oral secretions as needed. During a concurrent observation and interview on 5/20/2026 at 8:15 AM with MDS Nurse (MDSN), in Resident 8's room, observed at Resident 8's bedside a suction cannister dated 5/18/2026 half-filled with cloudy secretions. MDSN stated, the suction cannister should have been replaced after it was used to prevent infection. During an interview on 5/20/2026 at 2:25 PM with the Registered Nurse (RN) 1, RN 1 stated, Resident 8's oral suctioning are only done by RN, and she did not suction Resident 8 today so the secretions in the cannister must be old. RN 1 added, she would replace the suction cannister whenever she suctions Resident 8. RN 1 stated, suction cannister needs to be replaced after each use, because secretions could harbor bacteria and/or virus when it just sits there and Resident 8 could get sick from an infection. During an interview on 5/20/2026 at 3:21 PM with the Director of Nurses (DON), DON stated, the facility did not have a specific policy to when to dispose of a dirty suction cannister, though facility's suction cannister such as the one used by Resident 8 was a single-use item so it should have been disposed of after used. DON stated, since the suction cannister was dirty and dated 5/18/2026, it could have harbored bacteria and/ or virus that could potentially result in Resident 8 getting sick from an infection. A review of the facility's policy and procedure (P&P) titled, Infection Control - Policies and Procedure, (6/21/2022) indicated objectives includes prevent and control infections and maintain a safe and sanitary environment for personnel, residents, visitors and public. A review of the facility's policy and procedure (P&P) titled, Cleaning & Disinfecting of Residents Care Equipment, (1/1/2012) indicated semi- critical items consist of items that come in contact with mucous membrane (i.e. respiratory equipment), and single use items are disposed of after single use.

Based on observation, interview, and record review, the facility failed to ensure one of one sampled residents (Resident 1), who was at risk for fall due to poor safety awareness and history of repeated falls was provided care and services to prevent recurrent falls in accordance with the facility's policy and procedures (P&P). The facility failed to: 1. Ensure a fall assessment and reassessment was conducted to identify the risk factors and cause of each fall, in accordance with the facility ' s Fall Management Program. 2. Ensure the care plan interventions were revised after each unwitnessed falls ([DATE], [DATE] and [DATE]) by addressing what caused the fall that included identifying the resident ' s behavior, poor safety awareness due to severe cognition impairment and inability to communicate as a result of dementia (a progressive state of decline in mental abilities), in accordance with the facility ' s P&P on Dementia Care. 3. Ensure to communicate to all facility staff Resident 1 ' s need for a person-centered observation or monitoring systems to address the identified risk factors for falls, in accordance with the facility P&P on Resident Safety. As a result of these deficient practices, Resident 1, who had an unwitnessed fall with no injuries inside his room due to getting up unassisted on [DATE] and [DATE], sustained another unwitnessed fall on [DATE] at 8:07 PM. Resident 1 complained of left hip pain, head pain, bruising to the left forehead and was transferred to the General Acute Care Hospital (GACH) on [DATE] via 911 emergency services. The GACH indicated Resident 1 sustained a fracture (a break in the bone) to the left upper leg. The GACH record indicated Resident 1 underwent a left hip hemiarthroplasty (a surgical procedure that replaces or reconstructs a joint) on [DATE]. Findings: During a review of Resident 1 ' s admission Record [AR], the AR indicated the resident was originally admitted on [DATE], and readmitted on [DATE], with diagnoses that included dementia, Alzheimer ' s disease (a disease characterized by a progressive decline in mental abilities), fractures, and muscle wasting (weakening, shrinking, and loss of muscle). During a review of Resident 1 ' s History and Physical (H&P), dated [DATE], the H&P indicated the resident had the capacity to understand and make decisions. During a review of Resident 1 ' s care plan for impaired communication, initiated on [DATE], revised on [DATE], included interventions initiated on [DATE], to evaluate Resident 1 ' s ability to comprehend. During a review of Resident 1 ' s care plan for communication, initiated on [DATE], indicated the resident has communication problems related to her confusion, language barrier, and dementia. During a review of Resident 1 ' s care plan for safety, initiated on [DATE], indicated the resident has poor safety awareness related to impaired cognition and attempts to perform [activities of daily living] beyond physical ability. Resident self-propels in wheelchair. The care plan added the resident is at risk for falls, elopement, and injury. The care plan included interventions for facility staff to include strategies to reduce the risk of falls and injury. During a review of Resident 1 ' s care plan for falls, initiated on [DATE], indicated the resident is at risk for falls related to history of falls, dementia, Alzheimer ' s disease, poor safety awareness, and wheeling self around in the wheelchair and a Fall Score of 15 (High Risk for Falls). The care plan included the following interventions initiated on [DATE]: -Assist Resident with ambulation (walking) and transfers, utilizing therapy recommendations. -Determine Residents ability to transfer. -Evaluate fall risk of admission and [as needed]. -If fall occurs, alert provider. -If fall occurs, initiate frequent neuro and bleeding evaluation per facility protocol. -If resident is a fall risk, initiate fall risk precautions. During a review of Resident 1 ' s Minimum Data Set (MDS – a federally mandated resident assessment tool), dated [DATE], the MDS indicated the resident had severely impaired cognition (the ability to process thoughts). The MDS indicated the resident requires substantial assistance (helper does more than half the effort) on activities such as toileting, bathing, dressing, changing position from sitting to lying and lying to sitting on side of the bed. The MDS also indicated the resident is dependent (helper does all the effort on activities such as transferring from chair to chair or bed to chair. The MDS also indicated the resident was not assessed on activities such as sitting to stand due to medical condition or safety concerns. Further review of the MDS also indicated Resident 1 requires supervision (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) to operate and move while on a manual wheelchair for at least 150 feet. The MDS assessment did not indicate that the resident had any falls prior to MDS assessment, admission/readmission/entry/reentry from the facility. During a review of Resident 1 ' s Fall Risk Evaluation (FRE), dated [DATE], the FRE indicated the following information regarding Resident 1 ' s fall risks: -Resident 1 had no falls in past 3 months. -Resident 1 had intermittent confusion. -Resident 1 was chairbound (state of being confined to a chair/wheelchair) and incontinent (does not have the ability to control over urination or defecation). -Resident 1 had 1 to 2 predisposing diseases. -Resident 1 had a change in condition in the last 14 days from the time of assessment. -Resident 1 was recently hospitalized from the time of assessment due to hypotension (low blood pressure) and bradycardia (slow heart rate). -Resident 1 was taking 1 to 2 medications at the time or within the last 7 days of assessment. -Resident 1 was at risk for falls. -Interventions included to assist resident with ambulation and transfers, determine resident ' s ability to transfer, evaluate fall risk on admission and [as needed], and if resident is a fall risk, initiate fall risk precautions. During a review of a physician order dated [DATE], indicated an order for Resident 1 to have bilateral landing pads (or floor mat, (a thin foam that is placed beside the bed as a cushion for when a resident falls) due to risk of falls. Check for placement every shift. During a review of Resident 1 ' s Change in Condition Evaluation (CIC), dated [DATE], timed at 10:49 PM, the CIC indicated Resident 1 was, observed to be sitting up right [at] her bedside atop the landing pad. During a review of a physician order dated [DATE] (five months after the [DATE] fall), indicated an order for Resident 1 to have a bed alarm to remind resident not to get up unassisted. The order further indicated for the charge nurse to monitor for proper placement and function. Every shift document Y if the alarm is in place and functioning properly, and N if not. During a review of a physician order dated [DATE] (five months after the [DATE] fall), indicated an order for Resident 1 to have a wheelchair alarm to remind resident not to get up unassisted. The order further indicated for the charge nurse to monitor for proper placement and function every shift. During a review of Resident 1 ' s Fall Risk Evaluation (FRE), dated [DATE], the FRE indicated the following information regarding Resident 1 ' s fall risks: - Resident 1 had no falls in past 3 months. - Resident 1 was disoriented (confused) x 3 at all times. - Resident 1 was chairbound and incontinent. - Resident 1 had poor vision (with or without glasses). - Resident 1 had 1 to 2 predisposing diseases. - Resident 1 had balance problems while standing and walking. - Resident 1 requires the use of assistive devices such as a cane, wheelchair, or walker. - Resident 1 was taking 3 to 4 medications at the time or within the last 7 days of assessment. During a review of Resident 1 ' s care plan for risk of falls, initiated on [DATE], revised on [DATE], the care plan indicated the resident is at risk for falls related to confusion, gait and balance problems, poor communication and comprehension, and unaware of safety needs. The care plan included the following interventions: May have a bed alarm to remind resident not to get up unassisted. Charge nurse to monitor for proper placement and function, initiated on [DATE] (two months after Fall Risk Evaluation on [DATE]). -May have a wheelchair alarm to remind resident not to get up unassisted. Charge nurse to monitor for proper placement and function, initiated on [DATE] (two months after Fall Risk Evaluation on [DATE]). Anticipate and meet the resident ' s needs. During a review of Resident 1 ' s Fall Risk Evaluation (FRE), dated [DATE], timed at 4:11 PM, the FRE indicated the resident the following information regarding Resident 1 ' s fall risks: -Resident 1 had no falls in past 3 months. -Resident 1 was disoriented (confused) x 3 at all times. - Resident 1 was chairbound and incontinent. - Resident 1 had poor vision (with or without glasses). - Resident 1 had 1 to 2 predisposing diseases. - Resident 1 had balance problems while standing and walking. - Resident 1 requires the use of assistive devices such as a cane, wheelchair, or walker. - Resident 1 was taking 3 to 4 medications at the time or within the last 7 days of assessment. During a review of Resident 1 ' s CIC, dated [DATE], timed at 11:20 PM, the CIC indicated the resident had an unwitnessed fall. The CIC indicated facility staff, heard an alarm coming from [Resident 1 ' s room]. The CIC indicated the Resident 1 was sitting down on the floor next to her bed. The CIC added that the resident was unable to state what occurred, however, she was noted with facial redness. During a review of Resident 1 ' s Fall Risk Evaluation (FRE), dated [DATE], timed at 11:17 PM, signed by the Assistant Director of Nursing (ADON), the FRE indicated if the total score was 10 or greater, the resident is considered as high risk for potential falls, prevention protocol should be initiated immediately and documented on the care plan. The FRE indicated the following information regarding Resident 1 ' s fall risks: -Resident had a history of 3 or more falls in past 3 months. -Resident 1 was disoriented x 3 at all times. -Resident 1 was chairbound and incontinent. -Resident 1 had poor vision (with or without glasses). -Resident 1 had a change in condition in the last 14 days. -Resident 1 ' s gait (ability to walk) and balance were not assessed. The evaluation was blank. -Resident 1 was taking 3 to 4 medications at the time or within the last 7 days of assessment. The FRE did not include interventions on the FRE Sections for 5. Risk for Falls, to indicate if Resident 1 was at risk for falls and Clinical Suggestions During a review of Resident 1 ' s Post Fall Evaluation (PFE) dated [DATE], timed at 11:23 PM, the PFE indicated the resident had a fall on [DATE]. The PFE indicated the resident ' s Pre-Fall Score was 15 (High Risk) and the resident Post Fall Score was now a 17 (High Risk). The PFE indicated the resident did not sustain any injuries from this fall. The PFE indicated Resident 1 was unable to state what she was doing (prior to the fall). During a review of Resident 1 ' s IDT Progress Notes- Falls, dated [DATE], timed at 11:58 AM, the IDT note indicated on [DATE] at 11:00 PM, the nurse heard an alarm coming from Resident 1 ' s room. The notes indicated the nurse found Resident 1 sitting down on the floor next to the bed. The notes indicated the root cause of the fall was poor safety awareness, impaired cognition, and unsteady gait and transfer. The notes indicated interventions such as remind resident regarding safety precautions, bed and wheelchair alarm, bed on the lowest position, and floor mats. During a review of Resident 1 ' s CIC, dated [DATE], timed at 8:07 PM, indicated the resident had another fall. The CIC indicated the resident took self to room and attempted to be independent without calling for help. The CIC indicated the wheelchair alarm sounded and when staff responded, the resident was noted on the floor, reaching for left hip/facial grimacing. The CIC also indicated the resident had skin discoloration on left top of head. The CIC added the resident was transferred via 911 at 8:37 PM. During a review of a physician order dated [DATE], the order indicated May transfer [Resident 1] via 911 due to [status post/after] fall for further evaluation 7 days bed hold. During a review of Resident 1 ' s care plan for impaired cognitive function or impaired thought processes, initiated on [DATE], and revised on [DATE], the care plan included goals for the resident to maintain safety by the review date. The care plan indicated to cue, reorient, and supervise [Resident 1] as needed. During a review of Resident 1 ' s Actual Fall care plan that happened on [DATE] at 11 PM (night shift), the care plan developed on [DATE], indicated the resident sustained another unwitnessed fall on [DATE] at 8:07 PM (evening shift). The care plan included the following interventions with corresponding dates of initiation: -Monitor for hypoglycemia (low blood sugar levels) [related to] Insulin (injectable medication that is used to control the blood sugar) use, initiated on [DATE], revised on [DATE]. -Monitor for hypoglycemia and bradycardia [related to] Glimepiride (oral medication used to control the blood sugar) use, initiated on [DATE], revised on [DATE]. -Monitor for dizziness, hypotension, and bradycardia [related to] Amlodipine (oral medication used to control or lower the blood pressure) use, initiated on [DATE], revised on [DATE]. -Hypotension can cause dizziness or blurry vision which may increase the risk of falling. Please monitor [blood pressure] as indicated, initiated on [DATE], revised on [DATE]. -Low vitamin D level may cause muscle weakness, initiated on [DATE], revised on [DATE]. -May have a bed alarm to remind resident not to get up unassisted. Charge nurse to monitor for proper placement and function, initiated on [DATE]. -May have a wheelchair alarm to remind resident not to get up unassisted. Charge nurse to monitor for proper placement and function, initiated [DATE] -For no apparent acute injury, determine and address causative factors of the fall, initiated [DATE]. During a review of the resident ' s entire care plans on [DATE] at 12:09 PM in the presence of Assistant Director of Nursing (ADON), the ADON stated the resident ' s care plans did not address Resident 1 ' s specific behavior and poor safety awareness/inability to communicate, which caused the multiple falls, but instead focused on the resident ' s medications. The ADON stated the care plans did not have updated interventions to address the resident ' s behavior and poor safety awareness after the fall happened again on [DATE], because the bed alarms and wheelchair alarms were ordered on [DATE] and, therefore, they were not new fall interventions. The ADON further stated frequent visual checks or close monitoring of Resident 1 or moving Resident 1 closer to the Nurse Station would have prevented the resident ' s fall with injury on [DATE]. During a review of the resident ' s entire medical records on [DATE] at 12:09 PM in the presence of the Assistant Director of Nursing (ADON), the resident ' s medical records did not indicate documented evidence that the resident was assessed if the resident understood that the sound of the wheelchair alarm meant for the resident not to get up unassisted. During a review of the resident ' s entire medical record on [DATE] at 12:09 PM in the presence of the ADON, the resident ' s medical records did not indicate documented evidence that the resident was closely monitored prior to the fall on [DATE]. During a review of Resident 1 ' s Trauma Surgery History and Physical (H&P) from the GACH, dated [DATE], timed at 11:12 PM, the GACH H&P indicated Resident 1 was brought into the GACH by emergency medical services (EMS 911). The GACH H&P indicated Resident 1 ' s chief complaint indicated left hip and head pain. The H&P indicated Resident 1 ' s left forehead showed bruising, and the left lower extremity was tender to palpation (touch) over the hip. The GACH H&P also indicated Resident 1 sustained a left hip fracture. During a review of Resident 1 ' s GACH Orthopedic Surgery Consult note, dated [DATE], the note indicated the resident sustained a left displaced femoral neck (a part of the thigh bone) fracture after a fall. The note indicated the resident will have a plan for a left hemiarthroplasty. During a review of Resident 1 ' s GACH Advanced Care Planning Note, dated [DATE], the note indicated the resident underwent a left hip hemiarthroplasty on [DATE]. The notes also indicated Resident 1 has not had meaningful recovery. During a review of Resident 1 ' s GACH Advanced Care Planning Note, dated [DATE], the note indicated the resident ' s health status has declined both mentally and physically since [the resident ' s] [hospital] admission/surgery, despite full support. The note indicated Resident 1 ' s family member (FM) wishes to change [the resident ' s] code status (type of emergent treatment a person would or would not receive if their heart or breathing were to stop) to do not attempt resuscitation (DNR, medical order that directs healthcare providers not to perform cardiopulmonary resuscitation (CPR, an emergency lifesaving procedure when the heart stops beating). During a phone interview on [DATE] at 3:19 PM with Licensed Vocational Nurse (LVN) 5, LVN 5 stated that on [DATE], about 20 minutes prior to Resident 1 ' s fall, LVN 5 saw Resident 1 on her wheelchair in the hallway. LVN 5 stated she was called by Certified Nursing Assistant (CNA) 5 into Resident 1 ' s room. LVN 5 stated when she arrived inside Resident 1 ' s room, the wheelchair alarm was ringing and the resident was lying on the floor next to the wheelchair, on her left side. LVN 5 stated Resident 1 appeared to have pain in her head and the left side of her body. LVN 5 added when the resident was interviewed, the resident was not able to provide an answer as to what happened prior to the fall. During a phone interview on [DATE] at 9:48 AM with CNA 2, CNA 2 stated Resident 1 wheels herself around the facility. CNA 2 stated Resident 1 is able to stand up with staff assistance. CNA 2 further added when the wheelchair alarm sounds, it means the resident wants something. CNA did not state that the wheelchair alarm indicated the resident is trying to get up unassisted. During a phone interview on [DATE] at 10:23 AM with CNA 3, CNA 3 stated Resident 1 is confused and wheels self around the facility using her wheelchair. CNA 3 stated Resident 1 usually goes back to bed at around 7:00 PM to 8:00 PM every night. During the same phone interview on [DATE] at 10:27 AM with CNA 3, CNA 3 stated on [DATE] at 7:55 PM, he saw Resident 1 on the wheelchair in the hallway. CNA 3 stated he was tending to another resident when he heard an alarm ring at around 8:07 PM. CNA 3 stated he went to Resident 1 ' s room immediately, and he saw the resident lying on the floor next to the wheelchair. CNA 3 could not recall the exact time that he responded to Resident 1 ' s room. CNA 3 stated LVN 5, Treatment Nurse (TN) 1, and Registered Nurse (RNS) 2 responded when he called for help. CNA 3 added Resident 1 is not a resident that is on close monitoring by staff. During an interview and concurrent record review on [DATE] at 11:26 AM with TN 1, Resident 1 ' s entire medical records were reviewed. TN 1 stated Resident 1 is confused and does not follow commands. TN 1 stated Resident 1 ' s medical records did not indicate that the resident would be and was closely monitored by facility staff as an added intervention to prevent further falls, as indicated in the facility ' s P&P, titled Fall Management Program, residents may require more frequent observation of activities and whereabouts. During a phone interview on [DATE] at 11:50 AM with RNS 2, RNS 2 stated Resident 1 does not know how to follow directions because of confusion related to dementia. RNS 2 stated Resident 1 ' s use of the wheelchair alarm is not new, because it has been used previously, before Resident 1 ' s fall on [DATE]. RNS 2 stated Resident 1 ' s room was not in front of any of the Nurses ' Station for closer monitoring. RNS 2 further added Resident 1 is a high fall risk resident. During an interview and record review on [DATE] at 12:09 PM with the ADON, Resident 1 ' s medical records were reviewed. The ADON stated the bed and wheelchair alarm was ordered and placed for Resident 1 ' s use since 12/2024 (before [DATE] and [DATE] episodes of falls), to remind the resident not to get up unassisted. The ADON stated there was no documented evidence in the medical records that Resident 1 understood that the sound coming from the bed and wheelchair alarm meant to remind the resident not to get up by herself. The ADON stated the use of the wheelchair alarm did not work because Resident 1 fell on [DATE]. During the same interview on [DATE] at 12:09 PM with the ADON, the ADON stated other interventions added in the Resident 1 ' s Actual Fall care plan initiated on [DATE] in response to the resident ' s fall on [DATE], that included monitoring for hypoglycemia, bradycardia, dizziness, and hypotension, were not adequate enough to prevent further falls because Resident 1 ' s fall was related to the resident ' s behavior of trying to get up unassisted. The ADON stated the resident ' s care plan should have included strategies to prevent falls such as frequent visual checks/monitoring and/or moving the resident closer to the Nurses ' Station would have been the appropriate interventions to prevent the resident from repeated falls. The ADON stated if Resident 1 ' s bed or wheelchair alarm was already ringing, it will already be too late, because that means Resident 1 was already trying to get up. During an interview on [DATE] at 1:10 PM with Director of Nursing (DON), the DON stated the cause of Resident 1 ' s fall on [DATE] was due to the resident ' s lack of safety awareness and getting up without staff assistance. The DON stated changing the resident ' s room to a room closer to the Nurses ' Station would be hard because of the resident ' s diagnosis of dementia. The DON stated that if the resident ' s room was changed to a room near the Nurses ' Station for closer monitoring, after the fall on [DATE], it could have changed the outcome of the resident ' s fall on [DATE], but stated he was not sure of what the outcome would be. During an interview and concurrent record review on [DATE] at 3:01 PM with the ADON, Resident 1 ' s entire medical records were reviewed that included the nurses' notes, care plans, IDT progress notes, CICs. The ADON stated Resident 1 ' s IDT Progress Notes- Falls, dated [DATE], documented at 11:58 AM, did not indicate that changing Resident 1 ' s room to a room closer to the station or frequent/closer staff monitoring was discussed. The ADON also stated there is no documented evidence that Resident 1 ' s roommates were interviewed regarding the fall on [DATE]. During a review of the facility ' s P&P, titled Fall Management Program, revised [DATE], indicated the following: a. Interdisciplinary (IDT) and/or licensed nurse will develop a care plan according to the identified risk factors and root cause of the fall. b. The licensed nurse will evaluate the resident ' s response to the interventions on the weekly summary and update the resident ' s care plan as necessary. c. Residents may require more frequent observation of activities and whereabouts. d. Residents may require a structured environment or routine. During a review of the facility ' s P&P titled, Resident Safety, revised [DATE], indicated the following: a. The IDT will establish a person-centered observation or monitoring systems for the resident to address the identified risk factors identified. b. To observe the safety and wellbeing of the residents, a resident check will be made at least every two hours around the clock by nursing service personnel. The person-centered care plan may require more frequent safety checks. During a review of the facility ' s P&P titled, Dementia Care, revised 10/2017, indicated the following regarding the care of a resident with a diagnosis of dementia: a. The resident ' s plan of care will reflect a baseline of common behaviors (target behaviors) exhibited by the resident, interventions and specific goals. b. Behavioral interventions are individualized approaches that are provided as part of a supportive physical and psychosocial environment, and are directed toward understanding, preventing and relieving, a resident ' s distress or to accommodate loss of abilities. c. The IDT will develop plans of care and interventions in an attempt to understand and address behaviors as a form of communication and modify the environment and daily routines to meet the resident ' s needs/preferences. d. Interventions will be assessed, including benefits and complications of interventions, in a timely manner. e. Interventions will be regularly monitored for efficacy, risks, and benefits.

Based on observation, interviews, and record reviews, the facility failed to provide treatments and services for two of two sampled residents (Residents 1 and 2) by failing to: 1. Ensure Resident 1's food allergy and allergic reaction to fish were transcribed and verified in the resident's Dietary Profile and Meal Ticket, in accordance with the facility's policy and procedure on Food Allergies and Reference Sheets, and Diet Record Maintenance to alert facility staff of the resident's food allergies. 2. Ensure Resident 1's care plan (a nursing care plan provides direction on the type of nursing care the individual may need) on food allergy was developed to include the type of allergic reaction manifested by the resident and implemented the care plan on food allergy (fish allergy) to ensure Resident 1 was free from allergic reaction. 3. Ensure Licensed Vocational Nurse (LVN) 3 communicated with the facility's Dietary Department by indicating Resident 1's fish allergy on the Diet Communication Slip upon Resident 1's admission to the facility on [DATE], as indicated in Resident 1's Order Summary Report and in accordance with the facility's policy and procedure titled Diet Orders. 4. Ensure the facility's Dietary Supervisor (DS) checked Resident 1's Allergy Report found in the resident's electronic records and General Acute Care Hospital (GACH) 1's History and Physical (H&P), during initial resident interviews. In addition, to check accuracy of the Dietary Communication Slip, the resident's Diet Type Report (a list of residents, their corresponding diets and other information such as allergies) and Meal Tickets, in accordance with the Dietary Supervisor's documented Job Description. 5. Ensure Resident 2's care plan on food allergies to eggs, milk and milk products, shrimp, wheat, beef, tomato, pork, orange juice was implemented. 6. Ensure the facility had a system in place for licensed nurses, certified nurse assistants, dietary supervisor, and kitchen staff to implement the facility's policy and procedure titled Food Allergies and Reference Sheets, to ensure the resident's entire care team (interdisciplinary team) is made aware of Residents 1 and 2's food allergies and its reaction. The facility was aware Resident 1 had fish allergy but Resident 1 was served fish on [DATE] (tuna salad sandwich) and [DATE] (lemon ginger fish). The facility was aware Resident 2 was allergic to wheat, but on [DATE], during a lunch tray line (an area used to dish out resident's food) observation, the kitchen staff served triple fruit crisp and garlic white bread that contained wheat, to Resident 2. As a result of these deficient practices, Resident 1 had an allergic reaction on [DATE], after eating fish for lunch. Resident 1 had difficulty breathing and was observed with watery eyes and swollen face. The facility's licensed nurses called 911 emergency medical services (EMS), EMS intubated (healthcare provider inserts a tube through person's mouth or nose down to their airway) Resident 1 and administered three doses of epinephrine (used in emergencies to treat very serious allergic reactions). Resident 1 passed away upon arrival to the General Acute Care Hospital (GACH) 2 emergency room (ER) due to anaphylaxis (severe allergic reaction including closure of airways). This deficient practice had the potential to cause life-threatening conditions such as anaphylactic shock (severe allergic reaction including closure of airways), severe tachycardia (increased heart rate), cardiac arrest (heart stops beating suddenly) and death for Resident 2. On [DATE] at 7 PM, while onsite at the facility, the Director of Nursing (DON) and the Administrator (ADM) were verbally notified of 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) situation regarding the facility's failure to have a system in place for licensed nurses, certified nurse assistants, dietary supervisor, and kitchen staff to ensure the resident's entire care team (interdisciplinary team) is made aware of Residents 1 and 2's food allergies and its reaction. Resident 1, who was identified as having food allergies to fish was served fish on [DATE] and [DATE], that resulted to Resident 1's death. Resident 2, who was identified as having food allergy to wheat was served wheat on [DATE]. On [DATE] at 7:13 PM, the IJ was removed in the presence of the ADM, DON, Registered Dietitian (RD) 1, Nursing Consultant 1 (NC 1) and NC 2 after the facility submitted an acceptable 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) and the surveyor verified and confirmed onsite the facility's implementation of the IJ Removal Plan. The accepted IJ Removal Plan indicated the following information: 1. Registered Dietitian (RD) 1 educated Resident 2 about avoiding food that she was allergic to minimize adverse reaction. RD 1 reviewed all resident's meals served on [DATE] to ensure accuracy on meals served for breakfast prior to distribution of trays to the residents. RD 1 observed dietary staff during meal preparation on [DATE] for breakfast, lunch, and dinner to ensure tray accuracy before the trays were served to the residents. RD 1 in-serviced nursing staff on [DATE], about wheat allergy and wheat containing foods. 2. RD 1 conducted training with dietary staff on [DATE], including aides and cooks regarding diet communication form processing, meal ticket creation, meal preparation following recipes and spreadsheet, tray line process and food allergies. RD 1 conducted interviews with all residents with food allergies and food preferences to ensure accuracy of allergies transcribed on the meal tickets based on Residents medical records. 3. The DON provided education to LVNs (Licensed Vocational Nurses) and Certified Nursing Assistants (CNA) on [DATE], regarding food allergies, meal tray verification and tray accuracy. 4. The DON audited the Nutritional Care plans to ensure that allergies and allergic reactions of all residents with known allergies are entered in the care plans. 5. The DON provided in-service education to LVN 3 who admitted Resident 1 on [DATE], regarding completion of dietary communication of diet orders and restrictions, allergies with the kitchen staff. The DON and DSD provided in-service on [DATE] to LVNs regarding the process of communication of diet orders, restrictions, allergies to the kitchen. 7. The Regional Dietitian provided education on [DATE], [DATE] and [DATE] to Cooks and Dietary Staff on the following: Diet Communication Form Processing, Meal ticket creation, meal preparation following the recipe and spreadsheet, tray line process and food allergies. 8. The Regional Dietitian updated Resident 2's Dietary Profile and care plan on [DATE] for food preferences, food allergies and meal tray ticket. The Regional Dietitian reverified Resident 2's food allergies and updated Resident 2's meal tray ticket indicating the food allergies of Resident 2 according to the Dietary Profile. 9. Resident 2's physician placed an order for Resident 2 to obtain an allergy test determining allergy severity and reactions to wheat. The physician will notify Resident 2 and her family upon the receipt of the allergy test. 10. Licensed Nurses and RD 1 revised Resident 2's Nutritional Comprehensive Care Plan on [DATE] based on Resident 2's dietary interview. 11. The facility designee conducted a meal tray verification learning validation testing on [DATE] to the two LVNs and CNAs who verified Resident 2's meal tray on [DATE]. 12. The DON, designee and dietary manager reviewed and audited 99 current diet orders, allergies, tray cards on [DATE] to ensure all dietary allergies were reflected on resident's records. 13. The DON and designee conducted rounds and observations of current residents and assessed if any residents were exhibiting signs and symptoms of allergic reactions. 14. The Regional Dietitian conducted a second audit of the diet orders, dietary profiles and meal ticket to ensure diet restrictions, preferences and food allergies are accurately entered in the system. No other residents were identified. 15. The DON reported to the attending physician of four (4) other residents who had no history or were unable to recall allergic reactions. Attending physician ordered an allergy test. The facility drew an allergy test on [DATE] to the 4 residents. The attending physician will notify the resident and family of the allergy test. 16. The Regional Dietitian audited and observed the following on [DATE] - Conducted skill competency validation to the dietary staff regarding transcription of dietary orders, restrictions, food preferences, and allergy information into the Resident Dietary System (RDS) to generate accurate meal tickets. - Observed dietary staff during the meal preparation for breakfast, lunch, and dinner. - Observed tray line service for breakfast, lunch, and dinner for tray accuracy prior to placing the meal trays in the meal cart. 17. The Regional Dietitian provided in-service education to nursing staff on wheat allergen and food to avoided. 18. The Regional Dietitian will orient, train, and conduct competency regarding dietary policies and procedures, diet communication from processing meal ticket, RDS system, meal preparation, tray line, food allergies, dietary profile, and care plan development once the Dietary Manager was hired. 19. The facility implemented of the new process on how to handle food allergy on [DATE]: The dietary manager will conduct an audit of current diet orders, diet order and communication forms, food allergies, meal tray ticket from the RDS system, dietary profile, and care plan weekly for 4 weeks then bi-monthly for 2 months to ensure accuracy of diet of residents. Cross Reference to F806 Findings: A review of Resident 1's Admission Record indicated the facility admitted the resident on [DATE], with diagnoses that included Type 2 diabetes mellitus (DM, a health condition when the body does not use insulin properly causing increase in blood sugar), chronic obstructive pulmonary disease (COPD-a group of lung diseases that block airflow and make it difficult to breathe), and essential hypertension (high blood pressure). A review of Resident 1's Minimum Data Sheet (MDS, a standard assessment tool that measures health status), dated [DATE], indicated the resident's cognition (a mental process that take place in the brain, including thinking, attention, language, learning, memory, and perception) was severely impaired. The MDS indicated Resident 1 needed partial/moderate (helper does less than half of the effort. Helper lifts, holds, or supports trunk or limbs and provides more than half the effort) assistance when eating. A review of Resident 1's physician diet order, dated [DATE], indicated Resident 1's diet was No Added Salt (NAS, no salt packet on the tray) consistent carbohydrates (CCHO, the same amount of carbohydrate served each meal), regular texture, thin consistency. A review of Resident 1's GACH 1 History and Physical (H&P, details of physician examination of the resident), dated [DATE], indicated, Resident 1's allergic reaction to fish was anaphylactic reaction. A review of Resident 1's Order Summary Report, for [DATE], signed by Physician 1 on [DATE], indicated Allergies: fish. A review of Resident 1's Allergy Report printed by the facility with created date [DATE] indicated Resident 1 had a food allergy and the allergy was Fish. The Allergy Report severity indicated unknown. The Allergy Report indicated blank on Reaction Manifestation and blank on Reaction Note. A review of a facility document titled Diet Communication Slip dated [DATE], and signed by LVN 3, indicated Resident 1's name, room number, regular diet, no concentrated sweets, no added salt diet. The Allergies Section of the Diet Communication Slip was left blank. A review of Resident 1's care plan indicated that on [DATE], a care plan was developed for Resident 1's food allergy, titled Resident allergic to fish and at risk for allergic reaction (4 days after the physician's order summary report indicating the resident was allergic to fish). The care plan indicated a goal for Resident 1 to be free of allergic reaction through the next review date. The care plan interventions included, to list all allergies in the resident's face sheet, have an allergy sticker on the chart, list allergies to medications, and treatment administration sheet. The care plan interventions also included to notify the physician for further change of condition or allergic reaction, and to administer antihistamine (a class of drugs commonly used to treat symptoms of allergies) as ordered. A review of the facility's fall menu spreadsheet dated [DATE], approved by RD 2 on [DATE] indicated, CCHO, NAS diet included the following food item on the tray: Lemon ginger fish 3 ounces (oz, a unit of measurement) A review of the facility's recipe titled Lemon-Ginger Fish not dated, indicated ingredients included: fish fillet, thawed (suggest tilapia, pangasius-swai, cod), ginger, jarred or ginger, ground, melted margarine, lemon juice and salt. A review of a physician's telephone order dated [DATE] timed 12:30 PM, authored by the case manager (CM), indicated an order for Resident 1 to receive Epinephrine Injection kit 1 milligrams (mg/milliliter (ml) (a unit of measurement) inject 1 mg intramuscularly (under the muscle) one time only for anaphylaxis (a severe, potentially life-threatening allergic reaction). A review of Resident 1's progress notes from [DATE] to [DATE], with a note titled SBAR [Situation, Background, Assessment and Recommendations] Summary for Providers dated [DATE] signed by Registered Nurse (RN) 1 timed at 12:30 PM, indicated, At 12:15 PM, Certified Nursing Assistant (CNA 1) served lunch plate to Resident 1. Around 12:25 PM, the resident called the CNA and complained of shortness of breath. CNA (CNA 1) called LVN (LVN 2), and he paged Registered Nurse 1 (RN 1) to assess Resident 1 around 12:26 PM. Resident 1 was assessed at 12:28 PM, Resident 1's Oxygen saturation (amount of oxygen circulating in the blood) was at 88% (normal oxygen saturation: 95 to 100%). RN 1 administered oxygen 2 liters via nasal cannula (a medical device to provide supplemental oxygen therapy to people who have lower oxygen level) and elevated the resident's head of bed. Oxygen saturation was rechecked, and it was 91%. RN 1 asked Case Manager (CM) to call Resident 1's physician around 12:30 PM. (Physician 1) ordered epinephrine 1 mg via intramuscular (under the muscle) injection and to call 911 emergency service. LVN 1 was delegated to call 911 around 12:31 PM. Around 12:32 PM, epinephrine was administered to left thigh of Resident 1 but no effect. No vital signs (clinical measurements, specifically pulse rate, temperature, respiration rate, and blood pressure, that indicate the state of a patient's essential body function) appreciated (found or noted) around 12:35 PM. CPR (cardiopulmonary resuscitation [an emergency life-saving procedure that is done when someone's breathing or heartbeat has stopped]) initiated and 911 (EMS) came around 12:38 PM and took over to continue CPR and resident was taken to (GACH 2) around 1 PM. A review of Resident 1's Fire Department Patient Care Report, dated [DATE], timed at 1:03 PM, indicated Emergency Medical Services (EMS) was notified at 1:03 PM, EMS was dispatched at 1:04 PM, En route at 1:05 PM, and arrived at the facility at 1:07 PM. The Report indicated under EMS Narrative Resident 1 was found in bed pulseless (a condition where your heart stops), apneic (a temporary stop of breathing), pupils fixed/dilated (when the black circles in the colored part of the eyes [iris] gets larger, usually caused by brain damage/injury), unresponsive. The Report indicated that upon arrival the EMS arrival, they found facility staff performing CPR on Resident 1, for approximately 3 minutes. The Report indicated that according to facility staff, Resident 1 was Seen approximately 10 minutes before being found in full cardiac arrest, conversing and being alert and oriented times 3 (patient is alert and oriented to person, place and time). The Report indicated Per facility staff patient (Resident 1) had eaten lunch, which was a fish meal. Unknown if patient has any allergies to fish . A review of Resident 1's GACH 2 records dated [DATE] titled ED Provider Notes authored by the ED Physician, indicated (Resident 1) was brought in from the (facility) where the resident was in cardiac arrest, CPR for 18 minutes. The ED Physician wrote that according to the paramedics, 3 (three) epinephrine were given and Resident 1 lost pulses and ED Physician immediately intubated Resident 1. The ED Physician wrote Resident 1 was given another epinephrine and CPR was continued until the ultrasound (an imaging method that uses sound waves to produce images of structures within the body) showed no heart movement at 1:53 PM. At 2:06 PM, Resident 1 was defibrillated (use of electrical current to help a person's heart return to normal rhythm) in the ED and there was no change in heart movement at 2:06 PM. The ED Physician wrote Diagnosis Death secondary to cardiac arrest with severe metabolic (a condition in which acids build up in the body) and respiratory acidosis (occurs when the blood is too acidic due to high levels of carbon dioxide [the gas formed when carbon is burned, or when people or animals breathe out). The ED Physician further wrote that he spoke to Resident 1's attending physician, Physician 1, who stated Resident 1 was allergic to fish and she was given fish. During an interview on [DATE] at 9:15 AM, CNA 1 stated she worked on [DATE] during the 7 AM to 3 PM shift and was assigned to Station 1 and to Resident 1. CNA 1 stated on [DATE] at around 12:30 PM, she responded to Resident 1's call light and upon CNA 1's entrance to Resident 1's room, Resident 1 verbalized to her that she was having an allergic reaction to fish. CNA 1 stated, Resident 1 was exhibiting shortness of breath. CNA 1 stated she ran out of Resident 1's room to get the oxygen tank and informed LVNs 1 and 2, who both attended to Resident 1. CNA 1 stated the kitchen staff served fish that looked like tilapia to Resident 1 for lunch. CNA 1 stated Resident 1 ate the whole fish. CNA 1 stated, she was aware that Resident 1 was allergic to fish and seafood but unsure of the allergic reaction. CNA 1 could not recall who passed Resident 1's lunch tray on [DATE]. During an interview on [DATE] at 10:46 AM, LVN 1 stated he worked on [DATE] during the 7 AM to 3 PM shift as a desk nurse. LVN 1 stated he observed Resident 1 coughed, held her neck with swollen face, and had watery eyes. LVN 1 stated that Resident 1 stated she had a hard time breathing. LVN 1 further stated that LVN 2 checked the facility's electronic medical records for Resident 1's food allergy and the resident's records indicated Resident 1 was allergic to fish. LVN 1 stated he was aware Resident 1 was allergic to fish as he saw fish as food allergy indicated in the resident's Medication Administration Record (MAR, a record detailing the medications given to the residents by a healthcare professional). LVN 1 stated the fish came from Resident 1's lunch tray served by the facility's kitchen. LVN 1 stated RN 1 told the Case Manager (CM) to call Resident 1's physician (Physician 1). During an interview on [DATE] at 3:44 PM, the DON stated according to her investigation, RN 1 and LVN 2 administered oxygen while Resident 1 was having shortness of breath. The DON stated Resident 1 ate fish that came from the facility's kitchen during lunch meal on [DATE]. The DON stated that based on their investigation, RN 1 and LVN 2 checked Resident 1's meal tray for accuracy and Resident 1's Meal Ticket did not indicate Resident 1 was allergic to fish. The DON stated the DS did not indicate Resident 1's allergy to fish on the resident's Meal Ticket. The DON stated the DS could not say if he checked Resident 1's electronic medical records to confirm. The DON stated Resident 1 passed away on [DATE]. During an interview on [DATE] at 4 PM, the ADM stated that on [DATE], he had witnessed Resident 1's change of condition (allergic reaction) around 12:15 PM to 12:30 PM, however, he got out of the scene so nursing staff could take care of the situation. The ADM stated Resident 1's fish allergy was indicated in the electronic medical records; however, the DS did not indicate the fish allergy on Resident's 1 meal ticket. The ADM stated the incident could have been avoided if the DS checked the electronic medical records for Resident 1's food allergy and indicated the fish allergy on the meal ticket correctly. The ADM stated the DS's employment was terminated from the facility. During a telephone interview on [DATE] at 4:12 PM, LVN 2 stated he worked on [DATE] during the 7 AM to 3 PM shift at Station 1. LVN 2 stated that at around 12:20 PM, CNA 1 called him for help because Resident 1 was having difficulty breathing. LVN 2 stated Resident 1 told him she was having a hard time breathing because she ate fish. LVN 2 stated Resident 1 told him she was allergic to fish when he arrived in Resident 1's room. LVN 2 stated the fish came from the resident's lunch tray, but he did not know Resident 1 was allergic to fish until he checked the electronic medical records. LVN 2 stated Resident 1's oxygen saturation was around 80%. LVN 2 stated he called RN 1 to assess Resident 1. LVN 2 stated he administered oxygen, elevated Resident's 1 head of the bed and rechecked Resident's 1 oxygen which was around 90% at that time. LVN 2 stated that he and RN 1 checked Resident 1's tray earlier that morning however, Resident 1's Meal Ticket did not indicate fish allergy. During an interview on [DATE] at 10:06 AM, CNA 2 stated she worked on [DATE], during the 7 AM to 3 PM shift and was assigned in Station 1. CNA 2 stated that on [DATE], she checked Resident 1's lunch meal tray accuracy and delivered the tray to Resident 1. CNA 2 stated Resident 1's meal ticket indicated Resident's 1 name, room number but did not indicate food allergies and food dislikes. CNA 2 stated she saw a food that looked like it was fried and breaded and mixed vegetables on Resident 1's lunch tray, but unable to tell what it was. During a telephone interview on [DATE] at 11:53 AM, the Dietary Supervisor (DS) stated the facility's process of communicating food allergies to the facility's kitchen. The DS stated that nursing staff would give a nursing communication slip (Dietary Communication Slip) which contained the resident's name, diet order and any known food allergies to the kitchen staff. The DS stated that after the receipt of the Dietary Communication Slip, he would visit the residents to obtain their food preferences. The DS stated, the Dietary Communication Slip did not always indicate the food allergies of the residents. The DS stated that during off hours (time when kitchen was closed), the nurses would leave the Dietary Communication Slip in a box outside the kitchen door. The DS stated the kitchen staff served fish on [DATE] for lunch meals. The DS stated he was not aware that Resident 1 was allergic to fish because the Dietary Communication Slip only indicated Resident 1's name and diet. The DS stated the Dietary Communication Slip did not indicate Resident 1 had food allergy to fish. The DS could not remember if he checked Resident 1's Allergy Report found in the resident's electronic medical records. The DS stated he gave the original Dietary Communication Slip that did not indicate Resident 1's food allergy to fish, to the DSD, on [DATE], after Resident 1 had the allergic reaction. During an interview on [DATE] at 3:44 PM, with Resident 1's attending physician (Physician 1), Physician 1 stated he was Resident 1's primary physician. Physician 1 stated he was notified on [DATE] at around 1:30 PM via text message from the facility's phone that Resident 1 had been transferred to the acute hospital (GACH 2) and Epinephrine had been administered by the facility staff. Physician 1 stated he was not notified by the facility staff before Resident 1 was transferred to GACH 2. Physician 1 stated he did not know who sent him the text message from the facility's phone because it did not indicate the name of who sent the text message. Physician 1 stated he did not know what happened to Resident 1 but was informed by facility staff afterwards, that Resident 1 was allergic to fish and ate fish on [DATE]. During an interview and concurrent record review on [DATE] at 4:48 PM, LVN 3 stated she was the admitting nurse who admitted Resident 1 to the facility. LVN 3 stated she could not remember why she put Resident 1's Allergy Report severity as unknown and allergy manifestation as blank on Resident 1's Allergy Report. LVN 3 stated she forgot to include Resident 1's fish allergy in the Diet Communication Slip. LVN 3 stated that on [DATE], upon Resident 1's admission to the facility, she saw that Resident 1 was allergic to fish upon review of Resident 1's GACH 1 record but did not see Resident 1's (allergy) severity reaction. LVN 3 stated she was busy that night ([DATE]) when she admitted Resident 1 and must have overlooked, putting down Resident 1's allergies on the Diet Communication Slip provided to the kitchen. LVN 3 stated she should have put Resident1's allergies on the Diet communication slip so that the Kitchen staff and DS would know Resident 1 had fish allergies. During a telephone interview on [DATE] at 4:08 PM, RN 1 stated that on [DATE] at around 12:30 PM, LVN 2 called an overhead page regarding Resident 1 needing help. RN 1 stated Resident 1 was sitting on her bed, had watery eyes, and swollen face, particularly around the eyes. RN 1 stated Resident 1 had signs of difficulty of breathing because she was moving her hands towards her neck. RN 1 stated Resident 1's oxygen saturation was at 88%. RN 1 stated he asked CNA 1 to grab the oxygen tank and administered Resident 1 oxygen. RN 1 stated the CM told him that she spoke to Physician 1 and Physician 1 ordered to administer epinephrine and call 911. RN 1 stated he administered epinephrine to Resident 1's left thigh at around 12:32 PM. RN 1 stated that the epinephrine had no effect to Resident 1 as Resident 1 was still having shortness of breath. RN 1 stated that at that time, Resident 1 was not really talking as compared to the time when he initially got in her room. RN 1 stated LVN 2 performed CPR to Resident 1. RN 1 stated the paramedics took Resident 1 to GACH 2 at around 1 PM. During the same interview, on [DATE] at 4:08 PM, RN 1 stated he was not aware that Resident 1 was allergic to fish. RN 1 stated he was the one who checked Resident 1's food tray against the Diet Type Report prior to lunch. RN 1 stated the Diet Type Report did not indicate Resident 1's food allergies. RN 1 stated Resident 1's meal ticket indicated NKFA (No Known Food Allergy) that was why the CNA handed the tray with fish to Resident 1. During a telephone interview on [DATE] at 5:39 PM, with Resident 1's representative (Family 1), Family 1 stated the facility staff was aware of Resident 1's fish allergies prior to Resident 1's death on [DATE]. Family 1 stated she had visited Resident 1 in the facility, in the late afternoon of [DATE]. Family 1 stated she was in the room with Resident 1 when a CNA (unknown) brought in Resident 1's dinner. RP 1 stated she saw the dinner tray contained what appeared to be Tuna (food containing fish). Family 1 stated she asked the CNA if the tray she was bringing contained tuna because Resident 1 was allergic to fish. Family 1 stated the CNA confirmed it was tuna. RP 1 stated she told CNA 1 to immediately remove the dinner tray because Resident 1 was severely allergic to fish. Family 1 stated right after the CNA left with the dinner tray, she informed a licensed nurse of the incident and informed LVN 1 that Resident 1 could not eat fish because she was severely allergic to it. Family 1 stated LVN 1 assured her he would inform the dietary (kitchen) staff about Resident 1's fish allergy. Family 1 stated Resident 1 had been confused since admission to the facility. Family 1 stated if Resident 1 was not confused she would not have eaten the fish because Resident 1 knew she was allergic to fish. During an interview on [DATE] at 6:50 PM, LVN 1 stated he worked on [DATE]. LVN 1 stated he could not remember if speaking to Resident 1's family on [DATE]. LVN 1 stated he did not remember Resident 1's Family 1 speaking to him about Resident 1 being served Tuna salad and Resident 1's fish allergy. LVN 1 stated if he was notified of Resident 1's fish allergy on [DATE] by Family 1 he would have reported to the kitchen staff or Dietary supervisor. A review of the facility's Fall Menu dated [DATE] to [DATE], indicated the menus served to the residents on [DATE], for dinner included Cream of mushroom soup, Dill Tuna Salad Sandwich, Potato chips and fruit. 2. During an interview with Resident 2, on [DATE] at 9:24 AM, Resident 2 stated she was allergic to eggs, milk, wheat, sour food, and spicy food. Resident 2 stated she vomited blood and had blood in her bowel movement when she eats sour and spicy food; however, she does not remember what her allergic reactions to eggs, milk, and wheat. During the tray line observation and record review on [DATE] at 11:58 AM, the diet meal ticket for Resident 2 was reviewed. The diet meal ticket indicated Resident 2 was on NAS, regular with thin liquid and included allergies to egg, wheat, shrimp, tomato, orange juice, pork, beef, and milk. A review of Resident 2's Admission Record indicated the facility initially admitted the resident on [DATE], and readmitted the resident on [DATE], with diagnoses that included unspecified severe protein-calorie malnutrition (lack of protein and calorie in the diet causing weight and muscle loss), hypertensive heart disease with heart failure (a group of medical condition resulting from unmanaged high blood pressure) and anemia (a condition which the body does not have enough health red blood cells). A review of Resident 2's MDS, dated [DATE], indicated Resident 2's cognition was moderately impaired. The MDS indicated Resident 2 needed set up only and clean-up assistance when eating. A review of Resident 2's Physician diet order, dated [DATE], indicated Resident 2's diet was NAS regular texture. The diet order indicated Resident 2 was allergic to egg, shrimp, tomato, orange juice, pork, beef, wheat, and milk. A review of Resident 2's care plan titled Allergies dated [DATE], indicated Resident 2 had a Potential allergic reaction related to resident is allergic to: aspirin (medication is used to reduce fever and relieve minor to moderate pain), azithromycin (antibiotic that fights bacteria), eggs, milk and milk products, shrimp, wheat, beef, tomato, pork, orange juice. The care plan indicated Resident 2's allergic reaction was rash per a family member. The care plan goals indicated the resident will have no allergic reaction daily . A review of the facility's diet list (a list contained resident's name, diet and allergies used to check against resident's tray) titled Diet Type Report dated [DATE], indicated, Resident 2's diet was NAS, regular texture and Resident 2's allergies included egg, shrimp, tomato, orange juice, pork, beef, wheat and milk. A review of the facility's diet manual titled Gluten-Restricted Diet (a type of protein naturally found in wheat, grains, barley and rye), (not dated) indicated, This diet elimin [TRUNCATED]

Based on observation, interview and record review, the facility failed to ensure meals did not contain food allergens (a substance that causes an allergic reaction) for two (2) of 2 sampled residents (Residents 1 and 2) with known food allergies, in accordance with the facility's policy and procedures titled Food Allergies and Reference Sheets, by: 1. Serving fish and fish containing products to Resident 1 who was allergic to fish. The facility was aware Resident 1 had fish allergy but Resident 1 was served fish on [DATE] (tuna salad sandwich) and [DATE] (lemon ginger fish). 2. Serving wheat (a cereal that yields a fine white flour used chiefly in breads, baked goods, and pastas) containing foods to Resident 2 who was allergic to wheat. On [DATE], during a lunch tray line (an area used to dish out resident's food) observation, kitchen staff served triple fruit crisp and garlic white bread that contained wheat to Resident 2. The facility was aware Resident 2 was allergic to wheat. 3. Ensuring the facility had a system in place for facility staff (licensed nurses, certified nurse assistants, dietary supervisor, kitchen staff) to implement the facility's policy and procedure titled Food Allergies and Reference Sheets, by making sure the ingredient list of foods was reviewed and recipes served to residents, which included fish for Resident 1 and wheat for Resident 2, were followed to verify that the items and meals prepared were truly allergen free. 4. Ensuring facility staff check Residents 1 and 2's meal tickets for accuracy, and food allergens as indicated in residents' electronic medical records, in accordance with the facility's policy and procedure titled Diet Record Maintenance. As a result of this deficient practice, Resident 1 had an allergic reaction on [DATE], after eating fish for lunch. Resident 1 had difficulty breathing and was observed with watery eyes and swollen face. The facility's licensed nurses called 911 emergency medical services (EMS), EMS intubated (healthcare provider inserts a tube through person's mouth or nose down to their airway) Resident 1 and administered two doses of epinephrine (used in emergencies to treat very serious allergic reactions). Resident 1 passed away upon arrival to the General Acute Care Hospital (GACH) 2 emergency room (ER) due to anaphylaxis (severe allergic reaction including closure of airways). This deficient practice had the potential to cause life-threatening conditions such as anaphylactic shock (severe allergic reaction including closure of airways), severe tachycardia (increased heart rate), cardiac arrest (heart stops beating suddenly) and death for Resident 2. On [DATE] at 7 PM, while onsite at the facility, the Director of Nursing (DON) and the Administrator (ADM) were verbally notified of 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) situation regarding food and nutrition services. Resident 1, who was identified as having food allergies to fish was served fish on [DATE] and [DATE]. Resident 2, who was identified as having food allergy to wheat was served wheat on [DATE]. On [DATE] at 7:11 PM, the IJ was removed in the presence of the ADM, DON, Registered Dietitian (RD) 1, Nursing Consultant 1 (NC 1) and NC 2 after the facility submitted an acceptable 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) and the surveyor verified and confirmed onsite the facility's implementation of the IJ Removal Plan. 1. Registered Dietitian 1 (RD 1) educated Resident 2 about avoiding food that she was allergic to minimize adverse reaction. RD 1 reviewed all residents' meals served on [DATE] to ensure accuracy on meals served for breakfast prior to distribution of trays to the residents. RD 1 observed dietary staff during meal preparation on [DATE] for breakfast, lunch and dinner to ensure tray accuracy before the trays were served to the residents. RD 1 in-serviced nursing staff on [DATE], about wheat allergy and wheat containing foods. 2. RD 1 conducted training with dietary staff on [DATE], including aides and cooks regarding diet communication form processing, meal ticket creation, meal preparation following recipes and spreadsheet, tray line process and food allergies. RD 1 conducted interviews with all residents with food allergies and food preferences to ensure accuracy of allergies transcribed on the meal tickets based on Residents medical records. 3. The DON provided education to LVNs (Licensed Vocational Nurses) and Certified Nursing Assistants (CNA) on [DATE], regarding food allergies, meal tray verification and tray accuracy. 4. The DON audited the Nutritional Care plans to ensure that allergies and allergic reactions of all residents with known allergies are entered in the care plans. 5. The DON provided in-service education to LVN 3 who admitted Resident 1 on [DATE], regarding completion of dietary communication of diet orders and restrictions, allergies with the kitchen staff. The DON and Director of Staff Development (DSD) provided in-service on [DATE] to LVNs regarding the process of communication of diet orders, restrictions, allergies to the kitchen. 7. The Regional Dietitian provided education on [DATE], [DATE] and [DATE] to Cooks and Dietary Staff on the following: Diet Communication Form Processing, Meal ticket creation, meal preparation following the recipe and spreadsheet, tray line process and food allergies. 8. The Regional Dietitian updated Resident 2's dietary profile and care plan on [DATE] for food preferences, food allergies and meal tray ticket. The Regional Dietitian reverified Resident 2's food allergies and updated Resident 2's meal tray ticket indicating the food allergies of Resident 2 according to the Dietary Profile. 9. Resident 2's physician placed an order for Resident 2 to obtain an allergy test determining allergy severity and reactions to wheat. The physician will notify Resident 2 and her family upon the receipt of the allergy test. 10. Licensed Nurses and RD 1 revised Resident 2's Nutritional Comprehensive Care Plan on [DATE] based on Resident 2's dietary interview. 11. The facility designee conducted a meal tray verification learning validation testing on [DATE] to the two LVNs and CNAs who verified Resident 2's meal tray on [DATE]. 12. The DON, designee and dietary manager reviewed and audited 99 current diet orders, allergies, tray cards on [DATE] to ensure all dietary allergies were reflected on resident's records. 13. The DON and designee conducted rounds and observations of current residents and assessed if any residents were exhibiting signs and symptoms of allergic reactions. 14. The Regional Dietitian conducted a second audit of the diet orders, dietary profiles and meal ticket to ensure diet restrictions, preferences and food allergies are accurately entered in the system. No other residents were identified. 15. The DON reported to the attending physician of four (4) other residents who had no history or were unable to recall allergic reactions. Attending physician ordered an allergy test. The facility drew an allergy test on [DATE] to the 4 residents. The attending physician will notify the resident and family of the allergy test. 16. The Regional Dietitian audited and observed the following on [DATE] - Conducted skill competency validation to the dietary staff regarding transcription of dietary orders, restrictions, food preferences, and allergy information into the Resident Dietary System (RDS) to generate accurate meal tickets. - Observed dietary staff during the meal preparation for breakfast, lunch, and dinner. - Observed tray line service for breakfast, lunch, and dinner for tray accuracy prior to placing the meal trays in the meal cart. 17. The Regional Dietitian provided in-service education to nursing staff on wheat allergen and food to avoided. 18. The Regional Dietitian will orient, train, and conduct competency regarding dietary policies and procedures, diet communication from processing meal ticket, RDS system, meal preparation, tray line, food allergies, dietary profile, and care plan development once the Dietary Manager was hired. 19. The facility implemented of the new process on how to handle food allergy on [DATE]: The dietary manager will conduct an audit of current diet orders, diet order and communication forms, food allergies, meal tray ticket from the RDS system, dietary profile, and care plan weekly for 4 weeks then bi-monthly for 2 months to ensure accuracy of diet of residents. Cross referenced to F684. Findings: A review of Resident 1's Admission Record indicated the facility admitted the resident on [DATE], with diagnoses that included Type 2 diabetes mellitus (DM, a health condition when the body does not use insulin properly causing increase in blood sugar), chronic obstructive pulmonary disease (COPD-a group of lung diseases that block airflow and make it difficult to breathe), and essential hypertension (high blood pressure). A review of Resident 1's Minimum Data Sheet (MDS, a standard assessment tool that measures health status), dated [DATE], indicated the resident's cognition (a mental process that take place in the brain, including thinking, attention, language, learning, memory, and perception) was severely impaired. The MDS indicated Resident 1 needed partial/moderate (helper does less than half of the effort. Helper lifts, holds, or supports trunk or limbs and provides more than half the effort) assistance when eating. A review of Resident 1's physician diet order, dated [DATE], indicated Resident 1's diet was No Added Salt (NAS, no salt packet on the tray) consistent carbohydrates (CCHO, the same amount of carbohydrate served each meal), regular texture, thin consistency. A review of Resident 1's Order Summary Report, for [DATE], signed by Physician 1 on [DATE], indicated Allergies: fish. A review of Resident 1's GACH 1 History and Physical (H&P, details of physician examination of the resident), dated [DATE], indicated, Resident 1's allergic reaction to fish was anaphylactic reaction. A review of Resident 1's Allergy Report printed by the facility with created date [DATE] indicated Resident 1 had a food allergy and the allergy was Fish. The Allergy Report severity indicated unknown. The Allergy Report indicated blank on Reaction Manifestation and blank on Reaction Note. A review of the facility's fall menu spreadsheet dated [DATE], approved by RD 2 on [DATE] indicated, CCHO, NAS diet included the following food item on the tray: Lemon ginger fish 3 ounces (oz, a unit of measurement) A review of the facility's recipe titled Lemon-Ginger Fish not dated, indicated ingredients included: fish fillet, thawed (suggest tilapia, pangasius-swai, cod), ginger, jarred or ginger, ground, melted margarine, lemon juice and salt. A review of Resident 1's progress notes from [DATE] to [DATE], with a note titled SBAR [Situation, Background, Assessment and Recommendations] Summary for Providers dated [DATE] signed by Registered Nurse (RN) 1 timed at 12:30 PM indicated, At 12:15 PM, Certified Nursing Assistant (CNA 1) served lunch plate to Resident 1. Around 12:25 PM, the resident called the CNA and complained of shortness of breath. CNA (CNA 1) called LVN (LVN 2), and he paged Registered Nurse 1 (RN 1) to assess Resident 1 around 12:26 PM. Resident 1 was assessed at 12:28 PM, Resident 1's Oxygen saturation (amount of oxygen circulating in the blood) was at 88% (normal oxygen saturation: 95 to 100%). RN 1 administered oxygen 2 liters via nasal cannula (a medical device to provide supplemental oxygen therapy to people who have lower oxygen level) and elevated the resident's head of bed. Oxygen saturation was rechecked, and it was 91%. RN 1 asked Case Manager (CM) to call Resident 1's physician around 12:30 PM. (Physician 1) ordered epinephrine 1 mg via intramuscular (under the muscle) injection and to call 911 emergency service. LVN 1 was delegated to call 911 around 12:31 PM. Around 12:32 PM, epinephrine was administered to left thigh of Resident 1 but no effect. No vital signs (clinical measurements, specifically pulse rate, temperature, respiration rate, and blood pressure, that indicate the state of a patient's essential body function) appreciated (found or noted) around 12:35 PM. CPR (cardiopulmonary resuscitation [an emergency life-saving procedure that is done when someone's breathing or heartbeat has stopped]) initiated and 911 (EMS) came around 12:38 PM and took over to continue CPR and resident was taken to (GACH 2) around 1 PM. During an interview on [DATE] at 9:15 AM, CNA 1 stated she worked on [DATE] during the 7 AM to 3 PM shift and was assigned to Station 1 and to Resident 1. CNA 1 stated on [DATE] at around 12:30 PM, she responded to Resident 1's call light and upon CNA 1's entrance to Resident 1's room, Resident 1 verbalized to her that she was having an allergic reaction to fish. CNA 1 stated, Resident 1 appeared to have shortness of breath. CNA 1 stated she ran out of Resident 1's room to get the oxygen tank and informed LVNs 1 and 2, who both attended to Resident 1. CNA 1 stated the kitchen staff served fish that looked like tilapia to Resident 1 for lunch. CNA 1 stated Resident 1 ate the whole fish. CNA 1 stated, she was aware that Resident 1 was allergic to fish and seafood but unsure of the allergic reaction. CNA 1 could not recall who passed Resident 1's lunch tray on [DATE]. During an interview on [DATE] at 10:46 AM, with LVN 1, LVN 1 stated he worked on [DATE] during the 7 AM to 3 PM shift as a desk nurse. LVN 1 stated on [DATE], at around lunch time, he observed Resident 1 coughed, held her neck with swollen face, and watery eyes. LVN 1 stated the fish came from Resident 1's tray served by the facility's kitchen. During an interview on [DATE] at 10:06 AM, CNA 2 stated she worked on [DATE], during the 7 AM to 3 PM shift and was assigned in Station 1. CNA 2 stated that on [DATE], she checked Resident 1's lunch meal tray accuracy and delivered the tray to Resident 1. CNA 2 stated Resident 1's meal ticket indicated Resident's 1 name, room number but did not indicate food allergies and food dislikes. CNA 2 stated she saw a food that looked like it was fried and breaded and mixed vegetables on Resident 1's lunch tray, but unable to tell what it was. CNA 2 stated that the process of passing the meal trays to the residents were as follows: (1) Two licensed nurses checked each resident's tray in the hallway from the kitchen against a list (Diet Type Report (a list of residents, their corresponding diets and other information such as allergies) for diet accuracy, consistency of food, food preferences, food likes and dislikes and food allergies. Once the licensed nurse checked the resident's tray, the licensed nurse passed the meal trays to the CNAs to deliver to the resident's room. (2) CNAs checked the meal ticket on the trays for resident's name, room number, allergies, dislikes, and food that the residents were supposed to be getting before giving it to the residents. If the meal trays were inaccurate, CNAs would not pass the trays to the residents and report it to the licensed nurse. During an interview on [DATE] at 3:44 PM, the DON stated RN 1 and LVN 2 administered oxygen while Resident 1 was having shortness of breath. The DON stated Resident 1 ate fish that came from the facility's kitchen during lunch meal on [DATE]. The DON stated that based on their investigation, RN 1 and LVN 2 checked Resident 1's meal tray for accuracy and Resident 1's meal ticket did not indicate Resident 1 was allergic to fish. The DON stated the Dietary Supervisor (DS) did not indicate Resident 1's allergy to fish on the resident's meal ticket. The DON stated the DS could not say if he checked Resident 1's electronic medical records to confirm. The DON stated Resident 1 passed away on [DATE]. During an interview on [DATE] at 4 PM, the ADM stated that on [DATE], he had witnessed Resident 1's change of condition (allergic reaction) around 12:15 PM to 12:30 PM, however, he got out of the scene so nursing staff could take care of situation. The ADM stated Resident 1's fish allergy was indicated in the electronic medical records; however, the DS did not indicate the fish allergy on Resident's 1 meal ticket. The ADM stated the incident could have been avoided if the DS checked the electronic medical records for Resident 1's food allergy and indicated the fish allergy on the meal ticket correctly. The ADM stated the DS's employment was terminated from the facility. During a telephone interview on [DATE] at 4:12 PM, LVN 2 stated he worked on [DATE] during the 7 AM to 3 PM shift at Station 1. LVN 1 stated that at around 12:20 PM, CNA 1 called him for help because Resident 1 was having difficulty breathing. LVN 2 stated Resident 1 told him she was having a hard time breathing because she ate fish. LVN 2 stated Resident 1 told him she was allergic to fish when he arrived in Resident 1's room. LVN 2 stated the fish came from the resident's lunch tray, but he did not know Resident 1 was allergic to fish until he checked the electronic medical records. LVN 2 stated, on [DATE], at approximately around 12:25 PM, Resident 1's oxygen saturation was around 80%. LVN 2 stated that he and RN 1 checked Resident 1's tray earlier that morning however, Resident 1's meal ticket did not indicate fish allergy. During a concurrent interview on [DATE] at 6:11 PM, with Nursing Consultant (NC) 1 and a record review of Resident 1's profile in the electronic medical records, Resident 1's profile indicated Resident 1 was allergic to fish written in red font. During a telephone interview on [DATE] at 10:59 AM, the Director of Staff Development (DSD) stated that residents who have known allergies, the specific allergies were written in red and those residents with no known food allergy, would indicate NKFA on their meal tickets. During an interview on [DATE] at 11:15 AM, the CM stated she went to Resident 1's room when she heard Resident 1 needed help on [DATE] at approximately around 12:30 PM. The CM stated she saw Resident 1 had an oxygen mask and struggling to breathe. The CM stated she observed Resident 1 had a swollen face. The CM stated she was aware that Resident 1 was allergic to fish and called 911 emergency medical services (EMS). During a telephone interview on [DATE] at 11:53 AM, the Dietary Supervisor (DS) stated the facility's process of communicating food allergies to the facility's kitchen. The DS stated that nursing staff would give a nursing communication slip which contained the resident's name, diet order and any known food allergies to the kitchen staff. The DS stated that after the receipt of the nursing communication slip, he would visit the residents to obtain their food preferences. The DS stated, the nursing communication slip did not always indicate the food allergies of the residents. The DS stated that during off hours (time when kitchen was closed), the nurses would leave the nursing communication slip in a box outside the kitchen door. The DS stated the kitchen staff served fish on [DATE] for lunch meals. The DS stated he was not aware that Resident 1 was allergic to fish because the nursing communication slip only indicated Resident 1's name and diet. The DS stated the nursing communication slip did not indicate Resident 1 had food allergy to fish. The DS could not remember if he checked Resident 1's Allergy Report found in the resident's electronic medical records. The DS stated he gave the original nursing communication slip that did not indicate Resident 1's food allergy to fish, to the DSD, on [DATE], after Resident 1 had the allergic reaction. During a telephone interview on [DATE] at 4:08 PM, RN 1 stated that on [DATE] at around 12:30 PM, Resident 1 was sitting on her bed, had watery eyes, and swollen face, particularly around the eyes. RN 1 stated Resident 1 had signs of difficulty of breathing because she was moving her hands towards her neck. RN 1 stated that the epinephrine he administered to the resident had no effect as Resident 1 was still having shortness of breath. RN 1 stated LVN 2 performed CPR on Resident 1. RN 1 stated the paramedics ([or EMS -Emergency Medical Services] a person trained to give emergency medical care to people who are injured or ill, typically in a setting outside of a hospital) took Resident 1 to GACH 2 at around 1 PM. RN 1 stated he was not aware that Resident 1 was allergic to fish. RN 1 stated he was the one who checked Resident 1's food tray against the Diet Type Report prior to lunch. RN 1 stated the Diet Type Report did not indicate Resident 1's food allergies. RN 1 stated Resident 1's meal ticket indicated NKFA (No Known Food Allergy) that was why the CNA handed the tray with fish to Resident 1. During an interview on [DATE] at 5:39 PM with Resident 1's representative (Family 1), Family 1 stated the facility staff was aware of Resident 1's fish allergies prior to Resident 1's death on [DATE]. Family 1 stated she visited Resident 1 in the late afternoon of [DATE]. Family 1 stated she was in the room with Resident 1 when a CNA (unknown) brought in Resident 1's dinner. RP 1 stated she saw the dinner tray contained what appeared to be Tuna (food containing fish). Family 1 stated she asked the CNA if the tray she was bringing contained tuna because Resident 1 was allergic to fish. Family 1 stated the CNA confirmed it was tuna. RP 1 stated she told CNA 1 to immediately remove the dinner tray because Resident 1 was severely allergic to fish. Family 1 stated right after the CNA left with the dinner tray, she informed a licensed nurse of the incident and informed LVN 1 that Resident 1 could not eat fish because she was severely allergic to it. Family 1 stated LVN 1 assured her he would inform the dietary (kitchen) staff about Resident 1's fish allergy. A review of the facility's Fall Menu dated [DATE] to 26, 2023, indicated the menu served to the residents on [DATE], for dinner, included Cream of mushroom soup, Dill Tuna Salad Sandwich, Potato chips and Fruit. A review of Resident 1's GACH 2 records dated [DATE] titled ED Provider Notes authored by the ED Physician, indicated (Resident 1) was brought in from the (facility) where the resident was in cardiac arrest, CPR for 18 minutes. The ED Physician wrote that according to the paramedics, 3 (three) epinephrine were given and Resident 1 lost pulses and ED Physician immediately intubated Resident 1. The ED Physician wrote Resident 1 was given another epinephrine and CPR was continued until the ultrasound (an imaging method that uses sound waves to produce images of structures within the body) showed no heart movement at 1:53 PM. At 2:06 PM, Resident 1 was defibrillated (use of electrical current to help a person's heart return to normal rhythm) in the ED and there was no change in heart movement at 2:06 PM. The ED Physician wrote Diagnosis Death secondary to cardiac arrest with severe metabolic (a condition in which acids build up in the body) and respiratory acidosis (occurs when the blood is too acidic due to high levels of carbon dioxide [the gas formed when carbon is burned, or when people or animals breathe out). The ED Physician further wrote that he spoke to Resident 1's attending physician, Physician 1, who stated Resident 1 was allergic to fish and she was given fish. 2. A review of Resident 2's Admission Record indicated the facility initially admitted the resident on [DATE], and readmitted the resident on [DATE], with diagnoses that included unspecified severe protein-calorie malnutrition (lack of protein and calorie in the diet causing weight and muscle loss), hypertensive heart disease with heart failure (a group of medical condition resulting from unmanaged high blood pressure) and anemia (a condition which the body does not have enough health red blood cells). A review of Resident 2's MDS, dated [DATE], indicated Resident 2's cognition was moderately impaired. The MDS indicated Resident 2 needed set up only and clean-up assistance when eating. A review of Resident 2's Physician diet order, dated [DATE], indicated Resident 2's diet was NAS regular texture. The diet order indicated Resident 2 was allergic to egg, shrimp, tomato, orange juice, pork, beef, wheat, and milk. During an interview with Resident 2, on [DATE] at 9:24 AM, Resident 2 stated she was allergic to eggs, milk, wheat, sour food, and spicy food. Resident 2 stated she vomited blood and had blood in her bowel movement when she eats sour and spicy food; however, she does not remember what her allergic reactions to eggs, milk, and wheat. During the tray line observation and record review on [DATE] at 11:58 AM, the diet meal ticket for Resident 2 was reviewed. The diet meal ticket indicated Resident 2 was on NAS, regular with thin liquid and included allergies to egg, wheat, shrimp, tomato, orange juice, pork, beef and milk. A review of the facility's diet list (a list contained resident's name, diet and allergies used to check against resident's tray) titled Diet Type Report dated [DATE], indicated, Resident 2's diet was NAS, regular texture and Resident 2's allergies included egg, shrimp, tomato, orange juice, pork, beef, wheat and milk. A review of the facility's diet manual titled Gluten-Restricted Diet (a type of protein naturally found in wheat, grains, barley and rye), (not dated) indicated, This diet eliminates all foods containing wheat. List of foods to avoid included bread, rolls, cookies, cakes or pies prepared with prohibited flours. During the tray line observation at the facility's hallway, on [DATE] at 12:50 PM, Resident 2's diet meal ticket indicated Resident 2's allergies included egg, wheat, shrimp, tomato, orange juice, pork, beef and milk as allergies . Resident 2's meal tray consisted of mashed potatoes, fried chicken, triple fruit crisp, garlic white bread, soup, cranberry juice and water. During the meal tray checking observation by licensed nurses on [DATE] at 1:02 PM, RN 2 and the Infection Preventionist Nurse [IPN] checked Resident 2's lunch tray against the Diet Type Report. During the observation, RN 2 read Resident 2's name, diet, allergies to egg, wheat, shrimp, tomato, orange juice, pork, beef and milk while IPN checked the diet meal ticket and foods on Resident 2's tray. The IPN handed Resident 2's meal tray containing wheat without any corrections. At this time, the State Agency (SA) intervened and alerted the facility staff to remove the tray being served to Resident 2 because the meal being served contained wheat. A review of the facility's recipe titled Garlic Bread (not dated), indicated Ingredients included garlic powder, melted margarine, parsley flakes, wheat bread of soft French bread. Serve 1 corn tortilla with 1 tsp margarine for gluten free diet. A review of the facility's recipe titled Triple Fruit Crisp not dated, indicated Ingredients included diced pears, diced peaches, canned crushed pineapple, lemon juice, cinnamon, softened margarine, all-purpose flour, uncooked rolled oats, and brown sugar. Serve mix fruit topped with gluten free whipped cream for gluten free diet. During a concurrent observation of Resident 2's lunch meal tray on [DATE] at 1:14 PM, in Resident 2's room and an interview with RD 1 and Resident 2, RD 1 stated, Resident 2 should have not been given bread nor granola in her tray and replaced the tray with a wheat free tray. RD 1 stated the possible outcome to Resident 2, who received food items that they were allergic to were allergic reactions such as rash, anaphylactic shock, and death. Resident 2 stated she was hungry and wanted to eat the bread, but she was told and tested in the past that she was allergic to wheat and did not know her allergic reaction if she ever ate wheat. Resident 2 stated that she was not aware what foods contained wheat and questioned if she was supposed to have had bread on her tray because of her wheat allergy. During an interview on ,d+[DATE]/ 2023 at 8:24 AM, the IPN stated that the facility's process of checking the resident's meal trays was to have two licensed nurses check the Diet Type Report against the diet meal ticket and the meal tray. After the 2 licensed nurses checked the meal for accuracy, they would hand the meal trays to the CNAs. The CNAs would recheck the meal trays for accuracy prior to serving to the residents. The IPN stated that on [DATE], he was the one who checked Resident 2's trays and RN 2 was holding the Diet Type Report. The IPN stated he checked everything on Resident 2's meal tray, diet meal ticket and read that Resident 2 was allergic to wheat; however, he did not know that the garlic white bread contained wheat. The IPN stated the possible outcome for Resident 2 who consumed foods that she was allergic to was anaphylactic shock, enlarge tonsils (either of a pair of prominent masses of tissues that lie one on each side of the throat) causing inability to breath and cardiac arrest. During an interview on [DATE] at 3:35 PM, RD 2 stated that the DS was the one who interviewed residents for food allergies and food preferences and that food allergies and preferences auto populate (data that is being inputted or entered were auto filled in every field in a form) in the dietitian's assessment for the residents. RD 2 stated they do not repeat or re-interview residents for food allergies. RD 2 stated it was important to have a system in place and have accurate allergy records for the residents because it could lead to different type of reactions including rashes and anaphylactic shock for those residents who consumed food that they were allergic to. A review of the facility's policy and procedure titled Diet Record Maintenance revised on [DATE] and approved by Quality Improvement Committee (QIC) on [DATE], indicated The diet record will contain the following information to be reflected on the resident's tray card: (g) allergies. A review of the facility's policy and procedure titled Diet Identification Card revised on [DATE] and approved by QIC on [DATE], indicated To ensure the resident receives the proper diet as ordered by the physician. II. Additional information available on the diet identification card should be completed for each resident. Additional information may include, food preferences, beverage, dining location and level of assistance. A review of the facility's diet manual titled Food Allergies and Reference Sheets, not dated, indicated Food allergies may produce adverse, sometimes life threatening, effects and eliminating the allergy causing food is the only way for residents to avoid a reaction. It is important that the resident's entire care team is made aware of the food allergy and its reaction. Special consideration must be taken within the facility kitchen, as well as any foods being brought in from outside sources for residents. The avoidance of cross contamination within the facility's kitchen is key when preparing food for residents with food allergies. This means that safe, non-allergic food must not come in contact with other potential allergenic foods within only step of the foodservice preparation and delivery. General considerations included reviewing ingredient list of foods used and recipes followed to verify that the items and meals prepared are truly allergen free. A review of the facility's job description titled Dietary Services Supervisor/Certified Dietary Manager not dated, indicated, Principal Responsibilities: ensures that meals are

Based on interview and record review, the facility failed to ensure one of seven sampled residents, Resident 1, who had a gastrostomy tube (GT, a device inserted into the stomach through the abdomen for nutrition and fluids), received sufficient fluid intake to maintain proper hydration and health. The facility failed to: Follow Resident 1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 1's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . This deficient practice resulted in Resident 1 not receiving the required amount of fluids daily for 34 days. On [DATE], Resident 1 experienced a change in mental status with shortness of breath requiring transfer to a General Acute Care Hospital 1 (GACH 1). Resident 1 was admitted to GACH 1 and Resident 1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 1 subsequently expired (died ) in GACH 1 on [DATE] (four days after admission). Findings: A review of Resident 1's Face Sheet (a record of admission) indicated Resident 1 was initially admitted to the facility, on [DATE], and readmitted on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 1 weighed 132 pounds (60 kilograms) and the height was 58 inches. A review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care-screening tool), dated [DATE], indicated Resident 1's cognitive skills was severely impaired. Resident 1 required total dependence (full staff performance every time) from staff for transferring, dressing, eating, toileting, and personal hygiene. A review of Resident 1's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician also ordered to give Glucerna 1.2 (a total supplemental nutritional formula) at 55 cc/hr. for 20 hours via G-tube. A review of Resident 1's Enteral Feeding Assessment, dated [DATE], completed by Registered Dietitian 2 (RD 2), indicated Resident 1 was currently receiving Glucerna 1.2 at 55cc/hr., water flushes at 25 cc/hr. for 20 hours. (total 500 cc) and 150 cc of water bolus every 4 hrs. (total 900 cc). According to this assessment, RD 2 recommended to increase the tube feeding of Glucerna 1.2 from 55 cc/hr to 62 cc/hr. RD 2's assessment also indicated Resident 1 needed 1478 cc to 1773 cc of fluids per day. There were no recommendations to change the order for free water (the amount of liquid an enteral formula is actual water as an ingredient). A review of Resident 1's Physician Order, dated [DATE], indicated to discontinue previous G-tube feeding order and to start Glucerna 1.2 at 62 cc/hr. for 20 hrs. per RD's recommendations. During an interview and record review, on [DATE] at 12:55 p.m., the Director of Nursing (DON) stated that Resident 1's care plan titled, Nutrition - Tube Feeding, dated [DATE], indicated to administer Glucerna 1.2 at 55 cc/hr. for 20 hrs. Resident 1's care plan did not include the administration of water flushes and water bolus as ordered by Resident 1's physician, on [DATE]. On [DATE], the facility staff updated the care plan to reflect the new order for Glucerna 1.2 at 62 cc/hr for 20 hrs. During an interview and record review, on [DATE] at 12:55 p.m., the DON stated that Resident 1's care plan titled, Nutrition and Hydration, dated [DATE], indicated the resident was at risk for weight loss and dehydration. Resident 1's care plan did not include the administration of water flushes and water bolus as ordered by Resident 1's physician, on [DATE]. A review of Resident 1's MAR for [DATE] and [DATE], indicated to, Flush tube with 25 cc of water every hour and 150 cc every 4 hours. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no documentation indicating that the facility's licensed nurses administered 150 cc of water every 4 hrs for a total of 1400 cc (500 cc plus 900 cc) of water per day. During an interview and concurrent record review of Resident 1's MAR for May and [DATE], on [DATE] at 12:55 p.m., the DON stated Resident 1's Physician Order, dated [DATE], indicated to give water 25 cc/hr. and 150 cc water every 4 hours. The DON stated the licensed nurse did not transcribe the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON also stated Resident 1's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . (totaling 900 cc per day). The DON stated that the licensed nurse should have transcribed (writing the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview and concurrent record review of Resident 1's MAR for May and [DATE], on [DATE] at 12:55 p.m., the DON stated Resident 1's MAR for May and [DATE] had no documentation to indicate the administration of water 150 cc boluses as ordered. The DON stated the water bolus were then not given by the facility staff. During an interview on [DATE] at 3 p.m., Licensed Vocational Nurse 1 (LVN 1), who took care of Resident 1, stated Resident 1's physician had a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . and 150 cc of water every 4 hrs. for bolus administration. LVN 1 stated the licensed nurse should have transcribed the order onto two different entries on the MAR. LVN 1 stated the continuous water flush of 25 cc/hr. would be documented by the licensed nurse every shift indicating the flushes were administered for the day, evening, and night shift. LVN 1 stated the order for 150 cc of water every 4 hrs. would be on another entry, and the licensed nurse would have to document administration every 4 hrs. LVN 1 stated he believed the schedule was 8 a.m., 12 p.m., 4 p.m., 8 p.m., 12 a.m., and 4 a.m. LVN 1 stated if there was no documentation on the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview and concurrent record review of Resident 1's Enteral Feeding, on [DATE] at 11:30 a.m., RD 1 stated Resident 1's Enteral Feeding Assessment, dated [DATE], indicated RD 2 made recommendations to increase Resident 1's tube feeding of Glucerna 1.2 from 55 cc/hr. to 62 cc/hr for 20 hrs. RD 1 stated Resident 1 was to receive continuous water flushes at 25 cc/hr. for 20 hrs, and also 150 cc water every 4 hours, which was given a total of 6 times a day to equal 500 cc (from continuous) and 900 cc (from every 4 hrs) for a total of 1400 cc in one day. RD 1 stated RD 2 did not make any recommendations to change the amount of free water Resident 1 needed. RD 1 stated Resident 1 needed at least 1400 cc of free water not including what Resident 1 gets from the tube feeding to maintain adequate hydration. RD 1 stated if Resident 1 did not get the free water boluses every 4 hrs. as recommended, then Resident 1 was at risk for dehydration. RD 1 stated that Resident 1's Enteral Feeding Assessment did not indicate any changes to the free water amount so the order still stands to continue with the same amount. During an interview, on [DATE] at 11:30 a.m., RD 1 stated after the RD makes recommendations, the RD would notify the charge nurses, DON, and Administrator (ADM) with a copy of a record titled, Clinical Recommendations, for the facility staff to follow-up with the resident's physician. RD 1 stated he would check back within 72 hrs if the physician followed the recommendations. A review of Resident 1's Change in Condition, dated [DATE], indicated Resident 1 had elevated temperature, altered mental status (AMS), shortness of breath (SOB), and desaturation (level of oxygen in the body is less than normal) of O2. The facility called 911 (an emergency call for immediate attention) to transfer Resident 1 to GACH 1 for further evaluation. A review of Resident 1's General Acute Care Hospital (GACH) Emergency Documentation, dated [DATE], indicated Resident 1's vital signs (measurements taken to help assess the general physical health of a person) included blood pressure of ,d+[DATE] (normal ,d+[DATE] millimeters of mercury [mmHg]), heart rate of 146 (normal 60 -100 beats per minute), respiratory rate of 48 (normal 12 - 16 breaths per minute), temperature 39.7 degree Celsius (103.4 degrees Fahrenheit, normal 98.6 degrees Fahrenheit). The resident received a total of 4 liters (L) of intravenous bolus (a single dose given all at once) for marked (severe) [CONDITION(S)] (elevated blood sugar levels of 896 mg/dL). The Emergency Documentation also indicated Resident 1's diagnostic impression (an opinion made based on symptoms and tests results collected) included [CONDITION(S)] secondary to multifactorial etiology (having multiple causes of disease), including septic shock (widespread infection causing organ failure and [CONDITION(S)]) and volume depletion (when an individual does not have enough fluid volume in there circulation)/severe dehydration. A review of Resident 1's GACH Consultation Note - Nephrology (medicine specializing in the kidneys), dated [DATE], indicated [CONDITION(S)] (when sodium levels in the blood is higher than normal, [CONDITION(S)] indicates a deficit of total body water caused by water intake being less than water losses) due to decreased free water intake. The consultation note also indicated Resident 1's calculated free water deficit at admission was 3100 cc then it increased to 4100 cc. A review of Resident 1's GACH, Discharge Documentation, dated [DATE], indicated during the hospital stay, Resident 1 had altered mental status and [CONDITION(S)] (not enough oxygen). Resident 1 had severe [CONDITION(S)] and acute hypoxic [CONDITION(S)] likely due to aspiration pneumonia (type of lung infection that is due to a relatively large amount of material from the stomach or mouth entering the lungs). Resident 1 was placed on comfort care and expired on [DATE]. A review of Resident 1's Certification of Vital Record, dated [DATE], indicated Resident 1's primary cause of death was severe [CONDITION(S)] and secondary causes of death included acute [CONDITION(S)], toxic [CONDITION(S)] (a general term that describes a disease that damages your brain), and pneumonitis (infection of the lungs) due to inhalation of food. A review of the facility's policy and procedure titled, Feeding Tube - Administration of Medication, dated ,d+[DATE], indicated there must be a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff will record in the resident's MAR. A review of the facility's undated policy and procedure titled, Physician Orders, dated [DATE], indicated medication orders will include the following: name of medication, dosage, frequency, duration, route of administration, and condition or diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The staff will transcribe the medication and treatment orders onto the appropriate resident administration record (such as the resident's MAR). A review of the facility's undated medication schedule titled, Facility Time Code Summary, indicated every 4 hours was 12 a.m., 4 a.m., 8 a.m., 12 p.m., 4 p.m., and 8 p.m.

Based on interview and record review, the facility failed to maintain nutritional status (food consumption) for one of three sampled residents (Resident 1) by failing to: 1. Conduct an accurate assessment of Resident 1's level of assistance needed with eating and physical assessment related to [MEDICAL CONDITION] (a condition characterized by an excess of watery fluid collecting in the cavities or tissues of the body) on both legs. 2. Provide one-on-one feeding assistance to Resident 1 during mealtimes. 3. Refer Resident 1 to the Registered Dietician (RD - a food and nutrition expert) timely. The RD did not evaluate the resident's nutritional needs until 10 days after admission. 4. Notify Resident 1's PCP (Primary Care Physician) regarding the RD's recommendations. 5. Notify Resident 1's PCP when the resident had a continued decline in food intake and weight loss. These deficient practices resulted in Resident 1's weight loss, for a total of 9 pounds (lbs) within three weeks (7/10/17 to 7/23/17). Resident 1 was placed on hospice care (a type of care that focuses on the palliation of a chronically ill) on 7/24/17. Findings: A review of Resident 1's Face Sheet (admission record) indicated, the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident 1's care plan for Nutrition and Hydration, dated 7/11/17, indicated the resident was at risk for weight loss related to right side weakness. The goals were for the resident to achieve adequate nutritional intake of at least 75 percent (%) each meal, and have no significant weight changes of 5 % or more. The staff approach interventions were for staff to offer assistance to the resident and refer the resident for dietary consultation as needed. The care plan did not indicate on how Resident 1 would receive assistance from staff or for staff to notify the resident's PCP when the resident experienced weight loss. A review of Resident 1's Occupational Therapy (OT, a form of therapy that encourages rehabilitation through the performance of activities required in daily life.) Evaluation and Plan of Treatment, dated 7/11/17, indicated the occupational therapist (OT 1) assessed Resident 1's self-feeding functional skills as total dependence. The resident did not attempt to initiate self-feed. A review of Resident 1's Interdisciplinary Team Conference Record (IDT, a group of health care professionals from diverse fields who work in a coordinated fashion toward a common goal for the resident), dated 7/12/17, indicated the IDT discussed Resident 1 was on puree diet (food has been ground, pressed and/or strained to a consistency of a soft, smooth, thick paste). There was no documentation indicating the IDT discussed the OT evaluation that Resident 1 was totally dependent on staff with eating. The next IDT was conducted on 7/24/17. A review of Resident 1's physician's orders [REDACTED]. The physician order [REDACTED]. A review of Resident 1's Speech Therapy (ST, training to help people with speech and language problems to speak more clearly) Evaluation and Plan of Treatment, dated 7/13/17, indicated the resident exhibited decreased oral motor functions, decreased cognitive functions (cerebral activities that lead to knowledge, including all means and mechanisms of acquiring information). The ST evaluation indicated Resident 1 had difficulty and/or inability to open oral cavity, decreased oral containment on the left, lack of mastication (chewing), decreased activity tolerance to complete meal and poor attention to task. The ST evaluation indicated the resident was able to follow directions and was responsive to cues. The ST evaluation indicated the resident will benefit from skilled ST services, caregiver training, education, and diet texture analysis. A review of Resident 1's Minimum Data Set (MDS - a resident assessment and care screening tool), dated 7/17/17, indicated Resident 1's cognition (the ability to think and reason) was severely impaired for daily decision making. Resident 1's MDS indicated that the resident required extensive assistance (staff provide weight bearing support) with bed mobility, transfer, dressing, and personal hygiene. The MDS indicated Resident 1 was totally dependent from staff with toilet use, and required supervision (oversight, encouragement or cueing) from staff with eating. A review of Resident 1's Weekly Weight Record indicated the following: a. On 7/10/17, the resident's weight was 108 lbs. b. On 7/16/17, the resident's weight was 104 lbs. Resident 1 had a 4 lbs weight loss (a severe weight loss of 3.7%) in 6 days (according to the severity of weight loss calculator, from www.hepher.org, a weight loss of 1-2 % is a significant weight loss and a weight loss of greater than 2% is a sever weight loss). c. On 7/23/17, the resident's weight was 99 lbs. This was an 8.3 percent weight loss from 7/10/17. On 7/30/17. d. On 7/30/17, the resident's weight was 84 lbs. A review of Resident 1's ADL (Activity of Daily Living) flowsheet record, indicated the resident's percentage of daily food intake by mouth as follows: From 7/11/17 to 7/14/17, Resident 1 ate 60 % to 90% for breakfast, 70% to 100% for lunch, and 40% for dinner. On 7/15/17, Resident 1 ate 80% for breakfast, 20% of lunch, and 20% dinner. On 7/16/17 and 7/17/17, Resident 1 ate 20% for breakfast, lunch, and dinner. On 7/18/17, Resident 1 ate 5% for breakfast, 5% for lunch, and 20% for dinner. On 7/19/17, Resident 1 ate 10% for breakfast, 10% for lunch, and 20% for dinner. On 7/20/17, Resident 1 refused breakfast, lunch, and dinner. On 7/21/17, Resident 1 refused breakfast, ate 20% of lunch, and 10% dinner. On 7/22/17, Resident 1 refused breakfast, lunch, and ate 10% for dinner. On 7/23/17, Resident 1 refused breakfast, lunch, and dinner. A review of Resident 1's ADL Flowsheet Record for the month of July 2017, indicated the nursing staff did not notify the charge nurse when Resident 1's food intake declined from 80% to 20% for lunch and dinner starting on 7/15/17, and continued to remain at 20% and less for multiple days. Resident 1's ADL Flowsheet indicated the nursing staff notified the charge nurse on 7/20/17, when the resident refused to eat both breakfast and lunch. The Certified Nursing Assistants (CNAs) documented in the ADL Flowsheet that Resident 1 was provided with supervision, oversight or verbal direction, encouragement or cueing (no hands on) during meals. A review of Resident 1's nurse's note, dated 7/15/17 and 7/16/17, indicated the charge nurse did not notify the resident's PCP regarding the resident's food intake had decline from 80% to 20%. A review of Resident 1's Nutritional Assessment (an evaluation tool to gather information to an individual's food and nutrient intake, lifestyle, and medical history), dated 7/20/17, indicated Resident 1 had low [MEDICATION NAME] level (amount of protein in the blood carries vital nutrients in the body) likely indicative of poor nutrition status (food necessary for health and growth). The nutritional assessment indicated the RD recommended for Resident 1 to received Pro-stat (protein supplement), 30 milliliter (ml) daily; high protein nourishment, 4 ounces (oz), three times a day with meals; and multivitamins with minerals daily. A review of Resident 1's care plan for Nutrition and Hydration, updated on 7/21/17, indicated the resident had poor food intake. The goal was for the resident to sustain her weight. The staff approach interventions did not indicate measures to prevent further weight loss for Resident 1. The staff approach interventions were not revised. A review of Resident 1's Physician and Telephone Order, dated 7/24/17, and timed at 11: 55 a.m., indicated to give Resident 1 Pro Heal (a medical food developed for the dietary management of wounds, and other conditions that would benefit from supplemental protein intake), 30 ml, daily; high protein nourishment, 4 oz., three times a day with meals; and multivitamins with mineral, one tablet daily. A review of Resident 1's Physician and Telephone Order, dated 7/24/17 without a timestamp, indicated to admit the resident to Hospice (care that focuses on the palliation of a chronically ill patient) with [DIAGNOSES REDACTED]. On 8/9/17, at 12:35 p.m., during an interview with the Speech Therapist (ST- work to prevent, assess, diagnose, cognitive-communication, and swallowing disorders), she stated Resident 1's oral function was weak. The ST stated that Resident 1 was totally dependent on staff assistance with eating. The ST stated Resident 1 required a staff to feed her during meals due to her mental cognition and weakness. On 10/23/17, at 11:45 a.m., during an interview, the MDS nurse (LVN 1) stated Resident 1 was not able to move her hands by herself. The MDS nurse stated Resident 1 was not on feeding assistance program (staff did not assist the resident during mealtimes). The MDS nurse stated she made a mistake on Resident 1's MDS assessment. On 10/24/17 at 2:05 p.m., during a follow up interview with the MDS nurse, she stated Resident 1's MDS assessment, dated 7/17/17, indicated the resident's eating function as supervision was inaccurate. The MDS nurse stated Resident 1 required extensive assistance to total dependent on staff with eating function. The MDS nurse stated Resident 1 was not assessed or provided with a one to one staff assist with eating. On 10/23/17, at 12:12 p.m., during an interview, the Director of Rehabilitation (DOR) stated Resident 1's right upper body with limitation in functional status, and the left upper body only able to move with no extra weight. The DOR stated Resident 1 was not able to perform tasks on her own and was totally dependent on staff. The DOR stated the rehabilitation department staff communicated with the Director of Staff Developer (DSD) and the Director of Nursing (DON) regarding Resident 1's progress during stand up meeting. On 10/23/17, at 12:30 p.m., during an interview, the Registered Nurse Supervisor (RN 1) stated she must have overlooked the MDS assessment on Resident 1's eating status. The RN 1 stated she signed the MDS only for completion, she did not sign the MDS for accuracy. The RN 1 stated LVN 1 did the assessment signed for accuracy. On 10/24/17, at 1:15 p.m., during an interview and a concurrent record review with the Dietary Supervisor (DS), she stated the RD that did the nutritional assessment for Resident 1 was not the facility's RD. The DS stated the RD who worked at the facility is no longer employed at the facility. The DS stated the RD evaluated Resident 1 on 7/20/17, 10 days after admission. During an interview, the DS stated the RD had some recommendations; however, the recommendations were relayed to Resident 1's PCP on 7/24/17 (4 days later). The DS stated he did not know the reason for the delay. The DS stated the RD's recommendation should be related to the resident's PCP, and initiated the following day of the recommendations. The DS stated it was important for the facility's staff to initiate interventions of the RD recommendations as soon as possible to prevent further weight loss. The DS stated there was a delay on initiating the RD recommendations for Resident 1's nutritional support. On 10/24/17, at 2:55 p.m., during an interview, the DON stated she does not have control on when the RD comes in the facility to assess Resident 1. The DON stated the RD's recommendations need to be relayed to the resident's PCP. The DON stated that sometimes the PCP would not call back right away. The DON stated Resident 1 had a 4 lbs weight loss within 6 days after admission. The DON stated a 4 lbs weight loss within 6 days was not a significant weight loss. The DON stated she could not remember if the OT mentioned that Resident 1 required feeding assistance with eating. On 10/27/17, at 9:30 a.m., during an interview and a concurrent record review with RN 1, she stated Resident 1 was not assessed or provided for one to one feeding assistance. RN 1 stated Resident 1 should have been assisted during meals. RN 1 stated it would be beneficial for Resident 1 to be on RNA (Rehab Nurse Aid) feeding program. RN 1 stated the Resident 1's PCP was not notified regarding the resident's food intake decline from 80% to 20% (starting on 7/15/17) because she assumed the PCP was aware of the issue. RN 1 stated Resident 1's PCP documented on the resident's physician progress notes [REDACTED]. RN 1 stated the RD's recommendations were implemented 4 days late, but it did not matter due to Resident 1's condition was already declining. RN 1 stated Resident 1's admission weight was 108 lbs. on 7/10/17 due to [MEDICAL CONDITION] (swelling) on both legs. RN 1 stated Resident 1 weighted 104 lbs. (4 lbs. weight loss) on 7/16/17 but the nursing staff did not assess and document if Resident 1 had [MEDICAL CONDITION] on both legs that day. On 10/27/17, at 10:45 am, a review of Resident 1's clinical record, indicated there was no documentation indicating Resident 1 had [MEDICAL CONDITION] on both legs. A concurrent interview was conducted with RN 1, she stated Resident 1 had [MEDICAL CONDITION], but it was not indicated on the resident's record to indicate if the weight loss was from the [MEDICAL CONDITION]. On 11/30/17, at 1 p.m., during an interview, the director of rehab services (DOR) stated she informed the DON two days after Resident 1 admitted to facility that Resident 1 required one to one feeding assistance from staff due to Resident 1's pronounced (noticeable) facial weakness. A review of facility's policy and procedure titled 'Evaluation of Weight & Nutritional Status,' revised on 3/2017, indicated for staff to ensure residents maintain acceptable parameters of nutritional status through evaluation of weight and diet. The facility's policy and procedure indicated that the facility will work to maintain an acceptable nutritional status for residents by: Assessing the resident's nutritional status and the factors that put the resident at risk of maintaining acceptable parameters of nutritional status; Defining and implementing interventions for maintaining or improving nutritional status that are consistent with resident's needs, goal, monitoring and evaluating the resident's response or lack of response to the interventions. The facility's policy and procedure included clinical evaluation that indicated registered Dietician and the Interdisciplinary Team (IDT, a team of professionals who work together toward a common goal) will further assess nutritional needs and goals of the resident within the context of his/her overall condition, including functional status (cues, hand over hand, extensive assistance).

Based on interview and record review, the facility failed to ensure that one of three sampled residents (Resident 1) was free from physical abuse. Resident 1 kicked Certified Nurse Assistant (CNA1) during diaper change and CNA 1 then slapped Resident 1 in the face in with an hand as witnessed by CNA 2. This deficient practice violated Resident 1's right to be free from physical abuse and placed Resident 1 at risk for psychosocial disturbance (behavioral problems) as care planned. Findings: A review of Resident 1's record titled, Face Sheet (admission record), that indicated Resident 1 was admitted to the facility on [DATE], and was re-admitted on [DATE], with [DIAGNOSES REDACTED]. (a long-term movement disorder that occurs when the brain cells that control movement start to die and cause changes in how you move), and muscle weakness. A review of Resident 1's record titled, Admission Assessment, dated 3/20/15, indicated that Resident 1 was alert and did not have behavioral and safety concerns, have any threatening or combative behavior. A review of Resident 1's record titled, Minimum Data Set ((MDS), a resident assessment and care screening tool), dated 2/1/17, indicated that Resident 1 was cognitively (refers to mental abilities or processes) intact. The MDS indicated that Resident 1 did not have disorganized thinking and altered level of consciousness or exhibit abnormal physical and verbal behavioral symptoms directed towards others such as hitting, screaming, kicking, abusing others sexually, disrobing or threatening others. The MDS indicated Resident 1 required extensive assistance (resident performed part of the activity; staff provided support with bearing weight, at times full staff performance of activity) with one person physical-assist for the following activities of daily living (ADL): bed mobility (how resident moves to and from lying position, turns side to side, and positions body while in bed), transfer (how resident moves between surfaces including to or from: bed, chair, wheelchair, standing position), and toilet use (how resident uses the toilet room, commode, bedpan, or urinal; transfers on/off toilet; cleanses self after elimination; changes pad; and adjust clothes). A review of the facility's investigation regarding the allegation of physical abuse and dated 4/20/17 at 9 p.m. indicated, that Resident 1 verbalized that he kicked CNA 1 because she was not answering the call light and he needed his diaper to be changed by CNA 1. Resident 1 stated that CNA 1 put her hand on his right cheek. He (Resident 1) cringed in fear for short time. A review of Resident 1's record titled, Resident Care Plan, dated 4/21/17, indicated that, an Alleged staff slapped resident on the face. Resident indicated he was hit on his R (right) face by staff. Resident at risk for psychosocial disturbance/changes secondary to allegation of physical abuse. The goal was for Resident 1 to be free from fear and minimize psychosocial disturbance/changes. The resident was no longer in the facility and could not be reached for interview. During a telephone interview on 5/9/17 at 1:45 p.m., CNA 2 stated that after dinner (could not remember the date and time), she was standing by the doorway of Resident 1's room and observed that CNA 1 was with Resident 1 inside Resident 1's room. CNA 2 stated that Resident 1 was upset and yelling and saying, Get out! Get out! at CNA 1 as CNA 1 was trying to change Resident 1's diaper. CNA 2 stated Resident 1 refused to have his diaper changed and kicked CNA 1. CNA 2 stated CNA 1 then used her opened hand to slap Resident 1 in the face. CNA 2 stated after CNA 1 hit Resident 1 in the face, CNA 1 (abuser) reported the incident to the Licensed Vocational Nurse (LVN 1). During a telephone interview on 5/10/17 at 12 p.m., CNA 1 stated she had taken cared of Resident 1 for three years. CNA 1 stated on 4/4/17, around 10:30 p.m., Resident 1's call light was on and CNA 1 went into Resident 1's room. CNA 1 stated that Resident 1 was not aggressive and was quiet. CNA 1 stated that it was her last chance during the her shift to change Resident 1's diaper and so she asked Resident 1 if he needed to change his diaper. CNA 1 stated Resident 1 was quiet and agreed to have his diaper changed. CNA 1 stated while she was changing Resident 1's diaper, Resident 1 asked CNA 1 to touch his private parts and CNA 1 told Resident 1, No and Resident 1 yelled at CNA 1, I don't need you because you don't help me. CNA 1 stated Resident 1 tried to hit her. CNA 1 denied slapping Resident 1. CNA 1 stated she notified LVN 1 about the incident and then LVN 1 talked to both Resident 1 and her (CNA 1). During a telephone interview on 5/10/14 at 2:47 p.m., LVN 1 stated that Resident 1 was overall a nice resident but when the resident did not like the care provided to him then he would express his anger by kicking. LVN 1 stated one day in April (could not remember the date and time), LVN 1 was the charge Nurse for Resident 1's that day. CNA 1 stated that Resident 1 was calm when she (CNA 1) came out of Resident 1's room. CNA 1 reported that Resident 1 kicked her. LVN 1 stated he spoke to Resident 1 and CNA 1, and Resident 1 stated he kicked CNA 1 because CNA 1 was in a rush while completing his ADL care with him. LVN 1 stated that Resident 1 had reported that while CNA 1 was providing care to him, CNA 1 slapped him in the face. A review of the facility's policy and procedures titled, Abuse- Prevention Program, dated November 2016 indicated, that the facility was responsible for ensuring the health, safety, and comfort of residents by preventing abuse and mistreatments. The policy indicated that the facility does not condone any form of abuse and develops Facility policies, procedures, training programs, and systems in order to promote an environment free from abuse and mistreatment. The policy indicated 'physical abuse' was defined as hitting, slapping, pinching and/or kicking.

Based on interview and record review, the facility failed to assess a resident for constipation (bowel movements that are hard to pass) to prevent the development of fecal impaction (solid, immobile bulk of human stool or feces that can develop in the rectum as a result of constipation), implement the plan of care to monitor for fecal impaction and stool consistency, and administer the medication Milk of Magnesia (MOM, a medication that reduces stomach acid, and increases water in the intestines which may induce defecation) if no bowel movement for two days as ordered by the physician for one of 18 sampled residents (Resident 13). 1. Resident 13, who had a firm abdomen and who was moaning and crying due to abdominal discomfort, did not have a bowel movement for three days. The facility did not assess the resident for constipation, monitor the consistency of the resident's stool, and administer the medication MOM when the resident did not have a bowel movement for three days. The facility did not have a policy and procedure on how to address constipation and/or fecal impaction for residents. These deficient practices resulted in Resident 13 being transferred to a general acute care hospital (GACH) for altered mental status, where she received oral laxatives and large intravenous (IV, within a vein) fluid boluses (a large volume of fluid or dose given intravenously and rapidly at one time); and had a manual fecal dis-impaction (manual removal of feces or stool). See F327 for additional information regarding Resident 13. 2. The facility failed to monitor the post-[MEDICAL TREATMENT] weight in accordance with the plan of care and the facility's policy and procedure for two of 18 sampled residents (12 and 14). Resident 12's post-[MEDICAL TREATMENT] weight ([MEDICAL TREATMENT]: a medical procedure using a machine to remove toxic substances or metabolic wastes from the bloodstream) was not monitored on 1/2/15. Resident 14's post [MEDICAL TREATMENT] weight was not monitored on November 17, November 28, and December 1, 2014. These deficient practices had the potential for fluid over/under load complications. Findings: 1. A review of Resident 13's Face Sheet (admission record) indicated the resident was admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. A review of the Dehydration Risk Assessment form, dated December 12, 2014, indicated Resident 13 had scored 60 out of 50 and above, which was considered a "high risk" for dehydration. The assessment indicated Resident 13 had difficulty swallowing liquids and required moderate or extensive assistance (full staff performance for part of the task) with fluid intake. A review of the Medication Record (a medication administration record), dated December 12 thru December 22, 2014, indicated Resident 13 was receiving a diet of pureed consistency (soft, smooth, thick paste consistency similar to a thick pudding) and nectar thickened liquids (liquids that have been thickened to a consistency which coats and drips off a spoon, similar to unset gelatin) every meal. According to the article titled, "Dehydration and Dysphagia: Challenges in the Older Adult," page 2, published by the Journal of Medical Speech-Language Pathology, dated August 2011, "...certain disease-related signs and symptoms also serve as markers for dehydration. One reported marker is reduced oral intake secondary to swallowing difficulty...older adults are the most vulnerable group for dysphagia (difficulty swallowing)...Although evidence-based management strategies are designed for those with dysphagia to maintain oral delivery of hydration (e.g. thickened liquids ...)... these interventions may potentially reduce fluid intake." The article indicated, "Dehydration is known to contribute to constipation, fecal impaction, urinary tract infections ...and [MEDICAL CONDITION] (a sudden or acute confusional state)..." A review of the Medication Record, dated December 12 thru 22, 2014, indicated Resident 13 received [MEDICATION NAME] (an opioid pain reliever used to treat moderate to severe pain) 25 milligrams by mouth every six hours routinely. Resident 13 received a total of 38 doses during her admission. Resident 13 also received 8 doses of [MEDICATION NAME] (an opioid pain medication) during her admission for pain management. According to the article titled, "Opioid-Induced Constipation," pages 382 and 383, published by the Journal of Pain and Palliative Care Pharmacotherapy (2012), "...the incidence of opioid-induced constipation in patients with nonmalignant (not life threatening) pain is about 40%...In the large bowel, propulsive (creating force leading to movement) peristaltic waves (the wavelike muscular contractions of the intestine that propel the contents onward by alternate contraction and relaxation) are markedly reduced...All these actions result in increased fluid reabsorption, causing desiccated (too dry) feces...All patients who start taking opioids should be warned about constipation...dietary and lifestyle changes can help; however, increased physical activity is often not possible in patients who are unwell..." A review of a facility's policy titled, "Pain Management," revised January 1, 2012, did not indicate the need to address constipation as a common adverse effect of elderly residents on routine opioid medications. Resident 13's preprinted care plan, initiated on December 12, 2014, was reviewed and indicated Resident 13 was at risk for dehydration related to nausea. The approaches, indicated in the care plan, included assessing Resident 13 for possible constipation. The care plan did not specify how the facility would assess Resident 13 for constipation. During an interview with a Licensed Vocation Nurse (LVN) 1, on January 9, 2015, at 10:35 a.m., she was asked how a licensed nurse assessed a resident at risk for constipation and impaction. LVN 1 stated licensed nurses had to monitor for bowel sounds, nausea, if a resident would not eat and had a feeling of being "full," hard abdomen, and small/hard bowel movements because "it could be impaction." Another preprinted care plan for Resident 13 titled, "Resident Care Plan, Constipation," initiated on December 12, 2014, was reviewed. The care plan indicated Resident 13 was at risk for constipation related to a decrease in mobility. The care plan did not mention Resident 13 was receiving [MEDICATION NAME] and [MEDICATION NAME] for pain management which may contribute to constipation. The approaches indicated in the care plan included to monitor for impaction, abdominal distention, and stool consistency and frequency; to encourage increased mobility as tolerated; to provide medication as ordered, and a handwritten entry of PRN (as needed) medications such as milk of magnesia (MOM), [MEDICATION NAME] suppository, and fleet enema. During an interview and record review with a Registered Nurse (RN) 1, on January 7, 2015 at 9:15 a.m., she was asked what the facility's care plan for Resident 13 that addressed the side effects of opioid pain medications. RN 1 was not able to answer and could not find a care plan that addressed the effects of pain medications to a resident's bowel movement. A review of Resident 13's Medication Record (a medication administration record) indicated a physician's orders [REDACTED]. effective. The Medication Administration Record [REDACTED]. The 5-day assessment Minimum Data Set (MDS, a standardized assessment and care planning tool), dated December 19, 2014, indicated Resident 13 was severely impaired in cognitive skills, and needed extensive assistance (resident involved in activity, staff provide weight-bearing support) in bed mobility, transfer, walking in corridor, eating, toilet use, and personal hygiene. The MDS indicated Resident 13 was always incontinent (no control) of bowel and the resident's pain intensity was described as "very severe and horrible." On January 8, 2015 at 1:55 p.m. during an interview, Certified Nursing Assistant (CNA) 1 stated Resident 13 was a "total assist with feeding and required a lot of help and encouragement." A review on an article titled, "Dehydration: Stopping a Sentinel Event (any unanticipated event in a healthcare setting resulting in death or serious physical or psychological injury to a patient or patients, not related to the natural course of the patient's illness)," published by "Nursing Homes," dated October 1999, indicated the following: 1. "Resident who cannot drink on their own requires staff intervention to be sure they receive adequate fluid intake. The care plan defines how the staff will accomplish this goal." 2. "If there are inadequate fluids in the body, the body has difficult time getting rid of body wastes, resulting in constipation or fecal impaction." 3. "An inadequate amount of fluid consumed also results in production of a very small amount of odorous, dark-colored urine. The result is often a urinary tract infection (UTI- infection in the bladder that holds the urine), and is a trigger for dehydration." 4. "When the body has inadequate fluids, less oxygen and glucose are circulated to the brain, resulting in confusion...decreased ability with activities of daily living and cognitive status." In a telephone interview with Family 1, on January 12, 2015 at 10:30 a.m., he stated Resident 13 refused to use the diaper and bedpan during toileting. Family 1 stated that Resident 13 would say she had to go to the bathroom and facility staff told the family the "resident cannot get out of bed right now because of her broken pelvis." Family 1 stated they (the family) were told it is alright to use the diaper for both bowel and bladder movements. A review of the Physician's Admission Order, dated December 12, 2014, indicated Resident 13 "May get up as tolerated" and "Weight bearing as tolerated." The Facility ADL (activities of daily living) Flow-sheet Record indicated Resident 13 had bowel movements on the following dates: a. On December 15, 2014, Resident 13's stool was medium in size during the day shift (7 a.m. - 3 p.m.) and small in size during the night shift (11 p.m. - 7 a.m.). b. On December 16, 2014, Resident 13's stool was small in size during the night shift. c. On December 17, 2014, Resident 13's stool was large in size during the night shift. d. On December 19, 2014, Resident 13's stool was small in size during the evening shift (3 p.m. - 11 p.m.). This was the resident's last recorded bowel movement until she was discharged to the hospital on December 22, 2014. There was no documented evidence in the clinical record the consistency of Resident 13's stool was monitored in accordance with the plan of care. A review the Daily Licensed Nurses Notes, dated December 17, 2014 at 5 a.m., indicated Resident 13 had a change of condition manifested by an episode of hematuria (blood cells leaking into the urine). The notes indicated "...fluids encouraged as tolerated to maintain adequate hydration..." There was no documented evidence to show how the facility encouraged Resident 13, who was confused and with dementia, to drink fluids to ensure adequate fluid intake; if the encouragement was effective; and if Resident 13 actually drank fluids to prevent dehydration and/or minimize the complications from dehydration. There was no documented evidence Resident 13 was re-assessed for increased risk for dehydration due to the change of condition and how the facility was going to manage the complications related to dehydration. On January 8, 2015 at 9:45 a.m., during an interview with the dietary manager, she was asked how Resident 13's fluid needs were calculated during her stay in the facility to prevent dehydration. The dietary manager stated the registered dietitian had not yet assessed Resident 13 during that time. A review of CNA (Certified Nurse Assistant) 1's documentation on the Facility ADL Flowheet Record on day shift, dated December 19, 2014, indicated a CNA reported to the nurse that Resident 13 had no bowel movement (BM) for three days (during the day shift). Last recorded bowel movement of Resident 13 was two days prior, December 17, 2014 during the night shift. On January 8, 2015 at 1:55 p.m., during an interview, CNA 1 stated she reported Resident 13 bowel status to her charge nurse because she noted the resident had no BM for three days. CNA 1 stated she remembered Resident 13 was moaning and crying and directed her discomfort to the area around the abdomen. A review of the Daily Licensed Nurses Notes, dated December 19, 2014, indicated Resident 13's abdomen was slightly firm and tender to touch, the resident tolerated the thickened fluid that was offered and she was encouraged to increase her fluid intake. There was no documented evidence that nursing interventions were implemented upon assessment of the resident's firm abdomen. There was no documented evidence of how the facility encouraged the resident to drink fluids or how the procedure was conducted. There was no documentation of how the facility provided the encouragement and if the encouragement was effective. There was no documented evidence Resident 13 was able to increase her intake of the thickened liquid. On January 9, 2015 at 10:35 a.m. during an interview, Resident 13's care plans were discussed with Licensed Vocational Nurse (LVN) 4. When LVN 4 was asked if she read her resident's care plans; she stated "I want to be honest with you. I don't read it all the time." On January 9, 2015 at 10:45 a.m., during an interview, LVN 4 stated if she could see a stool outside a resident's anal area, she could do the dis-impaction manually but she needs a physician's orders [REDACTED]. LVN 4 stated she would try to give a resident Milk of Magnesia (oral laxative) first, followed by an enema, and then she would call the doctor if the medications did not work. The Daily Licensed Nurses Notes, dated December 21, 2014 and timed at 2 p.m., indicated Resident 13 had a change of condition manifested by moaning, poor intake by mouth, and food pocketing (food stays inside the mouth, a common problem when there is a swallowing issue or the person does not want to swallow) and the physician was notified with no new order. The nurse's notes indicated Resident 13 opened her mouth to feed but she did not swallow; she was encouraged to increase her intake of food and fluid but it was not effective. On January 9, 2015, at 10:45 a.m., during an interview with LVN 4, she stated she called the physician during her shift (7 a.m. to 3 p.m.) on December 21, 2014, and informed the physician Resident 13 was not eating, pocketing food, and moaning. LVN 4 stated the physician did not order anything. LVN 4 was asked what the next step was when a physician did not order anything. LVN 4 stated, "I don't remember who told me but I remember somebody said that the physician is coming the next day anyway, to look at the resident." A review of the CNA (Certified Nurse Assistant) documentation on the Facility ADL Flowsheet Records indicated Resident 13 did not eat dinner on December 19, 2014; the resident ate 50% of the breakfast on December 20, 2014, but she did not eat lunch and dinner. On December 21, 2014, Resident 13 did not eat all three meals and again on December 22, 2014 for breakfast and lunch. Resident 13 did not eat for seven (7) consecutive meals from December 20 (Saturday) thru December 22, 2014 (Monday). A review of the Daily Licensed Nurses Notes, dated December 22, 2014 (time not documented), indicated Resident 13 refused breakfast and medications (including antibiotics and pain medications). The physician and nurse practitioner (NP) were notified and an order for [REDACTED]. According to the IV Medication Sheet, dated December 22, 2014 at 12:20 p.m., Resident 13 was started on IV fluids. A review of the CNA note documented in the Facility ADL Flowsheet Record, dated December 22, 2014, on a 7-3 a.m. shift, indicated a CNA reported to the nurse that Resident 13 had no bowel movement for two days. Last recorded bowel movement for Resident 13 was three days prior, on December 19, 2014 during the evening shift, and it was small in size. The Daily Licensed Nurse Notes, dated December 22, 2014 and timed at 1 p.m., indicated the interdisciplinary team (IDT, a group of health care professionals from diverse fields who work in a coordinated fashion toward a common goal for the patient) met and discussed the Resident's weight loss of three (3) pounds (lbs) in one week from 130 lbs to 127 lbs. There was no documented evidence that Resident 13's increased risk for dehydration, associated with weight loss, was discussed so a plan of care could be developed to prevent complications, such as constipation and fecal impaction. The Daily Licensed Nurses Notes, dated December 22, 2014, at 2:50 p.m., indicated Resident 13 refused her meal and medications, and the physician was informed. A physician telephone order, dated December 22, 2014 and timed at 3 pm, was made to transfer Resident 13 to a general acute care hospital (GACH). Resident 13 left the facility via ambulance at 4 pm. The facility's "Resident Transfer Record," dated December 22, 2014, indicated Resident 13's reason for transfer to GACH was altered mental status and refusal of medications and meals. A handwritten entry documented in the transfer form indicated that resident's last meal/snack feeding was on December 20, 2014, two days before the transfer. A review of GACH's Emergency Department (ED) Report, dated December 22, 2014 indicated Resident 13 had dry mucous membranes with mouth opened with eyes closed on physical examination. A critical care note in the report indicated the resident was "...noted to be dehydrated with her mouth open and noted by family to not be eating or drinking as well as she normally does...contracted on one side in pain with bleeding from perineum (the area between the bottom of the vaginal opening and the anus)...with very copious hard stool noted and dis-impacted with immediate release of a large amount of hematuria after stool was dis-impacted." A review of the ED critical care note indicated Resident 13 was given intravenous fluids as she "appeared clinically dry." The [DIAGNOSES REDACTED]. A review of Resident 13's History and Physical (GACH's), dated December 23, 2014, indicated "Patient also noted to have a fecal impaction, now having multiple bowel movements after dis-impaction." Resident 13's bowel was cleared with [MEDICATION NAME] (oral liquid laxatives) twice a day. During an interview with a Registered Nurse (RN) 1, on January 7, 2015 at 9:15 a.m., when asked if laxatives were given to Resident 13 during her stay in the facility from December 12 to 22, 2014, she stated, "We didn't give it." RN 1 was asked if a licensed nurse had checked Resident 13 for constipation and/or impaction since Resident 13 received [MEDICATION NAME] and [MEDICATION NAME] (opioid [MEDICATION NAME] and may cause constipation). RN 1 stated "I don't know," and that she could not find any documentation a nurse assessed Resident 13 for constipation and impaction. During an interview with the director of nursing (DON), on January 7, 2015 at 10:45 a.m., the DON stated the facility did not have a written policy and procedure on how to address constipation and/or fecal impaction for residents. On January 12, 2014 at 10:30 a.m. during a telephone interview, Family 1 stated he started getting concerned with Resident 13's health status on December 17, 2014 because she was not eating as much. On the 18th, Family 1 stated he noticed Resident 13 was not really conscious and constantly moaned and made "sounds." Family 1 stated he repeatedly asked what was being done and facility reported "they are aware." The next day, which was the 19th, Family 1 stated he told the facility Resident 13 was not getting any liquids and something was wrong with the resident. During the telephone interview, Family 1 stated the facility moved the resident to another room down the hall close to an outside door and he was not told of the reason why. Family 1 stated "I think it is because of the constant screaming and groaning." On the 20th of December, Family 1 stated he was really concerned because he could see Resident 13 getting worse and he told a licensed nurse that morning that Resident 13's abdomen looked kind of big and he (Family 1) stated, "We have to do something." The licensed nurse, who Family 1 spoke to that morning, stated, "What do you want us to do about it?" Family 1 stated, during the interview, "I took it in face value that the facility knew what they were doing. I was too naive. I thought Resident 13 will get the same care as the other residents there that were playing bingo. I didn't really know the warning signs. All I did was talk and remind the facility staff." 2. A review of Resident 12's clinical record indicated the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of Resident 12's nursing care plan dated December 15, 2014, indicated the resident was at risk for weight change, fluid deficit, and [MEDICAL CONDITION] (swelling caused by excess fluid trapped in your body's tissues). The staff's interventions were to monitor (to watch or keep track of) the pre and post [MEDICAL TREATMENT] weight. A review of the [MEDICAL TREATMENT] Communication Record form, dated January 2, 2015, indicated the section of the form to be completed by the [MEDICAL TREATMENT] center was incomplete; the post [MEDICAL TREATMENT] weight was not monitored and not documented. 3. On January 7, 2015, at 8:45 a.m., Resident 14 was observed sitting in bed eating her breakfast. A review of Resident 14's clinical record indicated the resident was admitted to the facility on [DATE], and readmitted on [DATE] with [DIAGNOSES REDACTED]. A review of the Minimum Date Set (MDS, a standardized assessment and care screening tool), dated November 5, 2014, indicated Resident 14 had no memory problems, was independent in cognitive skills for daily decision making, and required extensive assistance from staff for bed mobility, transfer, dressing, and personal hygiene. A physician's orders [REDACTED]. A review of Resident 14's nursing care plan, dated December 15, 2014, developed for the resident's risk for weight change, fluid deficit, and [MEDICAL CONDITION], indicated the goal was for the resident to not suffer from any injuries or complications. The staff's interventions were to monitor pre and post [MEDICAL TREATMENT] weight, and to notify the physician of any significant change in condition. A review of the [MEDICAL TREATMENT] Communication Record form dated November 17, 2014, November 28, 2014, and December 1, 2014 indicated the post [MEDICAL TREATMENT] weights were not monitored and not documented. There was no documented evidence the facility attempted to obtain the missing weight information from the [MEDICAL TREATMENT] center after the [MEDICAL TREATMENT] treatment. On January 7, 2015, at 11:25 a.m., during an interview, the licensed vocational nurse (LVN 1) stated the pre and post [MEDICAL TREATMENT] weight should be documented in the [MEDICAL TREATMENT] Communication Record form. LVN 1 stated when residents come back from the [MEDICAL TREATMENT] center without the post [MEDICAL TREATMENT] weight, the licensed nurses needed to call the [MEDICAL TREATMENT] center to obtain the missing weight. LVN 1 stated licensed nurses needed Resident 14's pre and post [MEDICAL TREATMENT] weight to monitor for signs and symptoms of fluid imbalance due to significant weight changes from [MEDICAL TREATMENT]. On January 7, 2015 at 11:50 a.m., during an interview with the Director of Nurses (DON) regarding the missing post [MEDICAL TREATMENT] weight, she stated the charge nurses or the nurse supervisors needed to obtain the missing post [MEDICAL TREATMENT] weight from the [MEDICAL TREATMENT] center. A review of the facility's undated policy and procedure titled "[MEDICAL TREATMENT] Care" indicated, the facility will arrange for [MEDICAL TREATMENT] care as ordered by the attending physician. The facility maintains a contract with a [MEDICAL TREATMENT] service provider which addresses communications between the facility and provider. The policy further indicated, the nursing staff, the [MEDICAL TREATMENT] provider staff, and the attending physician will collaborate on a regular basis with issues concerning the resident's care including the resident's current vital signs, weight, and any changes of conditions specific to the resident with each treatment.

Based on interviews and record review, the facility failed to provide the fluid intake necessary for proper hydration and to maintain the health of one of 18 sampled residents (Resident 13) after a change in condition by failing to: 1. Re-assess Resident 13 for increased risk for dehydration after being diagnosed with [REDACTED]. 2. Implement the facility's policy and procedure to conduct a nutritional assessment when a resident had a change of condition. 3. Update or develop a care plan to reflect the resident's current status for interventions to be identified and implemented. 4. Review the resident's fluid intake and potential for the presence of an acute underlying medical problem after the resident refused 3 meals consecutively. 5. Implement a fluid intake and output recording when Resident 13's risk for dehydration increased after the resident had a UTI diagnosed on [DATE], to meet the resident's fluid needs. Resident 13, who was assessed as a high risk for dehydration, had developed hematuria (blood cells leaking into the urine) and a urinary tract infection five days after her admission to the facility, on December 17, 2014. These deficient practices resulted in Resident 13 being transferred to a general acute care hospital (GACH) where she received large intravenous (IV, within a vein) fluid boluses (a large volume of fluid or dose given intravenously and rapidly at one time) and had a manual fecal dis-impaction (manual removal of feces or stool), which was related to undetected/untreated constipation (a complication related to dehydration). See F309 for additional information regarding Resident 13. Findings: A review of Resident 13's Face Sheet (admission record) indicated the resident was admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. A review of the Dehydration Risk Assessment form, dated December 12, 2014, indicated Resident 13 had scored 60 out of 50 and above, which was considered a "high risk" for dehydration. The assessment indicated that Resident 13 had difficulty swallowing liquids and required moderate or extensive assistance (resident involved in activity, staff provide weight-bearing support) with fluid intake. A review of the Medication Record (a medication administration record), dated December 12 thru December 22, 2014, indicated Resident 13 was receiving a diet of pureed consistency (soft, smooth, thick paste consistency similar to a thick pudding) and nectar thick liquids (liquids that have been thickened to a consistency which coats and drips off a spoon, similar to unset gelatin) every meal. According to the article titled "Dehydration and Dysphagia: Challenges in the Older Adult," page 2, published by the Journal of Medical Speech-Language Pathology, dated August 2011, "...certain disease-related signs and symptoms also serve as markers for dehydration. One reported marker is reduced oral intake secondary to swallowing difficulty...older adults are the most vulnerable group for dysphagia (difficulty swallowing)...Although evidence-based management strategies are designed for those with dysphagia to maintain oral delivery of hydration (e.g. thickened liquids ...)... these interventions may potentially reduce fluid intake." The article indicated that "Dehydration is known to contribute to constipation, fecal impaction, urinary tract infections...and [MEDICAL CONDITION] (a sudden or acute confusion-like state)..." Resident 13's clinical record contained a preprinted care plan, initiated on December 12, 2014, titled, "Resident Care Plan, Nutrition and Hydration." The care plan problem indicated Resident 13 was at risk for dehydration related to a decrease in fluid intake, dysphagia (difficulty swallowing), the use of thickened liquids, pain, refusal of meals/fluids, decreased perception of thirst, and poor appetite. The care plan goals indicated Resident 13 will maintain adequate hydration as evidence by "... normal urinary output as well as adequate nutritional intake of at least 75% each meal." The approaches indicated in the care plan included maintaining an intake and output log as indicated to encourage oral fluids and eating at each meal, offer fluids frequently, and monitor signs and symptoms of dehydration. A preprinted care plan, initiated on December 12, 2014 indicated that Resident 13 was at risk for dehydration related to nausea. The approaches indicated in the care plan included monitoring for signs and symptoms of dehydration and provide/encourage adequate hydration as tolerated. A review of the physician order, dated December 13, 2014, indicated an order to administer one liter of fluids (D5 ? NS (5% [MEDICATION NAME] or sugar in ? normal saline or salt solution) at 60 cubic centimeters per hour) intravenously (IV, within a vein) for hydration. The IV Medication Sheet indicated the IV fluids were administered to Resident 13. The Speech Therapy evaluation, dated December 15, 2014, indicated without skilled intervention at this time, Resident 13 would be at an increased risk of dehydration. The 5-day assessment Minimum Data Set (MDS, a standardized assessment and care planning tool) dated December 19, 2014, indicated Resident 13 was severely impaired in cognitive skills, and needed extensive assistance (resident involved in activity, staff provide weight-bearing support) in bed mobility, transfer, walking in corridor, dressing, eating, toilet use, and personal hygiene. On January 8, 2015 at 1:55 p.m. during an interview, Certified Nursing Assistant (CNA) 1 stated Resident 13 was a "total assist with feeding and required a lot of help and encouragement." An article titled, "Dehydration: Stopping a Sentinel Event (any unanticipated event in a healthcare setting resulting in death or serious physical or psychological injury to a patient or patients, not related to the natural course of the patient's illness)," published by "Nursing Homes," dated October 1999, indicated the following: 1. "Resident who cannot drink on their own requires staff intervention to be sure they receive adequate fluid intake. The care plan defines how the staff will accomplish this goal." 2. "If there are inadequate fluids in the body, the body has difficult time getting rid of body wastes, resulting in constipation or fecal impaction." 3. "An inadequate amount of fluid consumed also results in production of a very small amount of odorous, dark-colored urine. The result is often a urinary tract infection (UTI- infection in the bladder that holds the urine), and is a trigger for dehydration." 4. "When the body has inadequate fluids, less oxygen and glucose are circulated to the brain, resulting in confusion ... decreased ability with activities of daily living and cognitive status." The Facility ADL (activities of daily living) Flowsheet Record indicated Resident 13 was totally dependent (all care done by staff) for self-performance during mealtimes on the following dates: a. On December 13, 2014, Resident 13 was totally dependent on staff for breakfast, lunch and dinner. b. On December 14, 15, 16, and 17, 2014, Resident 13 was totally dependent on staff for breakfast and lunch. There was no documentation for Resident 13's performance for dinner. c. On December 18 and19, 2014, Resident 13 was totally dependent on staff for breakfast, lunch and dinner. Resident 13 did not eat (documented as zero intake) dinner on December 19, 2014. d. On December 20, 21, and 22, 2014, Resident 13 was totally dependent on staff for breakfast and lunch but was supervised (oversight or verbal direction, encouragement or cueing) only for dinner. Resident 13 ate 50% of her breakfast but she did not eat lunch and dinner on December 20, 2014. On December 21, 2014, Resident 13 did not eat all three meals. On December 22, 2014, Resident 13 did not eat breakfast and lunch. Resident 13 did not eat for seven (7) consecutive meals from December 20 (Saturday) thru December 22, 2014 (Monday). A review of the physician's order, dated December 16, 2014, indicated to provide Resident 13 with Med-pass (a nutritional drink to supplement calories and protein) 60 milliliters (ml) by mouth daily and HPN (high protein nutrition) four (4) ounces by mouth three times a day with meals. There was no documented evidence the Med-pass was offered to Resident 13 and if the resident drank 60 ml a day of the Med-pass. There was no documented evidence of Resident 13's consumption of the HPN with meals. A review of the Daily Licensed Nurses Notes, dated December 17, 2014 at 5 a.m., indicated that Resident 13 had a change of condition manifested by an episode of hematuria (blood cells leaking into the urine). The notes indicated, "...fluids encouraged as tolerated to maintain adequate hydration..." There was no documented evidence of how the facility encouraged Resident 13, who was confused and with dementia, to drink fluids to maintain adequate hydration. There was no documented evidence to indicate if the encouragement was effective and if Resident 13 actually drank fluids. There was no documented evidence of the amount of fluids drank by the resident to prevent dehydration which could lead to complications, such as UTI, constipation, and fecal impaction. There was no documented evidence Resident 13 was re-assessed for increased risk for dehydration due to the change of condition and how the facility was going to manage the complications related to dehydration. There was no documented evidence a care plan was developed for a new [DIAGNOSES REDACTED]. A review of the facility's policy and procedure titled, "Change of Condition Notification," revised January 1, 2012, indicated, "...Update the Care Plan to reflect the resident's current status..." On January 9, 2015 at 10:35 a.m. during an interview, Resident 13's care plans were discussed with Licensed Vocational Nurse (LVN) 4. When LVN 4 was asked if she reads her residents' care plans, she stated "I want to be honest with you. I don't read it all the time." A review of a laboratory result for urine chemistry (used to diagnose infection in the urine) dated December 18, 2014 indicated Resident 13 had a urinary tract infection. A handwritten note located at the bottom of the laboratory result indicated an order for [REDACTED]. A review of the Daily Licensed Nurses Notes, dated December 19, 2014, indicated that Resident 13's abdomen was slightly firm and tender to touch, urine still had blood, and she was receiving the antibiotics, Bactrim, for the urinary tract infection. The resident tolerated the thickened fluid offered and she was encouraged to increase her fluid intake. There was no documented evidence to indicate how the encouragement was provided. There was no documented evidence to indicate whether the encouragement was effective and the amount of the thickened liquid drank by Resident 13 and/or and if Resident 13 was able to increase her intake of the thickened liquid. A review of the facility policy titled "Evaluation of Weight and Nutritional Status," revised August 1, 2014, indicated that a nutritional assessment will be completed upon a resident's change of condition, the dietitian will complete a nutritional assessment initiated by the dietary manager upon admission for residents within 14 day, and the dietitian will provide a narrative of recommendations in the Assessment and identity any weight loss or dehydration risk factors. There was no documented evidence that Resident 13's nutritional assessment was completed when the resident had a change of condition on December 17, 2014, a condition that could affect her fluid intake. On January 8, 2015 at 9:45 a.m. during an interview, the dietary manager was asked if the facility's registered dietitian completes the nutritional assessment section of a newly admitted resident earlier than what was stated in the policy which was 14 days. The dietary manager stated it is based from the "resident's [DIAGNOSES REDACTED]." There was no documented evidence Resident 13 was evaluated by a registered dietitian within the resident's 10-day stay at the facility when she was identified as high risk for weight loss and dehydration. During the interview with the dietary manager, on January 8, 2014 at 9:45 a.m., she was asked how Resident 13's fluid needs were calculated during her stay in the facility to prevent dehydration. The dietary manager stated the registered dietitian has not yet assessed Resident 13 during that time. A review of the Dietary Questionnaire, dated December 13, 2014, conducted by the dietary manager, indicated an incomplete documentation of Resident 13's dietary preferences. The food and dining location preferences portion was left blank. An assessment of the resident's oral status which can affect eating was also left blank. The snack and nourishment in between meals portion was blank. A handwritten entry in the questionnaire indicated, "Resident confused." There was no documented evidence the dietary manager attempted to complete the Dietary Questionnaire when Resident 13 had a change of condition on December 17, 2014. On January 8, 2015 at 9:45 a.m., during an interview with the dietary manager, she stated "I was not able to complete my questionnaire because she (Resident 13) was confused." The Daily Licensed Nurses Notes, dated December 21, 2014 and timed at 2 p.m., indicated Resident 13 had a change of condition manifested by moaning, poor intake by mouth, and food pocketing (food stays inside the mouth, a common problem when there is a swallowing issue or the person does not want to swallow) and the physician was notified with no new order. The nurse's notes indicated Resident 13 opened her mouth to feed but she did not swallow; she was encouraged to increase her intake of food and fluid but it was not effective. On January 9, 2015 at 10:45 a.m., during an interview, LVN 4 stated she called the physician during her shift (7 a.m. to 3 p.m.) on December 21, 2014, and informed the physician Resident 13 was not eating, was pocketing food, and was moaning. LVN 4 stated the physician did not order anything. LVN 4 was asked what was the next step when a physician does not order anything. LVN 4 stated "I don't remember who told me but I remember somebody said that the physician is coming the next day anyway, to look at the resident." The ADL Flowsheet Record indicated Resident 13 had missed four (4) consecutive meals from December 20, 2014 (lunch and dinner) to December 21, 2014 (breakfast and lunch). A review of a facility policy and procedure titled "Food Intake - Recording Percentage and Nutritional Assessment," revised January 1, 2012, indicated if three (3) consecutive meals were refused by the resident, the charge nurse will review fluid intake and the presence/absence of an acute medical problem. There was no documented evidence that a licensed nurse reviewed Resident 13's fluid intake or presence of an acute underlying medical problem after the resident refused three (3) meals consecutively. A facility policy and procedure titled "Intake and Output Recording, " revised January 1, 2012, indicated intake and output recording may be instituted per an attending physician's order or a licensed nurse for any resident with risk of dehydration. There was no evidence the licensed nurse instituted a fluid intake and output recording when Resident 13 risk for dehydration increased after the resident experienced a change of condition on December 17, 2014. On January 9, 2015 at 11:30 a.m., during an interview with the director of nurses (DON), she was asked when a licensed nurse initiates an Intake and Output (I&O) monitoring. The DON stated the facility monitored the I&O of residents with "new gastrostomy tubes (GT- a tube that is placed directly into the stomach through an abdominal wall incision for administration of food, fluids, and medications), new Foley catheters (a urinary indwelling catheter), intravenous fluid hydration, and intravenous antibiotics administration." During the interview, the DON was asked to clarify the facility's policy and procedure and was asked if I&O were supposed to be monitored for residents with risk of dehydration. DON stated the facility monitored resident's I&O but "only for the duration of the intravenous fluids." A review of the Daily Licensed Nurses Notes, dated December 22, 2014 (time not documented), indicated Resident 13 refused breakfast and medications (including antibiotics and pain medications). The physician and nurse practitioner (NP) were notified and an order for [REDACTED]. The IV Medication Sheet, dated December 22, 2014 at 12:20 p.m., indicated Resident 13 was started on IV fluids. The Daily Licensed Nurse Notes, dated December 22, 2014 and timed at 1 p.m., indicated the interdisciplinary team (IDT, a group of health care professionals from diverse fields who work in a coordinated fashion toward a common goal for the patient) met and discussed the Resident's weight loss of three (3) pounds (lbs) in one week from 130 lbs to 127 lbs. There was no documented evidence that Resident 13's increased risk for dehydration, associated with weight loss, was discussed so that a plan of care could be developed to prevent complications, such as constipation and fecal impaction. The Daily Licensed Nurses Notes, dated December 22, 2014 at 2:50 p.m., indicated that Resident 13 refused her meal and meds and the physician was informed. A physician telephone order, dated December 22, 2014 and timed at 3 pm, was made to transfer Resident 13 to a general acute care hospital (GACH). Resident 13 left the facility via ambulance at 4 pm. The facility's "Resident Transfer Record" dated December 22, 2014 indicated that Resident 13's reason for transfer to GACH is altered mental status, and refusal of medications and meals. A handwritten entry documented in the transfer form indicated Resident 13's last meal/snack feeding was on December 20, 2014, two days before the transfer. A review of GACH's Emergency Department (ED) Report dated December 22, 2014 indicated Resident 13 had dry mucous membranes with mouth open with eyes closed on physical examination. A critical care note in the report indicated the resident was "...noted to be dehydrated with her mouth open and noted by family to not be eating or drinking as well as she normally does..." A review of the ED critical care note indicated Resident 13 was given intravenous fluids as she "appeared clinically dry" and she was started on intravenous [MEDICATION NAME] (antibiotics) for a white blood cell count (usually measured as part of a complete blood count that signifies infection if above normal range) of 34, 000 (normal range is 3,500 to 10,500 cells per mcL (microliter)) because of a UTI. The [DIAGNOSES REDACTED]. On January 12, 2014 at 10:30 a.m. during a telephone interview, Family 1 stated he started getting concerned with Resident 13's health status on December 17, 2014 because she was not eating as much. On the 18th, Family 1 stated he noticed Resident 13 was not really conscious and constantly moaned and "made sounds." Family 1 stated he repeatedly asked what was being done and the facility reported "they are aware." The next day, which was the 19th, Family 1 stated he told the facility Resident 13 was not getting any liquids and something was wrong with the resident. During the telephone interview, Family 1 stated the facility moved Resident 13 to another room down the hall close to an outside door and he was not told of the reason why. Family 1 stated "I think it is because of the constant screaming and groaning." On the 20th of December, Family 1 stated he was really concerned because he could see Resident 13 getting worse and he told a licensed nurse that morning that Resident 13's abdomen looked kind of big and he (Family 1) stated, "We have to do something." The licensed nurse, who Family 1 spoke to that morning, stated, "What do you want us to do about it?" Family 1 stated, during the interview, "I took it in face value that the facility knew what they were doing. I was too naive. I thought Resident 13 will get the same care as the other residents there that were playing bingo. I didn't really know the warning signs. All I did was talk and remind the facility staff."