Every finding on record at Alamitos Belmont Health and Rehabilitation

Based on interview, and record review, the facility failed to follow it's policy and procedures (P&P) titled Cardiopulmonary Resuscitation ([CPR] an emergency lifesaving procedure performed when the heart stops beating), which indicated the facility will provide CPR, to any resident requiring such care prior to the arrival of the emergency medical personnel, in the absence of an advance directives or a do not resuscitate (DNR) order for one of three sampled Residents (Resident 93).The Facility failed to:Activate the EMS system by paging or yelling loudly for Code Blue ( an emergency alert signaling that a person was experiencing a life-threatening situation, typically cardiac (heart) or respiratory arrest, requiring immediate resuscitation) on [DATE] at 5:00 a.m., when Resident 93 was observed by Certified Nurse Assistant (CNA) 1 unresponsive (not reacting to touch, sound or smell), not breathing, and without a pulse (heartbeat) in bed.Call 911 within five minutes after Resident 93 was observed unresponsive on [DATE] at 5:00 a.m.Ensure Certified Nursing Assistant (CNA) 1, Licensed Vocational Nurse (LVN) 1 and LVN 2 initiated CPR as soon as Resident 93 was observed unresponsive and without a pulse on [DATE] at 5:00 a.m. This deficient practice resulted in a delay of life-saving CPR for Resident 93, who was pronounced dead on [DATE] at 6:15 a.m. and placed 40 current residents, who had a full code (residents' choice of level of life saving treatment if found unresponsive) status of not receiving life saving measures immediately without loss of valuable time for being successfully revived.On [DATE] at 4:59 p.m., an Immediate Jeopardy ([IJ] a situation in which the facility's noncompliance with one or more requirements of participation had cause, or is likely to cause serious injury, harm, impairment, or death to a resident) was called due to the facility's failure to ensure CNA 1, LVN 1 and LVN 2 performed CPR without delays after finding Resident 93 unresponsive, in the presence of the Administrator (ADM) and the Director of Nursing (DON). On [DATE] at 3:35 p.m., the ADM submitted an acceptable IJ removal plan ([IJRP], an intervention to immediately correct the deficient practices). After verification of the IJRP's implementation through interview, and record review, the IJ was removed on [DATE] at 4:29 p.m., in the presence of the ADM. The IJRP included the following: 1.The interdisciplinary team (IDT healthcare team composed of various specialties') implemented a wristband identification system for code status for all residents Black dot: Do Not Resuscitate (DNR resident wishes no life saving measures if found with nor heart beat and not breathing), No dot : Full Code; If a resident is found unresponsive, staff will immediately initiate CPR. 2. The DON and the Director of Staff Development (DSD) will in-service all Registered Nurses (9), LVN's (23) and CNA's (68) regarding indications for CPR and American Heart Association (AHA) recommendations by [DATE].3. The in-services included the wristband identification system to immediately identify code status, and the updated CPR policy. 4. On [DATE], the IDT, including Social Services, Medical Records, DSD, and MDS, reviewed and verified all Physician Orders for Life-Sustaining Treatment (POLST is a form designed to improve patient care by creating a portable medical order form that records patients' treatment wishes so that emergency personnel know what treatments the patient wants in the event of a medical emergency) POLST forms and code status orders in the electronic medical records system to update the resident wristbands. All 77 residents' wristbands were updated.5.The admission Nurse will place a wristband indicating code status on each new admission. 6. The Treatment Nurse or Designee will conduct a follow-up daily review of new admission code status orders to verify the wristbands. 7. The DSD or Designee will in-service staff upon hire, annually, and as needed regarding the wristband identification system to immediately identify code status and the updated CPR policy 8. The Medical Records Director or Designee will conduct a daily review of the code status report to compare it to the resident wristbands. Any identified discrepancies will be immediately updated and reported to the DON. 9. The DON or Designee will report the progress of the monitoring to the Quality Assurance and Performance Improvement (QAPI a systematic, interdisciplinary, and comprehensive method for improving safety, quality of care, and resident quality of life) Committee monthly for 6 months or until substantial compliance has been achieved. Findings:During a review of Resident 93's admission Record, the admission Record indicated Resident 93 was admitted to the facility on [DATE] with diagnoses including end stage renal disease ([ESRD], irreversible kidney failure), anemia (a condition where the body does not have enough healthy red blood cells), diabetes mellitus ([DM], a disorder characterized by difficulty in blood sugar control and poor wound healing), and dementia (a progressive state of decline in mental abilities).During a review of Resident 93's Minimum Data Set ([MDS], a resident assessment tool) dated [DATE], the MDS indicated Resident 93 was severely cognitively (thinking process) impaired . The MDS indicated Resident 93 was dependent on staff for activities of daily living (ADL) such as hygiene, getting dressed and putting on footwear.During a review of Resident 93's physician order for life sustaining treatment ([POLST], a form that contains written medical orders for healthcare professionals regarding specific medical treatments that can or cannot be done at the end-of life) dated [DATE], the POLST indicated Resident 93 was a full code with resuscitation/CPR, trial period of artificial nutrition including feeding tube (a flexible, medical device used to deliver liquid nutrition, fluids, and medication directly into the stomach or small intestine when a person cannot eat or swallow safely).During a record review of Resident 93's Nurses Progress Notes dated [DATE], at 7:03 a.m., the Nurses Progress Notes indicated on [DATE] at 5:30 a.m., CNA 1 found Resident 93 cold to touch (indicating heart stopped circulating blood) and unresponsive. The Nurses Progress Notes indicated CNA 1 left Resident 93 and went to find LVN 1 to assess Resident 93. The Nurses Progress Notes indicated LVN 1 found Resident 93 with no heartbeat upon auscultation (listening for a heartbeat using a stethoscope [device used to detect and listen to heartbeat). The Nursing Progress Notes indicated Resident 93 had no detectable vital signs (measurements of the body's basic function, heartbeat, respiration rate [breathing], and blood pressure that indicate the state of a patient's essential body functions), no rise and fall of chest (not breathing). The Nursing Progress Notes indicated before being found unresponsive Resident 93 was last seen by CNA 1 around 4:30 a.m., coughing. The progress note indicated Resident 93 was a Full Code. The Nursing Progress Notes indicated emergency medical Technician (EMT)'s arrived at 5:45 a.m., and called Time of Death at 6:00 a.m.During a review of the EMT's run sheet (official document completed by EMT for every dispatched (sent) call dated [DATE], the run sheet indicated the EMT's were dispatched at 6:05 a.m., arrived at the facility at 6:10 a.m. and Resident 93 was pronounced dead at 6:15 a.m.During a telephone interview on [DATE] at 5:51 p.m., with LVN 1, LVN 1 stated on [DATE], at approximately 5:00 a.m., CNA 1 notified her (LVN 1) that Resident 93 was not responding, and CNA 1 could not wake the resident up. LVN 1 stated she got her stethoscope and asked LVN 2 to come with her to check on Resident 93 in his room. LVN 1 stated she (LVN 1) checked Resident 93's vital signs and the machine could not detect any vital signs. LVN 1 stated she (LVN 1) used her index and middle fingers to feel Resident 93's carotid pulse (the beating of blood flow in the vein that supplies oxygenated blood to the brain) and there was no pulse. LVN 1 stated Resident 93 was a full code, and she (LVN 1) initiated CPR on Resident 93 at approximately 5:30 a.m., (30 minutes after the resident was found unresponsive), until the emergency medical services arrived at 5:45 a.m LVN 1 stated the emergency medical services did not perform CPR. LVN 1 stated the emergency medical staff pronounced Resident 93 dead at 6:00 a.m.During an interview on [DATE] at 8:38 a.m., with LVN 2, LVN 2 stated on [DATE] at approximately 5:15 a.m., LVN 1 informed her she (LVN 1) could not detect any vital signs on Resident 93 and asked her (LVN 2) to verify the lack of vital signs on Resident 93. LVN 2 stated LVN 1 went to check Resident 93's chart for the resident's code status and called the emergency services. LVN 2 stated she (LVN 2) checked his vital signs twice and the machine could not find a reading. LVN 2 stated the second time she (LVN 2) checked Resident 93's vital signs, around 5:40 a.m., LVN 1 was back in the room, and started CPR. LVN 1 asked LVN 2 to go to the front door to wait for emergency medical services to arrive. LVN 2 stated if staff knew the resident's code status, they could have started CPR as soon as Resident 93 was observed unresponsive and without a heartbeat. LVN 2 stated there was a delay in initiating CPR.During an interview on [DATE] at 11:28 a.m., with the Director of Staff Development (DSD), the DSD stated LVN 1, LVN 2 and CNA 1 should have performed CPR on Resident 93, right away when Resident 93 was pulseless and not breathing. The DSD stated staff starting CPR right away would have a higher chance of saving the residents' life. The DSD stated the facility's system was for licensed staff to check a resident's code status in the electronic medical record, and initiate CPR, until emergency medical services personnel take over. During a concurrent interview and record review on [DATE] at 3:25 p.m., with the Director of Nursing (DON), the Nurses Progress Note dated [DATE] was reviewed. The DON stated the Nurses' Progress Note did not indicate the staff members started CPR immediately on Resident 93 when three different staff members, CNA 1, LVN 1 and LVN 2 found the resident unresponsive. The DON stated when CNA 1 found Resident 93 unresponsive and with no knowledge of the resident's code status, CNA 1, LVN 1 and LVN 2 should have tried to find out if Resident 93 was a full code, and initiated CPR right away. The DON stated there was no system in place for emergency situations such as Resident 93's to ensure timely CPR. During a review of the American Heart Association [DATE] CPR and Emergency Cardiovascular Care (ECC) Guidelines (https://cpr.heart.org/en/resuscitation-science/cpr-and-ecc-guidelines/adult-basic-life-support), the guidelines indicated after identifying an individual that was not responsive and not breathing, the rescuer should activate the emergency response system first, then immediately begin CPR, beginning with chest compressions at a rate of 100 to 120 a minute and delivering 2 breaths in between compressions. The guidelines indicated immediate chest compression was critical to improve the individual's outcomes by providing high-quality CPR.During a review of the American Red Cross Training Services Program article (https://www.redcross.org/take-a-class/cpr/performing-cpr/what-is-cpr), the article indicated CPR increased the likelihood of surviving cardiac arrest, when the heart stopped beating or and fails to circulate (to move in a circle) blood to the brain and other vital organs. CPR can double or triple the chance of survival by giving continuous chest compressions.During a review of the facility's policy and procedures (P&P) titled Cardiopulmonary Resuscitation (CPR), revised 12/2023, the P&P indicated it was the policy of this facility to provide basic life support (BLS), including CPR, to any resident requiring such care prior to the arrival of emergency medical personnel in the absence of an advance directive. The P&P indicated staff should check for responsiveness, quality of breathing and pulse simultaneously and if the Resident was unresponsive, not breathing (occasional gasps are not breathing) and no pulse, activate EMS system:1. Page or yell loudly for Code Blue to the area2. Call 9113. Designate an individual to bring code cart and if available, bring Automated External Defibrillator (AED a portable life-saving device used in emergencies when someone is experiencing sudden cardiac arrest) to unresponsive person, start CPR per American Heart Association guidelines for any resident in cardiac or respiratory arrest.

Based on observation, interview and record review, the facility failed to: a. Ensure one of three resident's (Resident 10) Potassium Chloride Oral Solution (mineral and electrolyte that regulates fluid balance, sends nerve signals, and regulates muscle contractions) was administered in the correct form.b. Ensure Licensed Vocational Nurse (LVN) 2 indicated the date and time a Lidocaine patch (medication for pain) was applied for one of one resident (Resident 39).c. Document the correct remaining quantity of Morphine Sulfate (potent pain medication), for one of one resident's (Resident 78)The deficient practices had the potential to result in medication errors including residents' diagnoses not being treated, or too much medication being administered.Findings: a. During a review of Resident 39's admission Record, the admission Record indicated Resident 39 was originally admitted to the facility on [DATE] with diagnoses including weakness, and peripheral vascular disease (circulation disorder where blood vessels outside the heart and brain narrow or become blocked, reducing blood flow to the limbs). During a review of Resident 39's Minimum Data Set ([MDS] resident assessment tool), dated 12/26/2025, the MDS indicated Resident 39's cognitive skills (functions your brain uses to think, pay attention, process information, and remember things) for daily decision-making were moderately impaired. Resident 39 needed assistance with eating and supervision with other activities of daily Living (ADLs- activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 39's Order Summary Report, the Order Summary Report indicated Lidocaine HCl External Patch 4 %, apply to bilateral knee topically one time a day, ordered 12/17/2025. During an observation on 1/26/2026 at 9:24 a.m., with LVN 2, in Resident 39's room, LVN 2 applied the Lidocaine patches on Resident 39's knees without labeling the patches with a date and time. b. During a review of Resident 10's admission Record, the admission Record indicated Resident 10 was originally admitted to the facility on [DATE] with diagnoses including anemia (a condition where the body does not have healthy red blood cells), sick sinus syndrome (heart rhythm disorder) , atherosclerotic (buildup of fats and other substances in and on the artery walls), heart disease, and atrial fibrillation (irregular heartbeat). During a review of Resident 10's MDS, dated [DATE], the MDS indicated Resident 10's cognitive skills for daily decision-making were intact. The MDS indicated Resident 10 needed set-up assistance when eating, oral hygiene, and substantial assistance (helper does more than half the effort) with personal hygiene, and showering. During a review of Resident 10's Order Summary Report, the Order Summary Report indicated Potassium Chloride Oral Solution, Give 15 milliliters by mouth two times a day for potassium supplement on Lasix (water pill used to treat edema associated with heart failure) dated 1/23/2026. During an observation on 1/26/2026 at 9:45 a.m., with LVN 2, in Resident 10's room, LVN 2 administered the Potassium in pill form not liquid form (as indicated in the dated 1/23/2026) to Resident 10. During an interview on 1/27/2026 at 3 p.m., with LVN 2, LVN 2 stated the wrong potassium form was administered; the liquid form and not the pill form should have been administered to Resident 10. LVN 2 stated she did not indicate the date and time on the Lidocaine patch for Resident 39. During an interview on 1/29/2026 at 12:24 p.m. with the Director of Nursing (DON), the DON stated Resident 39's medication orders need to be administered in the correct form as ordered by the physician for resident safety. The DON stated Resident 10's lidocaine patch needs to be removed when it is time, but there was not time and date of when it was administered. The DON stated the lidocaine patches could not stay on the Resident 10's knees all day and the facility needs to follow pharmacy policies and procedures. During a review of the facility's policy and procedure (P&P) titled, Medication Administration- General Guidelines, dated 5/2022, the P&P indicated medications shall be administered as prescribed in accordance with good nursing principles and practices. The right drug is applied for each medication. During a review of Resident 78's admission Record, the admission Record indicated Resident 78 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 78's diagnoses included anemia (a condition where the body does not have enough healthy red blood cells), diabetes mellitus ([DM]-a disorder characterized by difficulty in blood sugar control and poor wound healing), and hypertension ([HTN]-high blood pressure). During a review of Resident 78's History and Physical (H&P), dated 9/4/2024, the H&P indicated Resident 78 had fluctuating capacity to understand and make decisions. During a review of Resident 78's MDS, dated [DATE], the MDS indicated Resident 78 was rarely/never understood. The MDS indicated Resident 78 was dependent on facility staff for activities of daily living such as hygiene, showering, dressing, putting on/taking off footwear. During a review of Resident 78's Order Summary Report, dated 1/16/2026, the Order Summary Report indicated morphine sulfate oral solution 20 mg/mL (milligram per milliliter, a unit of measurement for medication) give 0.25 mL orally every 2 hours as needed for mild pain (1-3 pain level) or shortness of breath with respiration rate between 21-25 breaths per minute (BPM) 0.25 mL equal 5 mg and give 0.5 mL orally every 2 hours as needed for moderate pain (4-6 pain level) or shortness of breath with respiratory rate of 26- 30 BPM 0.5 mL = 10 mg and give 0.75 mL orally every 2 hours as needed for severe pain (7-10 pain level) or shortness of breath with respiratory rate of more than 30 per minute, 0.75 mL equals 15 mg. During a concurrent observation, interview and record review on 1/28/2026 at 9:47 a.m., with Licensed Vocational Nurse (LVN) 4 with the East Station Medication Cart 4, Resident 78's morphine sulfate oral medication bottle, and the facility's liquid controlled medication tracking system for morphine sulfate oral medication were reviewed. Resident 78's morphine sulfate medication bottle contained approximately 10 mL's. The facility's controlled medication tracking system indicated a quantity of 10.50 mL remaining on 1/27/2026 at 11:03 a.m.(the previous day) with the last dose administered on 1/28/2026 at 1:24 a.m. with no indication of how much was left in the bottle. LVN 4 stated the licensed nurses were pulling the medication out from the bottle but did not indicate how much was left in the bottle on the tracking form. LVN 4 stated there was 15 mL in the bottle to start, minus each dose taken out of the bottle according to the tracking form came to 9.25 mL that should be left in the bottle but the tracking form indicated there was 10.50 mL left on 1/27/2026 and no indications of how much was in the bottle with the last administration date of 1/28/2026 at 1:24 a.m. LVN 4 stated licensed nurses should be documenting how much was pulled out and how much was left in the bottle consistently and accurately on the tracking form. LVN 4 stated pulling out the medication and not documenting it accurately can leave the next licensed staff confused with how much was in the bottle and the count would not be correct. During an interview on 1/29/2026 at 11:55 a.m., with the Director of Nursing (DON), the DON stated when licensed staff are giving pain medications like morphine, licensed staff should document accurately on the tracking form and the electronic Medication Administration Record (eMAR). The DON stated licensed staff should be writing the amount taken out of the bottle and the amount that's left in the bottle onto the tracking form. The DON stated the importance of accurate documentation of the amount of medication taken out of the bottle and the amount that's left in the bottle was to be accountable of the medication so there was no confusion on how much was left in the bottle when the next licensed staff draws up the medication from the bottle. The DON stated the staff should be pulling out the dosage ordered and documented how much was given to the residents, and how much was left in the bottle, staff should be doing the math. DON stated the licensed staff should not be looking at the bottle and eyeing it to see how much was left in the bottle, that was not the correct way to do it because not all licensed staff will see the same amount. During a review of the facility's policy and procedures (P&P) titled Preparation and General Guidelines of Controlled Substances, dated May/2022, indicated, medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, disposal, and recordkeeping in the facility, in accordance with federal and state laws and regulations. accurate accountability of the inventory of all controlled drugs is always maintained.when a controlled substance is administered, the licensed nurse administering the medication immediately enters the following information on the accountability record (CDR) and the medication administration record (MAR) such as date and time of administration (MAR, and Accountability Record), the amount administered (Accountability Record), the remaining quantity (Accountability Record), and initials of the nurse administering the dose, completed after the medication is actually administered (MAR, and Accountability Record).

Based on observation interview and record review the facility failed to handle or store food in a sanitary manner by the following:a. Facility kept 30 salt and pepper shakers without labels, covers, and dates after use in the dry food storage area.b. [NAME] 1 and [NAME] 2 did not wear a hair net to fully cover their hair while handling food.These failure has the potential to increase the risk of cross-contamination and foodborne illness.Findings:a. During a concurrent observation and interview on 1/26/2026 at 9:00 a.m., with the Dietary Supervisor (DS) in the dry food storage area, there were 15 white and 15 black powdery substances inside glass shakers without labels, covers, and dates with holes on the metal tops. The covers fell off from the shakers by being placed upside down. The DS stated those were salt and pepper shakers. The DS stated dietary staff should empty the containers and wash them after every single use before putting them back to store them to prevent foodborne illness. The DS stated they should not store opened and unlabeled food items in the dry food storage area. b. During a concurrent observation and interview on 1/27/2026 at 11:48 a.m., with the Registered Dietician (RD) in the kitchen, [NAME] (CK) 1's hair net did not fully cover her head. The RD stated there were hairs that were not contained in the hair net on both sides and back of CK 1's head. CK 2 was wearing hair cover with exposed hair, confirming hair on both sides and back of her head out of the cover.During an interview on 1/27/2026 at 12:54 p.m., with the DS, the DS stated if staff does not cover hair fully, the hair can fall into the food, and can cause food borne illness.During an interview on 1/29/2026 at 1:51 p.m., with the Director of Nursing (DON), the DON stated kitchen staff need to cover all their hair with hair nets while working in the kitchen to prevent infection control and sanitary reasons.During a review of the facility's policy and procedure(P&P), titled Dress Code, dated 2023, indicated proper dress for staff in food and nutrition services departments are: Hat for hair, if hair is short, which completely covers the hair and hair net for hair, if hair is long (over the ears or longer).During a review of the facility's P&P, titled Storage of food and supplies, dated 2023, indicated dry bulk foods (flour, sugar, dry beans, food thickener, spices, etc.) should be stored in seamless metal or plastic containers with tight covers, or in bins which are easily sanitized. Bins/containers are to be labeled, covered and dated. The P&P indicated dry food items which have been opened, such as pudding, gelatin, biscuit mix, pancake mix, dry cereal, spices, coffee, noodles, etc., will be tightly closed, labeled and dated, open, non-food items are to be tightly closed to prevent exposure to pests. The P&P also indicated All food will be dated - month, day, year.

Based on interview and record review, the facility's Quality Assessment and Assurance ([QA&A] develop and implement appropriate plans of action to correct identified quality deficiencies) and Quality Assurance Performance Improvement ([QAPI] takes a systemic, interdisciplinary, comprehensive, and data driven approach to maintaining and improving safety and quality in nursing homes while involving residents and families, and all nursing home caregivers in practical and creative problem solving) committee failed to identify facility and resident care issues, develop and implement appropriate plans of action to ensure QAA/QAPI committee systemically implemented and evaluated measures to maintain a system to immediately identify residents' code status in an emergency situation that warrants initiation of a resident's CPR without loss of valuable time to implement life saving measures.These deficient practices have the potential to cause delay in life saving measures for 40 current residents who wish to have full treatment in a life-threatening situation.Findings: During a telephone interview on [DATE] at 5:51 p.m., with LVN 1, LVN 1 stated on [DATE], at approximately 5:00 a.m., CNA 1 notified her (LVN 1) that Resident 93 was not responding, and CNA 1 could not wake the resident up. LVN 1 stated she got her stethoscope and asked LVN 2 to come with her to check on Resident 93 in his room. LVN 1 stated she (LVN 1) checked Resident 93's vital signs and the machine could not detect any vital signs. LVN 1 stated she (LVN 1) used her index and middle fingers to feel Resident 93's carotid pulse (the beating of blood flow in the vein that supplies oxygenated blood to the brain) and there was no pulse. LVN 1 stated Resident 93 was a full code, and she (LVN 1) initiated CPR on Resident 93 at approximately 5:30 a.m., (30 minutes after the resident was found unresponsive), until the emergency medical services arrived at 5:45 a.m LVN 1 stated the emergency medical services did not perform CPR. LVN 1 stated the emergency medical staff pronounced Resident 93 dead at 6:00 a.m. During an interview on [DATE] at 8:38 a.m., with LVN 2, LVN 2 stated on [DATE] at approximately 5:15 a.m., LVN 1 informed her she (LVN 1) could not detect any vital signs on Resident 93 and asked her (LVN 2) to verify the lack of vital signs on Resident 93. LVN 2 stated LVN 1 went to check Resident 93's chart for the resident's code status and called the emergency services. LVN 2 stated she (LVN 2) checked his vital signs twice and the machine could not find a reading. LVN 2 stated the second time she (LVN 2) checked Resident 93's vital signs, around 5:40 a.m., LVN 1 was back in the room, and started CPR. LVN 1 asked LVN 2 to go to the front door to wait for emergency medical services to arrive. LVN 2 stated if staff knew the resident's code status, they could have started CPR as soon as Resident 93 was observed unresponsive and without a heartbeat. LVN 2 stated there was a delay in initiating CPR. During an interview on [DATE] at 11:28 a.m., with the Director of Staff Development (DSD), the DSD stated LVN 1, LVN 2 and CNA 1 should have performed CPR on Resident 93, right away when Resident 93 was pulseless and not breathing. The DSD stated staff starting CPR right away would have a higher chance of saving the residents' life. The DSD stated the facility's system was for licensed staff to check a resident's code status in the electronic medical record, and initiate CPR, until emergency medical services personnel take over. During a concurrent interview and record review on [DATE] at 3:25 p.m., with the Director of Nursing (DON), the Nurses Progress Note dated [DATE] was reviewed. The DON stated the Nurses' Progress Note did not indicate the staff members started CPR immediately on Resident 93 when three different staff members, CNA 1, LVN 1 and LVN 2 found the resident unresponsive. The DON stated when CNA 1 found Resident 93 unresponsive and with no knowledge of the resident's code status, CNA 1, LVN 1 and LVN 2 should have tried to find out if Resident 93 was a full code, and initiated CPR right away. The DON stated there was no system in place for emergency situations such as Resident 93's to ensure timely CPR. During an interview on [DATE] at 4:24 p.m. with the Administrator (ADM), the ADM stated he heard about Resident 93 passing during the early morning of [DATE]. The ADM stated staff had to check the resident's code status before initiating chest compressions. The ADM stated the staff did CPR, but staff did not immediately do CPR when they found Resident 93 unresponsive. The ADM stated the QAPI/QA&A committee was not aware of the systemic failure of immediately identifying the resident's code status.During a review of the facility's policy and procedure (P/P) titled QA&A Committee and QAPI Plan dated 2025 indicated to provide excellent quality care to the residents served.meet to exceed the needs, expectations and requirements of our residents while maintaining good outcomes and perceptions of resident care in a cost-effective manner. The principals of QAPI are taught to facility staff and volunteers on an ongoing basis. QAPI activities aim for the highest levels of safety, excellence in Resident Choice, Quality of Life, Clinical Care, Management Practices, Facility Standards, Resident and Family Satisfaction Surveys and Audits.

Based on observation, interview, and record review, the facility failed to implement infection control measures by failing to:A. Ensure visitors and the staff wore Personal Protective Equipment (PPE - clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) properly for one of three sampled residents (Resident 78) who was on Enhanced Barrier Precaution [EBP-an infection control measures, primarily in nursing homes, requiring staff to wear gowns and gloves during high-contact care for residents with multidrug-resistant organisms or increased risk factors like wounds/devices, expanding beyond Standard Precautions to prevent multidrug-resistant organism(MDRO) spread where direct contact is likely].B. Ensure two of two residents (Resident 10 and 11) were tested for Corona virus disease ([COVID-19] contagious infectious disease) and placed on transmission-based precautions ([TBP] infection control measures used in healthcare settings, in addition to standard precautions, for patients known or suspected of being infected) when they presented with respiratory infection symptoms. These failures had the potential to result in compromised infection control measures and the spread of infection among residents, staff, and visitors. Findings: A. During a review of Resident 78's admission record, the admission record indicated Resident 78 was initially admitted to the facility on [DATE] and last re-admission was on [DATE] with urinary tract infection (UTI- an infection in the bladder/urinary tract), uterine cancer (a cancer that starts in the uterus, the organ where a fetus grows during pregnancy), Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and chronic kidney disease (the kidneys have become damaged over time). During a review of Resident 78's History and Physical (H&P), dated [DATE], the H&P indicated, Resident 78 had fluctuating capacity to understand and make decisions. During a review of Resident 78's Minimum Data Set (MDS-a resident assessment tool), dated [DATE], the MDS indicated Resident 78 required dependent assistance (Helper does all of the effort) from two or more staff for shower/bath, dressing, toilet hygiene, transfer, hygiene, bed mobility, and set up or clean-up assistance (Helper sets up or cleans up) from one staff for eating. During a concurrent observation and interview on [DATE], at 12:41 p.m., with Licensed Vocational Nurse (LVN) 4 in Resident 78's room, LVN 4 was checking Resident 78's blood pressure and her nursing uniform was touching Resident 78's bed linen. LVN 4 was wearing a mask, but she did not wear a gown and gloves. Resident 78's Family Member (FM) 1 was at the bedside holding Resident 78's hands after LVN 4 finished checking Resident 78's blood pressure. FM 1 did not wear any PPE. There was EBP signage by the entrance for Resident 78. LVN 4 stated, Resident 78 was on EBP, and she should have worn a gown and gloves because checking blood pressure was a high contact resident care activities, and required a mask, gown and gloves to be worn to prevent spreading infection. LVN 4 stated, she should have educated FM 1 regarding wearing PPE while touching Resident 78's hands. During an interview on [DATE], at 12:45 p.m., with FM 1, FM 1 stated, she has been visiting Resident 78 many times, but the staff did not tell her to wear PPE when/if she was touching Resident 78. FM 1 stated, no one provided her with any education or information regarding wearing PPE in EBP room to prevent infection from spreading. During an interview on [DATE], at 12:42 p.m., with the Infection Preventionist Nurse (IPN), the IPN stated, the staff should wear mask, gown, and gloves before performing high contact activities with a resident on infection prevention precautions, such as bathing, hygiene care, changing, transferring, and checking blood pressure to prevent cross contamination (the physical movement or transfer of harmful bacteria from one person, object or place to another) when they were caring for the residents who were on EBP. The IPN stated, the staff should have provided education for visitors and asked them to wear PPE as well. During an interview on [DATE], at 12:07 p.m., with the Director of Nursing (DON), the DON stated, PPE should be worn correctly based on the requirements for different kinds of infections. The DON stated, Resident 78 was on EBP due to having a foley catheter (or indwelling catheter- a thin, flexible tube inserted through the urethra into the bladder to drain urine continuously) which was an invasive line. The DON stated EBP required wearing a mask, a gown, and gloves before performing high contact care that required touching the residents. The DON stated, the staff must wear proper PPE to protect themselves and vulnerable residents. During a review of Resident 78's Order Summary Report (OSR), dated [DATE], the OSR indicated, place Foley catheter size 16 French (Fr) by gravity drainage ordered on [DATE]. The OSR indicated, place a privacy bag in place for foley catheter and monitor placement every shift ordered on [DATE]. During a review of Resident 71's Care Plan Report (CPR) titled, Resident 78 was at risk for UTI related to Foley Catheter Placement revised [DATE], the CPR Goal indicated, Resident 78 will not have UTI by the target review date of [DATE]. The CPR Interventions indicated, use Enhanced Barrier Precautions. During a review of the facility's Policy and Procedure (P&P) titled, IPCP Standard and Transmission-Based Precautions, revised 3/2024, the P&P indicated, Policy: It is the policy of this facility to implement infection control measures to prevent the spread of communicable disease and conditions. Procedure: 3. Enhanced Barrier Protection (EBP): used in conjunction with standard precautions and expand the use of PPE through the use of gowns and gloves during high-contact resident care activities that provide opportunities for indirect transfer of Multi Drug Resistant Organisms (MDRO infectious organisms that are resistant to different medications)to staff hands and clothing then indirectly transferred to residents or from resident-to-resident. (e.g., residents with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization with MDROs). B. During a review of Resident 10's admission Record, the admission Record indicated Resident 10 was originally admitted to the facility on [DATE] with diagnoses including anemia (a condition where the body does not have healthy red blood cells), sick sinus syndrome (heart rhythm disorder) , atherosclerotic (buildup of fats and other substances in and on the artery walls). heart disease, and atrial fibrillation (irregular heartbeat). During a review of Resident 10's ([MDS] resident assessment tool), dated [DATE], the MDS indicated Resident 10's cognitive (ability to make decisions of daily living) skills for daily decision-making were intact. The MDS indicated Resident 10 needed set-up assistance when eating, oral hygiene, and substantial assistance (helper does more than half the effort) with personal hygiene, and showering. During a review of Resident 10's Situation Background Assessment Recommendation (SBAR) Communication Form, dated [DATE], the form indicated Resident 10 presented with a productive cough (also known as a wet cough, brings up mucus [phlegm or sputum] from the lungs to help clear the airways). During a review of Resident 11's admission Record, the admission Record indicated Resident 11 was originally admitted to the facility on [DATE] with diagnoses including cellulitis (skin condition that causes swelling and redness), asthma (chronic lung condition), and chronic kidney disease (condition where the kidneys become damaged and lose their ability to filter blood, leading to a buildup of waste and fluid in the body). During a review of Resident 11's MDS, dated [DATE], the MDS indicated Resident 11's cognitive skills for daily decision-making was intact. Resident 11 need set-up assistance when eating, oral hygiene, and substantial assistance with personal hygiene. During a review of Resident 11's SBAR Communication Form, dated [DATE] at 2:30 p.m., the form indicated Resident 11 presented with mild sore throat. During a review of Resident 11's SBAR Communication Form, dated [DATE] at 6:18 p.m., the form indicated Resident 11 presented with non-productive dry cough. During a concurrent interview and record review on with the Infection Prevention Nurse (IPN), Resident 10 and 11's medical records and Medication Administration Records (MARs) were reviewed. Resident 10 and 11's MAR indicated to monitor any Covid-19 signs and symptoms which included cough and sore throat. Resident 10 and 11's MAR indicated no Covid-19 test was conducted. The IPN stated Residents 10 and 11 presented with respiratory symptoms as indicated in the SBAR Communication forms and Residents 10 and 11 should have been tested for Covid-19 for early treatment and mitigation of possible spread. Resident 10 and 11 should have been placed on droplet/contact isolation (TBP to prevent spread of germs) until Covid-19 was ruled out according to Long Beach Public Health guidelines. During an interview on [DATE] at 12:24 p.m., with the DON, the DON stated the facility should follow the local public health departments' guidelines for residents' safety. During a review of the facility's policy and procedure (P&P) titled, Covid-19 Testing revised 10/2023, the P&P indicated testing will be performed according to current local and state health departments and Centers for Disease Control and Prevention (CDC) prevention guidelines. During a review of the facility's untitled P&P, revised 10/2023, the P&P indicated testing will be performed With residence who had symptoms consistent with COVID-19 regardless of vaccination status. During a review of Long Beach Health and Human Services document titled, Skilled Nursing Facility Covid-19 Guidance, dated [DATE], indicated residents or health care personnel (HCP) with signs or symptoms of Covid-19 like illness, regardless of vaccination status, should be: Isolated immediately (i.e., HCP sent home, residents remain in current room on transmission-based precautions Test immediately If first test was antigen and negative, test again 48 hours after the first test.

Based on interview and record review the facility failed to provide documented evidence of all employees, including physicians, COVID-19 (contagious disease) vaccine (medications used to prevent diseases usually given by injection or by mouth) status and the provision of education on benefits and potential side effects and offering of the 2025 to 2026 COVID-19 vaccine. This failure had the potential to result in staff and residents contracting COVID-19 which can cause serious illness, hospitalization, and death. Findings: During a concurrent interview and record review on 1/28/2026 at 12:38 p.m., with the Infection Prevention Nurse (IPN), the facility's Covid Staff Vaccination Status, undated, was reviewed. The IPN stated there was no documented evidence for physician or licensed practitioners' education on benefits and side effects was provided and the offering of 2025 to 2026 Covid-19 booster vaccine. The IPN stated the roster did not include physicians and it should include everyone that has direct access to the residents. During an interview on 1/29/2026 at 12:24 p.m. with the Director of Nursing (DON), the DON stated staff need to be educated and the current COVIE-19 booster should be offered to staff.During a review of the facility's policy and procedure (P&P) titled, Immunizations - Staff, revised 7/2023, the P&P indicated staff includes licensed practitioners.

Based on interview and record review the facility failed to validate 9 of 9 Registered nurses, 23 out of 23 Licensed Vocational Nurses (LVNs), and 68 out of 68 Certified Nurse Assistants (CNAs)'s competency for what to do when taking care of an unresponsive resident who was not breathing and had no pulse. The deficiency resulted in a delay in initiation of Cardiopulmonary Resuscitation ([CPR] an emergency, life-saving procedure performed when the heart stops beating, to maintain blood circulation to the brain) to one of one resident (Resident 93) and the deficient practice placed 40 residents at risk for a delay in receiving immediate CPR interventions. Findings:During a review of Resident 93's admission Record, the admission Record indicated Resident 93 was admitted to the facility on [DATE] with diagnoses including end stage renal disease ([ESRD], irreversible kidney failure), anemia (a condition where the body does not have enough healthy red blood cells), diabetes mellitus ([DM], a disorder characterized by difficulty in blood sugar control and poor wound healing), and dementia (a progressive state of decline in mental abilities). During a review of Resident 93's Minimum Data Set ([MDS], a resident assessment tool), dated [DATE], the MDS indicated Resident 93 was severely cognitively (thinking process) impaired and was dependent on activities of daily living such as hygiene, dressing and putting on footwear. During a review of employee personnel files for CNA1, CNA 2, LVN 1, and LVN 2, the personnel files indicated no documented evidence of facility validation of staff competency on CPR and how to respond to residents who were unresponsive, had no pulse, and had no respirations. During a review of the facility Skills Awareness and Competency form, revised [DATE], the form did not indicate staff CPR skills validation and how to respond to residents who were unresponsive, had no pulse, and had no respirations. During an interview on [DATE] at 8:38 a.m., with LVN 2, LVN 2 stated even though Resident 93 was found cold, unresponsive, with no pulse, and not breathing, LVN 1 and 2 waited to verify each others findings that Resident 93 was indeed not breathing, and had no pulse, then to find out Resident 93's code status (a medical order determining the extent of resuscitation efforts a patient wishes to receive if their heart or breathing stops) by going to the computer before initiating CPR. LVN 1 stated CPR was not started immediately.During an interview on [DATE] at 11:28 a.m., with the Director of Staff Development (DSD), the DSD stated the facility does not ensure or validate staff competency regarding CPR and how to respond to unresponsive residents with no pulse and no respirations. During an interview with the Director of Nurses (DON) on [DATE] at 3:54 p.m., the DON stated the facility did not ensure and validate staff competency for performing CPR timely and how to handle residents who were unresponsive, had no pulse, and had no respirations. During a review of the facility's policy and procedure (P&P) titled, Nursing Staff Competency, Revised 4/2025, the P&P indicated the facility will have appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment. The P&P indicated all licensed nurses shall have training in cardiopulmonary resuscitation (CPR). The P&P indicated Director of Staff Development, Nurse Manager or designee must validate all skills listed on the form for competent performance.During a review of the facility's 2025 Facility Assessment, revised [DATE], the facility's assessment indicated during emergency situations, the facility will develop and update annually or as needed an emergency preparedness plan, and the facility will train staff on emergency procedures and their roles during emergencies.Cross reference F678

Based on interview and record review, the facility failed to ensure a psychotropic medication (medications that affect brain activities associated with mental processes and behavior) was not used unnecessarily for one of three sampled residents (Resident 13) by failing to define and monitor resident specific, measurable target behaviors related to the use of Zyprexa [an atypical antipsychotic that's used to improve mood, thoughts, and behaviors for people with schizophrenia (a mental illness that is characterized by disturbances in thought) and bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs)]for Resident 13.This deficient practice of failing to ensure antipsychotic medication was used to treat a resident's specific, diagnosed condition, and monitor target behaviors related to the use of psychotropic medication increased the risk that Resident 13 could have experienced adverse effects (unwanted or dangerous medication-related side effects) related to psychotropic medication therapy, such as drowsiness, dizziness, constipation, or increased risk of fall, possibly leading to impairment or decline in their mental or physical condition or functional or psychosocial status.Findings:During a review of Resident 13's admission Record, the admission Record indicated, Resident 13 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including Alzheimer's Disease (a disease characterized by a progressive decline in mental abilities), schizophrenia (a mental illness that is characterized by disturbances in thought), and cerebral infarction (loss of blood flow to a part of the brain).During a review of Resident 13's History and Physical (H&P), dated [DATE], the H&P indicated, Resident 13 had no capacity (ability) to understand and make decision.During a review of Resident 13's Minimum Data Set (MDS - a resident assessment tool), dated [DATE], the MDS indicated Resident 13 required dependent assistance (Helper does all of the effort) from two or more staff for hygiene, shower, transfer, maximal assistance (Helper does more than half the effort) from one staff for dressing, bed mobility, and setup or clean-up assistance (Helper sets up or cleans up) from one staff for eating. During a review of Resident 13's Order Summary Report (OSR) dated [DATE], the OSR indicated, give Zyprexa 10 milligram (mg) by mouth at bedtime and 2.5mg by mouth in the evening related to schizophrenia manifested by hallucination (an experience involving the apparent perception of something not present) were ordered on [DATE]. The OSR indicated, monitor manifested behavior hallucinations every shift for Zyprexa use related to Schizophrenia was ordered on [DATE].During a concurrent interview and record review on [DATE], at 11:30 a.m., with Registered Nurse Supervisor (RNS) 1, Resident 13's Medication Administration Record (MAR), dated from [DATE] to [DATE] was reviewed. The MAR indicated, monitor behavior manifested by hallucination every shift for Zyprexa use related to Schizophrenia. The MAR indicated, Resident 13 had no hallucinations and there were no hallucinations documented from [DATE] to [DATE]. RNS 1 stated, she did not witness any signs and symptoms of hallucinations for Resident 13. RNS 1 stated, she was not sure what hallucinations that Resident 13 was experiencing because the term hallucinations were very general and not a specific targeted behavior for Zyprexa use. RNS 1 stated, target behavior should be specific and measurable, so psychiatrist or Nurse Practitioner ( a medical practitioner specializing in the diagnosis and treatment of mental illness) could refer to the documentation of behavior occurrences, and medication dosage to consider a Gradual Dose Reduction (GDR- a systematic approach to stepwise tapering of medication dosage to assess if a lower dose can effectively manage symptoms, conditions, or risks, or if the medication can be discontinued entirely). RNS 1 stated, the staff should have clarified with Psychiatric Nurse Practitioner (PNP)1 who prescribed Zyprexa for what specific target behaviors to monitor Resident 13 for. During a phone interview on [DATE], at 5:45 p.m., with PNP1, PNP 1 stated, she ordered Zyprexa for schizophrenia manifested by hallucinations because Resident 13's Family Member (FM) told PNP 1that Resident 13 believed people were pulling her legs to prevent her from getting up from her wheelchair. PNP 1 stated, this was the reason she disagreed with a GDR for Resident 13. PNP 1 stated, clinical documentation should have reflected the resident's condition and monitored target behaviors accurately because a GDR was based on clinical evidence. PNP 1 stated, if accurate target behaviors were not documented and monitored , Resident 13 might receive unnecessary psychotropic medications and would suffer from adverse reaction (an undesired or harmful effect of a drug). PNP 1stated, she was aware that unnecessary medication use could be a chemical restraint (the use of medications to restrict a person's movement or freedom of action, or to control behavior, when the medication is not part of a standard treatment for their condition) as well. During a concurrent interview and record review on [DATE], at 8:53 a.m., with the Minimum Data Set Coordinator (MDSC), Resident 13's Minimum Data Set (MDS), dated [DATE], [DATE], [DATE], [DATE] were reviewed. The MDS indicated, Resident 13 did not have any hallucinations and delusions (misconceptions or beliefs that are firmly held, contrary to reality). The MDS indicated, Resident 13 did not have any physical, verbal, and other behavioral symptoms toward others. The MDSC stated, she did not witness any behavioral issues, hallucinations and delusions for Resident 13. The MDSC stated, the target behaviors should be resident specific and measurable to reflect in clinical documentation.During an interview on [DATE], at 12:07 p.m., with the Director of Nursing (DON), the DON stated, target behavior should be specific and measurable to the resident's diagnosis. The DON stated, hallucinations could be caused by many things, and this should be clarified with PNP 1. The DON stated, monitoring specific target behavior was important, because GDR would be performed based on these data. The DON stated, inaccurate data would lead to delays on treatment, and the residents continuing to receive unnecessary medication. The DON stated, the resident might suffer from unnecessary side effects/adverse reactions. The DON stated, unnecessary medication could be considered as chemical restraint as well.During a review of Resident 13's Psychiatric Visit Progress Report (PVPR), dated [DATE], the PVPR indicated, GDR was contraindicated and no psychotropic medication adjustments needed. The PVPR indicated, continued with same dose of Zyprexa due to schizophrenia management for persistent psychotic symptoms such as auditory and visual hallucinations per daughters.During a review of Resident 13's Care Plan Report (CPR) titled, Resident 13 use psychotropic medication Zyprexa (also known as Olanzapine) related to behavior management for hallucination, initiated [DATE] and revised [DATE], the CPR Goal indicated, Resident 13 will reduce the use of psychotropic medication and will have fewer episodes of hallucination by target date of [DATE]. The CPR Interventions indicated, administer medications as ordered, and monitor and document for side effects and effectiveness. The CPR Interventions indicated, consult with pharmacy and PNP 1 to consider dosage reduction when clinically appropriate.During a review of the facility's Policy and Procedure (P&P) titled, Chemical Restraints and Psychotropic Medication Management, revised 4/2025, the P&P indicated, Policy: It is the policy of this facility to ensure that residents are free from chemical restraints imposed for purposes of discipline or convenience or that are not required to treat a specific condition as diagnosed and documented in the clinical record . Procedure: 3. The Licensed Nurse (LN) shall review the classification of the drug, the appropriateness of the diagnosis, its indication, behavior monitors and related adverse side effects prior to verification of admission orders with the Attending Physician . 8. The facility's Interdisciplinary Team (IDT) will review to ensure; a. Psychotropic medication was prescribed to treat a specific diagnosed condition, as documented in the clinical record; b. Not in excessive dosage; c. Behavior is not related to delirium or other reversible conditions; d. Monitoring for adverse consequences and effectiveness of medications are in place.

Based on interview and record review the facility failed to create a comprehensive person-centered care plan in a timely manner for one of three sampled residents' (Resident 7) Stage II (Partial-thickness loss of skin, presenting as a shallow open sore or wound) pressure ulcer (damage to the skin and underlying tissue caused by constant, long-term pressure, usually on bony areas like the hips, heels, or tailbone) on the sacrococcygeal (tailbone) area.This failure had the potential to result in delays with the necessary care and services to address Resident 7's wound care needs.During a review of Resident 7's admission Record, the admission Record indicated the facility readmitted Resident 7 on 11/28/2025 with diagnoses including metabolic encephalopathy (a brain dysfunction caused by a chemical imbalance from underlying illness) and Stage II pressure ulcer of sacral (tailbone) region. During a review of Resident 7's Minimum Data Set (MDS- a resident assessment tool), dated 12/4/2025, the MDS indicated Resident 7's cognition (functions your brain uses to think, pay attention, process information, and remember things) was moderately impaired. The MDS indicated Resident 7 required supervision assistance (helper provides verbal cues and/ or touching/ steading and/or contact guard assistance as resident completes activity) with eating, moderate assistance (helper does less than half the effort to complete the task) with personal hygiene, maximal assistance (helper does more than half the effort to complete task) with getting dressed and putting on/taking off footwear, dependent (helper does all of the effort) with oral hygiene and toileting hygiene. During a concurrent interview and record review on 1/29/26 at 12:00 p.m., with Registered Nurse Supervisor (RNS) 1, Resident 7's care plan titled, Potential for Pressure Ulcer development/ skin breakdown, created 11/28/2025 was reviewed. RNS 1 stated, Resident 7 was readmitted with a stage 2 pressure ulcer on her sacrococcyx on 11/28/2025. RNS1 stated the care plan did not indicate and have interventions for Resident 7's pressure ulcer upon admission. RNS1 stated the care plan did not address Resident 7's stage 2 pressure ulcer until 12/8/2025. RNS 1 stated the sacrococcyx pressure ulcer care plan was not developed in a timely manner, timely care plan development was essential as it guides staff in providing appropriate care and addressing patient needs and failure to have an updated care plan may result in unmet patient needs. During an interview on 1/29/2026 at 1 p.m., with the Director or Nursing (DON), the DON stated developing a comprehensive person-centered care plan promptly upon noticing the concerns, rather than waiting 10 days, is crucial. The DON stated this care plan is what the staff will follow. During a review of the facility's policy and procedure titled Skin and Wound Monitoring and Management, revised 4/2025, the P&P indicated facility nursing staff will identify and document in the resident's clinical records, the condition and pressure injury risk factors related to the development of unavoidable pressure injury. The P&P indicated this identification and implementation of a plan of care will begin at admission with the initial care plan and be completed throughout assessment process for developing a comprehensive plan of care.

Based on observation, interview, and record review, the facility failed to ensure appropriate coordination with the hospice (care focused on providing comfort and support to people who are in the final stages of a terminal illness, rather than trying to cure the disease) provider for one of two sampled residents (Resident 44).This failure had the potential to result in gaps in monitoring, and unmet hospice-related care needs for residents.Findings:During a review of Resident 44's admission Record, the admission Record indicated the facility admitted Resident 44 on 9/22/2025 with diagnoses including atherosclerotic heart disease (thickening or hardening of the arteries caused by a buildup of plaque in the inner lining of an artery) and phimosis (a condition where the foreskin is too to be tight to be pulled back over the head of the penis) During a review of Resident 44's History and Physical (H&P), dated 9/26/2025, the H&P indicated, Resident 44 had fluctuating capacity to understand and make decisions. During a review of Resident 44's Minimum Data Set (MDS- a resident assessment tool), dated 12/28/2025, the MDS indicated Resident 44' cognition (think, pay attention, process information, and remember things) was severely impaired. The MDS indicated Resident 44 required setup or clean-up assistance (helper sets up or cleans up; resident completes activity) with eating, moderate assistance (helper does less than half the effort to complete the task) with oral hygiene, maximal assistance (helper does more than half the effort to complete task) with dressings, personal hygiene, dependent with toileting hygiene, showering and putting on/taking off footwear. During a review of Resident 44's Order Summary Report, dated 9/22/2025, the Order Summary Report indicated an order to admit Resident 44 to hospice with an admitting diagnosis of atherosclerotic heart disease. During a review of Resident 44's care plan titled Hospice, revised 12/30/2025, the care plan indicated interventions to work cooperatively with the hospice team to ensure the resident's spiritual, emotional, intellectual, physical and social needs were met and work with nursing staff to provide maximum comfort for the Resident 44. During a review of Resident 44's hospice Client Calendar Report and Sign-In/Notes for December 2025 and January 2026, the report and notes indicated the corresponding hospice visit records did not match the scheduled visits on 12/18/25, 12/22/2025, 12/25/2025, 1/1/2026 for aide (certified nursing assistant) hospice visits and on 1/19/2026 for Registered Nurse hospice visit . There was no documentation indicating that the visits were rescheduled, completed later, or otherwise accounted for. During an interview on 01/28/2026 at 11:48 a.m., with the Social Service Director (SSD), the SSD stated her role in hospice coordination was limited to contacting the hospice provider to invite them to care planning meetings. During a concurrent interview and record review on 1/28/2026 at 12:05 p.m., with Registered Nurse Supervisor (RNS) 1, Resident 44's medical records were reviewed. RNS 1 stated hospice coordination is generally handled by social services and nursing. RNS 1 stated corresponding hospice visit sign-in documentation (indicating the hospice agency staff came to see the patient) did not match the scheduled visits on the hospice calendar, and there was no documentation indicating that missed visits were rescheduled or completed. RNS 1 stated lack of coordination and oversight of hospice resulted in interruption of hospice care goals and unmet resident needs. During an interview on 01/29/2026 at 1:51 p.m. with the Director of Nursing (DON), the DON stated facility is expected to coordinate with the hospice agency, including monitoring scheduled visits and ensuring services are provided as arranged to meet hospice residents' needs. During a review of the facility and the hospice provider's hospice services agreement (HSA), dated 2/1/2023, the HSA indicated clinical record should contain information including complete documentation of all services and events.During a review of the facility and the hospice provider's HSA, signed 9/23/2025, the HSA indicated, they have to facilitate cooperative efforts in performance of their respective obligations under this agreement.

Based on interview and record review, the facility failed to measure and document one of two sampled resident's (Resident 9) Stage II (Partial-thickness loss of skin, presenting as a shallow open sore or wound) pressure injury (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) on the sacrococcygeal (tailbone) area at least on a weekly basis after being admitted on [DATE]. The deficient practice resulted in poor tracking of the pressure ulcer's healing progress and had the potential to result in delayed care and services.Findings:During a review of Resident 9's admission Record, the admission Record indicated Resident 9 was originally admitted to the facility on [DATE] with diagnoses including chronic kidney disease (long-term, irreversible, and gradual loss of kidney function, often causing waste and fluid buildup in the body), anemia (a condition where the body does not have enough healthy red blood cells), and protein calorie malnutrition (nutritional status in which reduced availability of nutrients leads to changes in body composition and function).During a review of Resident 9's Minimum Data Set ([MDS] resident assessment tool), dated 12/15/2025, the MDS indicated Resident 9's cognitive skills (functions your brain uses to think, pay attention, process information, and remember things) for daily decision-making were intact. Resident 9 needed set-up assistance with eating, oral hygiene, substantial assistance (helper does more than half the effort to complete the task) with personal hygiene, dependent on staff (helper does all the effort) with toileting hygiene and showering. The MDS indicated Resident 9 was at risk for developing pressure injuries and had one unhealed Stage II pressure injury present on admission.During a review of Resident 9's Clinical admission [DATE] at 11:11 p.m., the admission form indicated Resident 9 had a Stage II pressure injury in the sacrococcygeal area measuring 4 centimeters in length by 3 centimeters in width, and 0 depth, 100 percent granulation tissue (new, moist, red, or pink connective tissue with new capillaries on the surface of a wound) and with light serosanguinous exudate (thin, watery, pink-to-light-red wound drainage).During a concurrent interview and record review on 1/28/2026 at 10:26 a.m., with Licensed Vocational Nurse (LVN)3, Resident 9's medical records were reviewed. LVN 3 confirmed and stated the only wound measurement of Resident 9's Stage II was conducted on admission [DATE]. LVN 3 stated as of 1/28/2026 (28 days) the pressure injury had not been measured to monitor progress. LVN 3 stated measurements and description of pressure injury need to be conducted on at least a weekly basis to track its progress. During an interview on 1/29/2026 at 12:24 p.m., with the Director of Nursing (DON), the DON stated the pressure injuries need to be measured minimally on a weekly basis to track the wound's progress. During a review of the facility's policy and procedure (P&P) titled, Skin and Wound Monitoring and Management dated 4/2025, the P&P indicated the resident with a pressure injury will receive necessary services to prevent infection, and prevent new, avoidable pressure injuries from developing. The P&P indicated a licensed nurse will assess/ evaluate at least weekly each area of alteration should include but not limited to measuring the skin injury.

Based on observation, interview, and record review, failed to follow their policy to replace missing dentures and provide a dentist visit for one of three sampled residents (Resident 15).This Failure had the potential to result in Resident 15 having discomfort while eating or chewing foods that could lead to unintended weight loss and lower self-esteem. Findings:During a review of Resident 15's admission Record, the admission Record indicated, Resident 15 was initially admitted to the facility on [DATE] and last re-admission was on 1/12/2026 with diagnoses including dysphagia (difficulty swallowing), breast cancer ( a disease where cells in the breast grow uncontrollably and form a tumor [abnormal growth]), and dementia (a progressive state of decline in mental abilities).During a review of Resident 15's History and Physical (H&P), dated 1/13/2026, the H&P indicated, Resident 15 had no capacity (ability) to understand and make decisions.During a review of Resident 15's Minimum Data Set (MDS - a resident assessment tool), dated 1/29/2025, the MDS indicated Resident 66 required dependent assistance (Helper does all of the effort) from two or more staff for bed mobility, toilet hygiene, maximal assistance (Helper does more than half the effort) from one staff for dressing, personal hygiene, and supervision or touching assistance (Helper provides verbal cues and/or touching/steadying and/or contact guard assistance) from one staff for eating.During a concurrent observation and interview on 1/26/2026, at 11:27 a.m., with Resident 15 in her room, Resident 15 did not have natural teeth. There were no dentures at the bedside. Resident 15 stated, she did not know where her dentures were. Resident 15 stated, she came in to the facility with both upper and lower dentures upon admission. Resident 15 stated, she asked facility staff to help her locate her dentures but no one has updated her on the status of her dentures. Resident 15 stated, she was having discomfort while she was trying to eat or chew food due to missing dentures. Resident 15 stated, she felt embarrassed when she was talking to other people with no teeth.During a concurrent interview and record review on 1/28/2026, at 11:06 a.m., with Registered Nurse Supervisor (RNS) 1, Resident 15's Resident's Clothing and Possessions (also known as Belongings List) dated on 12/5/2025 and 1/12/2026 were reviewed. The Resident's Clothing and Possessions indicated, Resident 15 had dentures on 12/5/2025 upon initial admission, but had no dentures on 1/12/2026 upon readmission from the General Acute Care Hospital (GACH). RNS 1 stated, Resident 15 lost her dentures during the hospitalization, and she should have notified the Social Service Director (SSD) for replacement. RNS 1 stated, if the resident did not have proper fitted dentures, the resident might have unintended weight loss.During a concurrent interview and record review on 1/28/2026, at 11:59 a.m., with the Social Service Director (SSD), Resident 15's Social Service Summary (SSS), dated from 1/16/2026 was reviewed. The SSS indicated, Resident 15 had upper and lower dentures. The SSD stated, she was not aware of the missing dentures. The SSD stated, the missing dentures should have been replaced as soon as possible to prevent unintended weight loss and discomfort while eating. The SSD stated, the nursing staff did not notify her regarding missing dentures, and she believed Resident 15 had the dentures when she visited her on 1/16/2026. The SSD stated, Resident 15 should be seen by dentist for missing dentures within three days.During an interview on 1/29/2026, at 12:07 p.m., with the Director of Nursing (DON), the DON stated, the SSD should have arranged a dental visit for Resident 15, to get the missing dentures replaced as soon as possible. The DON stated, the nursing staff should have communicated with the SSD regarding the missing dentures. The DON stated, providing dentures in a timely manner was important because it could affect Resident 15's ability to eat, and it could lead to social isolation.During a review of Resident 15's Order Summary Report (OSR), dated 1/12/2026, the OSR indicated, provide dental consultation and treatment as needed was ordered on 1/12/2026.During a review of Resident 15's Care Plan Report (CPR), titled Resident 15 had oral/dental health problems related to edentulous (no natural teeth) and the dentures were lost in the GACH, initiated 1/20/2026, the CPR Goal indicated, Resident 15 will be free from infection, pain or bleeding in the oral cavity. The CPR Interventions indicated, coordinate arrangements for dental care as needed.During a review of the facility's Policy and Procedure (P&P) titled, Ancillary Services, revised 12/2023, the P&P indicated, Policy: It is the policy of this facility that Social Services staff will coordinate ancillary services to promote residents' optimal well-being. i.e. Dental, Optometry, Ophthalmology, Audiology, Podiatry evaluations for residents. Procedures: 1. Social Services will maintain a system to monitor ancillary services . 4. Social Services staff member will request that nursing obtain a physician's order for evaluation(s) prior to scheduling of appointments.During a review of the facility's Policy and Procedure (P&P) titled, Dental Services, revised 4/2025, the P&P indicated, Policy: It is the policy of this Facility to ensure that its residents who require dental services on a routine or emergency basis have access to such services without barrier. It is likewise the policy of the Facility to repair or replace the dentures of a resident except in those situations where the loss or damage directly results from the action of an alert and oriented resident who is responsible for his/her own medical decisions. Procedure: 2. In the event that a Facility resident requires emergency dental services, for the repa1r or replacement of dentures or otherwise, the Facility will: Promptly and, in any event, no later than three (3) business days from the date of loss/damage, refer to the resident for dental services. Assist the resident in making the necessary dental appointments, when necessary or requested. 3. If a referral for dental services does not occur within three (3) business days from the date of loss/damage, the Facility will: Document what actions were taken to ensure the resident could eat, drink and communicate (if applicable) adequately while awaiting dental services. Document the nature of the extenuating circumstances which led to the delay.

During interview and record review the facility failed to ensure safe and appropriate discharge planning for one of three sampled resident (Resident 1) by arranging a transfer to an assisted living facility without verifying that the receiving facility could meet the resident's needs and without confirming the accuracy of the discharge destination.This failure to confirm the appropriateness of the discharge and the receiving facility's capability placed Resident 1 at risk for an unsafe and inappropriate transfer, jeopardizing the resident's health, safety, and continuity of care.Findings:During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses of but not limited to Stage 5 chronic kidney disease (the final stage where kidneys fail requiring dialysis[a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed]) , diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), dementia (a progressive state of decline in mental abilities) with anxiety (emotion characterized by feelings of tension, worried thoughts ) and multiple healing broken bone to the back. During a review of Resident 1's History and Physical (H&P), dated 8/1/2025, the H&P indicated Resident 1 had fluctuating capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS-a resident assessment tool), dated 9/20/2025, the MDS indicated Resident 1 was dependent on nursing staff for toileting, showering, dressing, putting on and taking off footwear, personal hygiene and transferring. During a concurrent interview and record review on 12/13/2025 at 11:13 a.m. with the Social Services Director (SSD), Resident 1's Physician Orders dated 12/12/2025 were reviewed. The orders indicated that Resident 1 was scheduled for discharge on [DATE] at 2:00 p.m. to an assisted living facility (a housing option that provides personal care and support services to residents who need help with daily tasks but do not require 24/7 medical care). The SSD confirmed that Resident 1 was being discharged to an assisted living facility and stated that the facility used a placement referral to make arrangements for this discharge. During a telephone interview on 12/13/2025 at 11:44 a.m. with the Administrator (ADM) of the assisted living facility, the ADM stated that the name of her facility was different from the one listed in Resident 1's Physician Orders. The ADM further stated that her facility was located in a different city and was an independent living facility that accepts residents who were very independent, require minimal care, and are ambulatory. The ADM explained that the facility typically does not accept residents with dementia. The ADM stated she had never heard of the facility name listed in the Physician Orders and was not expecting any admission on [DATE]. Additionally, the ADM confirmed she was not aware of any resident by the name of Resident 1. During an interview on 12/13/2025 at 1:09 p.m. with the Social Services Director (SSD), the SSD stated that typically, the assisted living facility visits their facility and communicates with nursing staff regarding residents' medications and diagnoses. The SSD stated she spoke with the assisted living facility's Administrator on 12/12/2025 regarding transportation arrangements. When asked to search for the assisted living facility online, the SSD stated she was unable to locate the facility. The SSD then contacted the Administrator of the assisted living facility, who explained that she had another resident scheduled for admission and initially thought Resident 1 was that individual with a similar name. The Administrator further stated she was confused about the situation and was not expecting Resident 1's admission. The SSD stated Resident 1 would not be discharged to the assisted living facility because it was not considered safe, and the discharge would be delayed.During a record review of Resident 1's Physician Orders, dated 12/13/2025 at 2:34 p.m., Resident 1 had an order to discontinue the discharge order to assisted living.During a review of the facility's policy and procedure (P&P), titled Criteria for Transfer and Discharge, date revised 4/2025, It is the policy of this Facility that each resident will remain in the Facility, and not be transferred or discharged unless the discharge or transfer is appropriate as per the existing criteria. When the Facility transfers or discharges a resident, the Facility shall ensure that the transfer or discharge is documented in the resident's medical record and appropriate information is communicated to the receiving health care institution or provider.

Based on interview and record review the facility failed to inform one of one sample resident ( Resident 1) that Resident 1's insurance would not cover the cost of a board and care facility ( a small, residential setting that provides housing, meals, and personal care assistance to a limited number of residents). This deficient practice compromised Resident 1's ability to make an informed decision, potentially leading to financial hardship and psychosocial distress. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including hypertension ( high blood pressure) and repeated falls. During a review of Resident 73's History and Physical (H& P) dated 3/13/2025, indicated Resident 1 does have the ability to make own decisions. During a review of Resident 73's Minimum Data Set ([MDS] resident assessment tool) dated 6/6/2025, the MDS indicated Resident 1 required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) with toileting hygiene and personal hygiene. During a telephone interview on 6/17/2025 at 10:30 a.m. with Resident 1, Resident 1 stated that he was currently residing at the board and care facility. Resident 1 stated that he was informed of the location prior to his discharge from the facility by the Social Service Staff (SSS-unknown). Resident 1 stated that he asked SSS would his insurance pay for his stay at the board and care, SSS replied yes. Resident 1 stated that once he arrived at the board and care, he was informed by the business office that his social security check would be used to pay for his stay at the board and care. Resident 1 stated that he does not mind where he was currently residing, however he does wish that he was informed about his financial obligation prior to transferring so that he could have made an informed decision. Resident 1 stated that he had experienced psychosocial harm (stress and anxiety) from being discharged , because he does not receive enough money from his social security check to cover the entire amount and that he would have a share of cost (is a monthly amount individuals must pay towards their medical expenses before Medi-Cal begins to cover the remaining costs). Resident 1 stated that he would not like to return to the facility because he feels as though the facility did not want him there. During a concurrent interview and record review on 6/18/2025 at 9:08 a.m. with Social Service Director (SSD), the SSD stated that she was responsible for assisting residents with transfers and discharges. SSD stated that she had not explained to Resident 1 the cost of the board and care and that she should have explained the cost prior to the resident being discharged to the board and care. SSD stated Resident 1 had the right to be informed because he had been able to decide if he wanted to go there. SSD stated that she does not know why she did not explain the financial aspects prior to Resident 1's discharge. SSD stated that Resident 1 probably felt betrayed and upset. During an interview on 6/18/2025 at 9:54 a.m. with the Director of Nursing (DON), the DON stated that before residents were discharged or transferred to another facility, SSD should inform residents' with written notice, reason for the discharge, location, their appeal rights, and payment expectations. The DON stated the residents should be informed of all those things in order for them to be able to make an informed decision. The DON stated the Resident 1 probably felt upset. During an interview on 6/18/2025 at 10:30 a.m. with the Administrator (Admin), the Admin stated that the facility had been trying to find placement for Resident 1 and when the board and care facility accepted him that they acted immediately to discharge Resident 1. During a review of the facility's policy and procedure (P&P) titled Criteria for Transfer and Discharge, dated 4/2025, the P&P indicated, It is the policy of this Facility that each resident will remain in the facility and not be transferred or discharged unless the discharge or transfer is appropriate as per the existing criteria. When the Facility transfers or discharges a resident, the facility shall ensure that the transfer or discharge is documented in the resident's medical record and appropriate information is communicated to the receiving health care institution or provider.

Based on observation, interview, and record review the facility failed to follow the menu and did not meet the nutritional needs of 46 of 81 residents on regular texture diets (diets with no restriction) when the residents did not receive three (3) ounce ([oz] unit of measurement) portions. This failure had the potential to result in decreased intake of nutrients resulting in unintended (not done on purpose) weight loss. Findings: During a review of the facility's daily spreadsheet titled Menus Cycle 4, dated 11/12/2024, the spreadsheet indicated residents on regular diet textures would get 3 oz of Meatloaf. During an observation on 11/12/2024 at 11:03 a.m., at the tray-line area (an area where meals were assembled on the trays), the meatloaf on the steam table varied in portion sizes. During a concurrent observation and interview on 11/12/2024 at 11:13 a.m., with [NAME] 1, [NAME] 1 weighed random pieces of meatloaf using the facility food scale. [NAME] 1 stated the first piece of meatloaf was 2.6 oz, the second piece was 3.6 oz, and the last piece was 2.5 oz. [NAME] 1 stated the portion size of the meatloaf should be 2 oz and she weighed the meatloaf once and increased the portion sizes because there were too many complaints from the residents that the portions were small. During an interview on 11/12/2024 at 11:20 a.m., with [NAME] 1, [NAME] 1 stated the portion sizes for meatloaf was 3 oz and not 2 oz after checking the menu spreadsheets. During an interview on 11/12/2024 at 11:25 a.m., with the Dietary Supervisor (DS), the DS stated the staff referred to menu spreadsheet to check the correct portion sizes of the food served in tray-line. The DS stated it was not okay for the meatloaf to be inaccurate in portion size and staff needed to follow the spreadsheet to ensure residents were getting an adequate amount of nutrition. During an interview on 11/12/2024 at 11:54 a.m., with the Registered Dietitian (RD), the RD stated it was important to check and follow the menu spreadsheet for portion sizes of the food to ensure they were providing adequate nutrition to the residents. The RD stated residents who got lesser portions would not get adequate nutrition which could lead to weight loss and residents who got bigger than recommended portions could gain weight as a potential outcome. During a review of the facility's standardized recipe titled Meatloaf (S-B/T), undated, the standardized recipe indicated Suggested portion size: 3 oz. Procedure: Slice into 3 oz portions. Top with gravy. (Should get 20 portions per pan). During a review of the facility's Policies and Procedures (P&P) titled Food Preparation, dated 2023, the P&P indicated, Procedure: (1) The facility will use approved recipes, standardized to meet the resident census. This count is kept current so that an accurate amount of food is prepared. (2) Recipes are specific as to portion yield, method of preparation, quantities of ingredients, and time and temperature guidelines. During a review of the facility's P&P titled Portion Control, dated 2023, the P&P indicated, Policy: To provide specific portion control information. Procedure: To be sure portions served equal sizes listed on the menu, portion control equipment must be used. A variety of portion control equipment should be available and utilized by employes portioning food. (3) A diet scale should be used to weigh meats. A scale that will weigh over two pounds or less accurate for weighing food in ounces. It is not always necessary to weigh every slice of meat, but test weighing should be done periodically to ensure accuracy.

Based on observation, interview, and record review, the facility failed to prepare food by methods that conserved flavor and appearance when: a. The buttered carrots had no butter flavor. b. The mashed potatoes were bland in taste and had no flavor. This failure had the potential to result in 80 of 81 facility residents, getting food from the kitchen including Residents 27, 42,78, and 82 at risk of unplanned weight loss, a consequence of poor food intake. Findings: During a review of Resident 42's Admission Record, the admission record indicated the facility admitted Resident 42 on 10/17/2024 with diagnoses including, but not limited to, chronic kidney disease ([CKD] a long term condition where the kidneys are damaged and cannot filter blood properly), chronic obstructive pulmonary disease ([COPD] a common lung disease that makes it difficult to breathe and protein-calorie malnutrition (a nutritional status where the body is lacking nutrients leading changes in the body composition and functions). During a review of Resident 42's Minimum Data Set (MDS, a resident assessment tool), dated 10/23/2024, the MDS indicated Resident 42' cognition (process of thinking and reasoning) was moderately intact for daily decision making. The MDS indicated Resident 42 required partial or moderate assistance (helper does less than half the effort) when eating. During a review of Resident 42's Order Summary Report, dated 11/3/2024, the order summary report indicated an order for a fortified (adding food items on the tray to provide additional nutrients) diet, no added salt([NAS] no salt packet served on the tray) with regular texture and thin liquid (fluids with no restriction) consistency. During an interview on 11/12/2024 at 11:44 a.m., with Resident 42, Resident 42 stated the food was bland. During a review of Resident 82's Admission Record, the admission record indicated the facility admitted Resident 82 on 10/16/2024 with diagnoses including, but not limited to, dysphagia (difficulty swallowing), and protein calorie malnutrition. During a review of Resident 82's MDS, dated [DATE], the MDS indicated Resident 82 was able to understand and make decisions. The MDS indicated Resident 82 required set up and clean-up assistance when eating. During a review of Resident 82's Order Summary Report, dated 11/5/2024, the order summary report indicated Resident 82 was ordered NAS, mechanical soft chopped texture (foods that are soft and easy to chew), thin liquid consistency diet. During an interview on 11/12/2024 at 11:44 a.m., with Resident 82, Resident 82 stated the food was horrible. During a review of Resident 78's Admission Record, the admission record indicated the facility admitted Resident 78 on 8/30/2024 with diagnoses including, but not limited to, chronic systolic (congestive) heart failure (a serious condition that occurs when heart cannot pump enough blood to meet the body's needs), acute respiratory failure ([ARF], a serious medical condition occurs when the body's is unable to provide enough oxygen to the blood and organs or remove enough carbon dioxide from the body) and ascites (a condition where fluid builds up in the abdomen that covers the abdominal organs.). During a review of Resident 78's MDS, dated [DATE], the MDS indicated Resident 78 was able to understand and make decisions. The MDS indicated Resident 78 required set up and clean-up assistance when eating. During a review of Resident 78's Order Summary Report, dated 8/30/2024, the order summary report indicated an order for NAS, regular texture, thin liquids diet. During an interview on 11/12/2024 at 10:19 a.m., with Resident 78, Resident 78 stated the food sucks and it's like poison. Resident 78 stated the kitchen offered alternative like sandwiches, but it was not good. During a review of Resident 27's Admission Record, the admission record indicated the facility admitted Resident 27 on 10/5/2024 with diagnoses including, but not limited to, dysphagia, obstructive and reflux uropathy (a blockage in the urinary tract that prevents urine from draining causing it to back up into the kidneys), and essential hypertension ([HTN] high blood pressure). During a review of Resident 27's MDS, dated [DATE], the MDS indicated Resident 27 was not able to understand and make decisions. The MDS indicated Resident 27 required set up and clean-up assistance when eating. During a review of Resident 27's Order Summary Report, dated 10/5/2024, the order summary report indicated an order for a NAS, regular texture, thin liquid consistency diet. During an interview on 11/12/2024 at 10:25 a.m., with Resident 27, Resident 27 stated the food was not good. During a review of the facility's daily spreadsheet titled Menus Cycle 4, 2024 dated 11/12/2024, the spreadsheet indicated residents on regular diet (diet with no restriction) and NAS would get the following food items: Meatloaf four (4) ounces (oz, unit measurement) Mashed potato half (1/2) cup (cup, household measurement) Gravy Buttered carrots 1/2 c Roll 1 each Margarine 1 each Winter fruit cup 3 1/4 oz Beverage 8 oz During a concurrent observation and interview on 11/12/2024 at 12:20 p.m., of the test tray (a process of checking the temperature, tasting, and evaluating the quality of food) with the Dietary Supervisor (DS) and Registered Dietitian (RD), the DS stated the buttered carrots did not seem to have a butter flavor and the mashed potatoes were bland in taste. The DS stated the cook maybe did not follow the recipe. The DS stated the residents may not eat the food and would not be happy with the food if was not flavorful. During a review of the facility's Policies and Procedures (P&P) titled Food Preparation, dated 7/19/2024, the P&P indicated, POLICY: Food shall be prepared by methods that conserve nutritive value, flavor, and appearance. PROCEDURE: (1) The facility will use approved recipes, standardized to meet the resident census. (3) Prepared food will be sampled. The Food and Nutrition Services employee who prepares the food will sample it to be sure the food has a satisfactory flavor and consistency. Use a clean spoon or put a small portion of the food in a dish and taste from the dish. (4) Poorly prepared food will not be served-such food is to either be improved, prepared again, or replaced with an appropriate substitution. Note that increased amounts of herbs and spices (not salt) may be added, since potency of products may vary. During a review of the facility's standardized recipe titled Buttered Carrots, undated, the standardized recipe indicated Ingredients: sliced carrots, salt, black pepper, melted margarine. If using butter buds instead of margarine: prepare the butter buds liquid by combining the warm water with the butter buds. Mix well. During a review of the facility's standardized recipe titled Mashed Potatoes, undated, the standardized recipe indicated Ingredients: water, potato pearl, margarine, salt, black pepper.

Based on observation, interview and record review, the facility failed to prepare foods in a form designed to meet individual needs when residents on puree level four (4) diet (diet consisted of food that are soft with pudding like consistency) received meatloaf that could not hold its shape and puree carrot were weeping water. This failure had the potential to result in coughing, choking (to keep from breathing the normal way) and death for eight (8) of 81 residents on the puree diet. Findings: During a review of the facility's daily spreadsheet titled Menu Cycle 4, dated 11/12/2024, the spreadsheet indicated residents' meals on puree level 4 diet would include the following foods on the tray: Puree meatloaf half (1/2) cup ([c] household measurement) Mashed potato with gravy 1/2 c Puree buttered carrots 1/3 c Puree bread 1 piece (pc) Margarine 1 pc. Puree winter fruit cup 1/3 c Beverage 8 oz. During a concurrent observation and interview on 11/12/2024 at 10:31 a.m., with [NAME] 1 in the tray-line (an area where foods were assembled on the trays) area, [NAME] 1 stated she already prepared the puree foods. The puree carrots in the steamtable appeared watery with a runny consistency and the puree meat looked like it would not hold its shape. During a concurrent observation and interview on 11/12/2024 at 12:27 p.m., with Dietary Supervisor (DS) and Registered Dietitian (RD), of the test tray (a process of checking the temperature, tasting, and evaluating the quality of food), the DS stated the puree meatloaf was spread out on the plate while the other puree food held its shape. The DS then read the diet manual definition of puree diet and stated, puree diet should be lump free, not firm and sticky, should hold it shape in place and no liquids seeping from the food. The DS stated the puree meatloaf did not hold its shape on the plate and there was liquid coming out from the puree carrots. The RD stated the puree diets are for residents with dysphagia (difficulty swallowing) and for those without teeth. The RD stated residents could aspirate (when something you swallowed enters the airways and lungs) especially for those residents with difficulty swallowing as a potential outcome of eating foods that were no prepared in the proper textures. The RD stated another potential outcome is that residents may not enjoy their food. During an interview on 11/13/2024 at 1:35 p.m., with [NAME] 1, [NAME] 1 stated puree food was a difficult texture to make and the meat was always watery. During a review of the facility's Diet Manual titled Dysphagia Diets, Puree IDDSI Level 4, dated 1/2022, the diet manual indicated Definition: A diet used in the dietary management of dysphagia with the food texture prepared lump-free, not firm or sticky ad holds its shape on the plate. The diet requires no biting or chewing. Any liquids must not separate from the food and the food can fall off a spoon a spoon intact. The food is more easily swallowed and prevents aspiration. All prepared pureed recipes should be tested prior to service to ensure the texture meets the International Dysphagia Diet Standardization Initiative ([IDDSI] a framework for categorizing food textures and drink thickness) guidelines. During a review of the facility's recipe titled Meatloaf (S-B/T) not dated, the recipe indicated, Puree: Place portion needed from regular prepare recipe into a food processor process to a fine texture. For every five portions needed, prepare a slurry with 1 tablespoon thickener and 1/2 cup hot liquid. Mix well with a wire whip. Add 1/2 of the slurry to the meat. Process for 1 minute. If too dry, add more slurry until meat is pudding consistency. During a review of the facility's recipe titled Buttered Carrots not dated, the recipe indicated, Puree: take drained portions needed from regular prepared recipe and place in a food processor. Process until fine. For every 5 portions, add 3 tablespoon thickener and 1/4 cup liquid. Process until smooth, scrape down sides of the bowl. Reprocess 30 second. Reheat to 165 F and serve with #12 scoop. During a review of IDSSI website titled IDDSI dated 7/2019, the IDSSI website indicated, Level 4 Pureed is usually eaten with spoon, falls off spoon in a single spoonful when tilted and continues to hold shape on the plate, no lumps, not sticky, and liquid must not separate from solid.

Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen when: a. Staff improperly labeled food products. 1. Jello was not labeled with product name. 2. Dry potato was improperly labeled. 3. Resident's food from outside was not labeled with the resident's name. b. Three (3) dented cans were stored with non-dented cans. c. There was chipped, cracked, and rusted kitchen utensils and equipment. 1. Chopping boards had scratches and had sauce splatter stored in the clean area. 2. Fruit cutter had rust. 3. Potato container cover had chips. 4. Can opener had chips. 5. 48 of 48 resident's tray were cracked. d. Kitchen equipment and food preparation surfaces were not cleaned and sanitized. 1. Clean area for storing pots and pans had crumbs and food particles. 2. Pans had food residue, spill and burnt surfaces. 3. Toaster had breadcrumbs residue. 4. Tray-line (an area where foods were assembled on the trays) top had rust and brown dirt particles. 5. Microwave had food splatter and dry sauces. e. [NAME] did not check the food temperature prior to tray-line service. f. Mashed potato in the steamtable was 125 degrees Fahrenheit ([ F] a scale of temperature). g. Staff did not perform hand hygiene. 1. [NAME] touched the garbage cover then put on new gloves. 2. [NAME] picked up a paper towel off the floor then proceeded plating food in tray-line. 3. Staff picked up two pieces of paper towel off the floor then proceeded working. h. Resident's freezer temperature was not monitored and checked. These failures had the potential to result in harmful bacteria growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to foodborne illness (a disease caused by consuming food or drinks that are contaminated by germs or chemicals) in 80 of 81 medically compromised residents who received food and ice from the kitchen. Findings: a. 1. During an observation on 11/12/2024 at 8:42 a.m., of the reach-in freezer, a green food item was not labeled with name. During an interview on 11/12/2024 at 9:11 a.m., with the Dietary Supervisor (DS), the DS stated their process of labeling and dating foods were as follows: (1) Label with product name. (2) Label with the date the product was made. (3) Label with expiration date. The DS stated they label food with the product name so that cooks could identify the food items and they label it with the date so that the staff could know the shelf life (length of time which a food item remains usable) of the product. The DS stated if food was not labeled with product name, the staff would not know the food product and could cause cross-contamination as a potential outcome to residents. 2. During an observation on 11/13/2024 at 9:27 a.m., of the dry potato container, the label indicated a use by date of 11/11/2024 and an expiration date of 11/9/2024. During an interview on 11/13/2024 at 9:55 a.m. with the DS, the DS stated the dry potato label was a typographical error and the expiration year was 2025 instead of 2024. 3. During a concurrent observation and interview on 11/13/2024 at 10:24 a.m. with Licensed Professional Nurse 1 (LVN 1), LVN 1 stated the residents' food inside the Resident Refrigerator was not labeled with the resident's name that the food item belonged to. LVN 1 stated it was important to label outside food with resident's name to make sure they were giving the right food to the right resident to comply with diets and food allergies. LVN 1 stated potential outcome to the residents could be allergic reactions and incorrect diets given to the residents. During a review of facility's Policies and Procedures (P&P) titled Labeling and Dating of Foods, dated 2023, the P&P indicated, POLICY: All food items in the storeroom, refrigerator, and freezer need to be labeled and dated based on established procedures for either food safety or product rotation (FIFO- First In-First Out). Once daily, the PM cook and or PM diet aide will be responsible to inspect the refrigerators and discard perishable foods that are TCS in order to ensure food safety. Working containers holding food or food ingredients that are removed from their original packages for use in the food facility, such as cooking oils, flour, herbs, potato flakes, salt, spices, and sugar, shall be identified with common name of the food, except that containers holding food that can be readily and unmistakably recognized, such as dry pasta, need not be identified. During a review of facility's Policies and Procedures (P&P) titled Foods Brought by Family or Visitors, dated 7/21/2023, the P&P indicated It is the policy of the facility that food(s) brought to a resident by family/visitors must be accepted by the resident; inspected before facility storage and stored and served in accordance with food safety professional standards. The use of outside foods is a possible intervention for residents with low intake, distinct food preferences, cultural/ethnic preferences, etc. This intervention preserves the resident right to self-determination as much as possible. (5) Resident food shall be stored in the following locations: Resident refrigerator or in the kitchen. Resident food stored in the facility kitchen will be easily distinguishable from facility food. All foods shall be labeled with the resident name, location, and date. During a review of Food Code 2022, the Food Code 2022 indicated, 3-501.17 Commercially processed food, open and hold cold, (B) except specified in (E) - (G) of this section, refrigerated, ready-to-eat time/temperature control for food safety food prepared and packed by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacture's use-by- date if the manufacturer determined the use-by date based on food safety. b.During a concurrent observation and interview on 11/12/2024 at 9:50 a.m. in the dry storage room with the DS, there were three (3) dented cans stored with the undented cans. The DS stated they separated dented cans in a designated area as dented cans could get a hole that the naked eye could not see and spoil, and it was bad for resident's consumption and residents could get sick from botulism (a rare but serious illness that occurs when the body's nervous system is attacked by a toxin produced by the bacteria). During a review of facility's P&P titled Food Storage-Dented Cans, dated 2023, the P&P indicated, POLICY: Food in unlabeled, rusty, leaking, broken containers or cans with side seam dents, rim dents, or swells shall not be retained or used by the facility. PROCEDURE: All dented cans (defined as side seam or rim dents) and rusty cans are to be separated from remaining stock and placed in a specified labeled area for return to purveyor for refund. All leaking cans are to be disposed immediately. During a review of Food Code 2022, the Food Code 2022 indicated, 3-101.11 Safe Unadulterated, and Honestly Presented. Food shall be safe, unadulterated, and, as specified under 3-601.12, honestly presented. 3-201.11 Compliance with Food Law. A primary line of defense ensuring that food meets the requirements of S3-101.11 is to obtain food from approved sources, the implications of which are discussed below. However, it is also critical to monitor food products to ensure that, after harvesting, processing, they do not fail victim to conditions that endanger their safety, make them adulterated, or compromise their honest presentation. The regulatory community, industry, and consumers should exercise vigilance in controlling the conditions to which foods are subjected and be alert to signs of abuse. FDA considers food in hermetically sealed containers that are swelled or leaking to be adulterated and actionable under the Federal Food, Drug, and Cosmetic Act. Depending on the circumstances, rusted, and pitted or dented cans may also present a serious potential hazard. c.During an observation on 11/12/2024 at 10:10 a.m., the chopping boards had scratches with dried up sauce spilled, the large white chopping board was chipped, the fruit slicer had rust and the container cover for the potatoes was chipped. 1.2.3. During a concurrent observation and interview on 11/12/2024 at 12:40 p.m., with the DS, the DS stated the chopping boards had scratches, and the potato container cover had cracks. The DS stated it was not okay to have kitchen equipment with cracks and scratches as the cracked pieces could get in the food and it would be a cross-contamination issue. The DS stated the slicer looked rusted, needed to be thrown away and should not be used in the kitchen due to cross-contamination. The DS stated the large chopping boards had chips and stains. The DS stated the large chopping boards should not be used and needed to be replaced. 4. During an observation on 11/13/2024 at 9:18 a.m., of the can opener, the can opener metal shelving had a chip. 5. During an observation on 11/13/2024 at 9:33 a.m., of the dishwashing process, 48 of 48 resident's meal trays had cracks and chips. During an interview on 11/13/2024 at 9:52 a.m., with the DS, the DS stated the can opener was just replaced last month and it should not have any chips as the particles could go in the can of food resulting in cross-contamination. During a concurrent observation and interview on 11/13/2024 at 10:06 a.m., with the DS, the DS stated the resident's tray had exposed metals and had cracks and chips. The DS stated they needed to get rid of them as residents and staff could get injured and it could be a physical contaminant to the resident's food. The DS stated cross contamination would be the potential outcome to the residents for having cracked and chipped trays. During a review of the facility's P&P titled Sanitation, dated 2023, the P&P indicated, (11) All utensils, counters, shelves, and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seams, cracks, and chipped areas. (12) Plastic ware, china, and glassware that becomes unsightly, unsanitary, or hazardous because of chips and cracks, or loss of glaze shall be discarded. Plastic ware is bleached as necessary to prevent staining. (20) Separate chopping boards are to be used for preparing meats and vegetables. After each use, chopping boards shall be thoroughly cleaned and sanitized. During a review of Food Code 2022, the Food Code 2022 indicated, 4-202.11 Food-Contact Surfaces. (A) Multiuse Food-contact surfaces shall be (1) Smooth (2) Free of breaks, open seams, cracks, chips, inclusions, pits, and similar imperfections. (3) Free of sharp internal angles, corners, and crevices, (4) Finished to have smooth welds and joints. d.During an observation on 11/12/2024 at 10:24 a.m. in the pots and pans storage area, the clean pots and pans had dirt, crumbs, and food debris on them. The Pans had food spillage and burnt surfaces. The Bread toaster was covered with plastic and had breadcrumbs and tray-line roof had rust and brown dirt particles. 1. During a concurrent observation and interview on 11/12/2024 at 12:37 p.m., with the DS, the DS stated the preparation areas and other areas in the kitchen were cleaned after each meal. The DS stated the clean storage area for pots and pans had food debris from breakfast and it was not okay due to cross-contamination. DS stated if there was cross-contamination, residents could get sick with stomach issues like vomiting and stomach pain as a potential outcome. 2.3.4. During a concurrent observation and interview on 11/12/2024 at 12:43 p.m., with the DS, the DS stated the bread toaster had crumbs and it should have been cleaned after each use. The DS stated this was a cross-contamination issue. The DS stated the tray-line roof was cleaned after every meal however, it looked dirty and rusted due to the steam coming out from the steamtable. The DS stated it was not acceptable due to cross-contamination of food in the tray-line. The DS stated residents could get sick with stomach pain and diarrhea as a potential outcome of the cross-contamination. 5. During an observation on 11/13/2024 at 9:20 a.m. of the microwave, the microwave had food splatters and dry sauces. During a concurrent observation and interview on 11/13/2024 at 9:52 a.m., with the DS, the DS stated the microwave was cleaned every after use, however, there was dried up spillage and food inside. The DS stated it was not acceptable to have dried up food spillage in the microwave due to cross-contamination. During a review of facility's P&P titled Sanitation, dated 2023, the P&P indicated, POLICY: The Food and Nutrition Service Department shall have equipment of the type and in the amount necessary for the preparation, serving and storing of food. There shall be adequate equipment for cleaning and disposal of waste and general storage. All equipment shall be maintained as necessary and kept in working order. (16) The kitchen staff is responsible for all the cleaning with the exception of ceiling vents, light fixtures, and the hood over the stove, while will be cleaned by maintenance staff. During a review of the facility's job task assignment log titled AM/PM Cooks Job Assignments, undated, the log indicated a schedule to clean all counter tops after use for AM cooks and cover, toaster, cutting boards for PM cooks. During a review of Food Code 2022, the Food Code 2022 indicated, 4-601.11 (E) Except when dry cleaning methods are used as specified under S 4-603.11, surfaces of utensils and equipment contacting food that is not time/temperature control for safety food shall be cleaned: (1) At anytime when contamination may have occurred; (2) At least every 24 hours for iced tea dispensers and consumer self-service utensils such as tongs, scoops, or ladles; (3) Before restocking consumer self-service equipment and utensils such as condiment dispensers and display containers; and (4) In equipment such as ice bins and beverage dispensing nozzles and enclosed components of equipment such as ice makers, cooking oil storage tanks and distribution lines, beverage and syrup dispensing lines or tubes, coffee bean grinders, and water vending equipment: (a) At a frequency specified by the manufacturer, or (b) Absent manufacturer specification, at a frequency necessary to preclude accumulation of soil or mold. e.During an observation on 11/12/2024 at 11:03 a.m., of the tray-line, [NAME] 1 started plating the food from the steamtable to the plates and trays without checking the temperature of the foods. During an interview on 11/12/2024 at 11:25 a.m., with the DS, the DS stated staff took the food temperature before plating the food in the tray-line to ensure food was hot and not undercooked. The DS stated the food temperature record log was blank. During a review of facility's P&P titled Meal Service, dated 2023, the P&P indicated, POLICY: Meals that meet the nutritional needs of the resident will be served in an accurate and efficient manner and served at the appropriate temperatures. (2) Food and Nutrition Services staff member will take the food temperatures prior to service of the meal with a thermometer prior to service of the meal with a thermometer that has been cleaned and sanitized. f.During an observation on 11/12/2024 at 11:03 a.m., [NAME] 1 took the mashed potatoes temperature in the steamtable and it was 125 F. During an interview on 11/12/2024 at 11:25 a.m., with the DS, the DS stated the holding temperature of food was 140 F, and if the mashed potatoes was not at 140 F, the residents could complain that the food was cold. During a review of facility's P&P titled Meal Service dated 2023, the P&P indicated (3) The food will be served on tray-line at the recommended temperatures indicated below and recorded on the daily therapeutic menu in the temperature column of regular food and next to the food item under the therapeutic diet column of each food served. Hot food serving temperature must be at or above minimum holding temperature of 140 F. the temperatures may also be recorded on a temperature log. The temperature of foods should be periodically monitored throughout the meal service to ensure proper hot or cold holding temperature. g.1. During an observation on 11/12/2024 at 11:06 a.m., [NAME] 1 touched the lid of the garbage can and put on new gloves without performing hand hygiene. 2. During an observation on 11/12/2024 at 11:20 a.m., [NAME] 1 touched the lid of the garbage can then went back to plating food for the residents. During an interview on 11/12/2024 at 4:06 p.m., with the DS, the DS stated staff must wash their hands as soon as they enter the kitchen, touched their face, hair and when they were coming back from their break. The DS stated staff must not touch the cover of the garbage can or wash their hands after their hands were in contact with dirt on the garbage can because of cross-contamination. During an observation on 11/13/2024 at 9:17 a.m., Dietary Aide 1 (DA 1) picked up two (2) pieces of paper towel off the floor then went back to work without handwashing. During an interview on 11/13/2024 at 1:28 p.m., with [NAME] 1, [NAME] 1 stated she needed to wash hands every time she started working and thought that it was okay to not wash hands as long as she could change her gloves. [NAME] 1 stated it was not oaky to touch the garbage lid then go back to work as the bacteria could be on the trash can and it could go to her hands and transfer to the food she handled. [NAME] 1 stated residents could get sick with diarrhea as a potential outcome. During a review of the facility's P&P titled Handwashing Procedure, dated 2023, the P&P indicated Hand washing is important to prevent the spread of infection. When to wash hands: (8) Touching trash can or lid. During a review of Food Code 2022, the Food Code 2022 indicated 2-301.14 When to Wash. Food employees shall clean their hands and exposed portions of their arms as specified under S 2-301.12 immediately before engaging in food preparation including working with exposed [NAME], clean equipment and utensils, and unwrapped single- service and single-use article and: (A) After touching bare human body parts other than clean hands and clean, exposed portions of arms; (B) After using the toilet room; (C) After caring for or handling service animals or aquatic animals as specified in 2-403.11(B); P (D) Except as specified in 2-401.11(B), after coughing, sneezing, using a handkerchief or disposable tissue, using tobacco products, eating, or drinking; (E) After handling soiled equipment or utensils;(F) During food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; G) When switching between working with raw food and working with ready-to eat food; (H) Before donning gloves to initiate a task that involves working with food; and (I) After engaging in other activities that contaminate the hands. h.During a concurrent observation and interview on 11/13/2024 at 10:20 a.m., with LVN 1, LVN 1 stated the 11-7 nurse shift monitored the temperature of the residents' refrigerator however the freezer temperature was not monitored, and they did not have a log. LVN 1 stated she did not know the reason why the freezer was not monitored because there was ice cream stored in there. LVN 1 stated they monitored the refrigerator and freezer for infection control purposes to ensure food was not spoiled and contaminated. LVN 1 stated residents could get sick with diarrhea and stomach issues if food was not in their proper temperatures. During a review of the facility's P&P titled Sanitation, dated 2023, the P&P indicated 21. Correct temperatures for the storage and handling of foods are used. Thermometers will be used to check temperatures of refrigerators, freezers, and food storeroom. Thermometers will be also used to check the food at mealtimes. During a review of the facility's P&P titled Cold Storage Temperature Monitoring and Record Keeping, dated 2023, the P&P indicated Food and Nutrition Services staff shall review and record temperatures of all refrigerators and freezers to ensure the correct temperatures for food storage and handling. Freezer temperature standards are 0 F or below. During a review of the facility's P&P titled Foods Brought by Family or Visitor, dated 2023, the P&P indicated (8) The temperature of the refrigerator and freezer will be monitored and logged by Nursing/Food Services staff in accordance with the facility professional food safety standards. Any deviations from the correct temperature standards will be reported to the Maintenance Department and/or the DSS for guidance and correction.

Based on observation, interview, and record review, the facility failed to dispose of garbage and refuse properly by not ensuring two (2) of the dumpster's (a large trash metal container designed to be emptied into a truck) were not overflowing with trash, and the dumpster lids remained closed. This failure had the potential to result in attracting birds, flies, insects, pest and possibly spread infection to 80 of 81 facility residents. Findings: During an observation on 11/12/2024 at 3:58 p.m., at the dumpster area, 2 dumpsters were overflowing with trash and the lids could not close. During a concurrent observation and interview on 11/12/2024 at 4:02 p.m., with the Dietary Supervisor (DS), the DS stated staff threw all the food trash into those dumpsters. The DS stated the dumpsters were overflowing with trash and were open and it was not okay as it could attract pest and rodents that could come in the facility. The DS stated rodents could carry diseases and could pass the disease to the resident as a potential outcome. During a concurrent observation and interview on 11/12/2024 at 4:09 p.m., with the Environmental Services Director (EVSD) at the dumpster area, the EVSD stated their trash vendor collected their trash once a day and would usually come around 3PM to 3:30 p.m., however they were late today because it was holiday yesterday. The EVSD stated the dumpster was overflowing and it was not okay that it was not closed as it could attract flies and the environment would smell. The EVSD stated this practice was not safe for the resident as it could get resident sick as a potential outcome. During a review of facility's Policies and Procedures (P&P) titled Miscellaneous Areas, dated 2023, the P&P indicated, Procedure: (1) All food waste must be placed in sealed leak-proof, non-absorbent, tightly closed containers (i.e. plastic bags) and shall be disposed of as necessary to prevent a nuisance or unsightliness. (2) Garbage and trashcan must be inspected daily that no debris is on the ground. or surrounding area, and that the lids are closed. The trash collection area is a potential feeding ground for vermin and rodents and must be kept clean. During a review of Food Code 2022, indicated, 5-501.116 Cleaning Receptacles. Proper storage and disposal of garbage and refused are necessary to minimize the development of odors, prevent such waste from becoming an attractant and harborage of breeding place for insects and rodents, and prevent the soiling of food preparation and food service areas. Improperly handled garbage creates nuisance conditions, makes housekeeping difficult, and may be possible source of contamination of food, equipment, and utensils. Outside receptacles must be constructed with tight-fitting lids or covers to prevent the scattering of the garbage or refuse by birds, the breeding of flies, or the entry of rodents. Proper equipment and supplies must be made available to accomplish thorough and proper cleaning of garbage storage areas and receptacles so that unsanitary conditions can be eliminated.

Based on observation, interview and record review, the facility failed to ensure staff wore personal protective equipment ([PPE], clothing or equipment that protects the wearer from injury or illness) while providing direct resident care for one of three sampled residents (Resident 70) who was on enhanced barrier precaution/protection ([EBP], infection control intervention using gown and gloves during high contact resident care activities designed to reduce the transmission of multi-drug resistant organisms). This failure had the potential to result in the transmission of infectious microorganisms and increase the risk of causing an outbreak in the facility. Findings: During a review of Resident 70's Admission Record, the Admission Record indicated Resident 70 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of metabolic encephalopathy (a brain disorder that occurs when an underlying condition causes a chemical imbalance in the blood that affects the brain), gastrostomy tube ([G-Tube], a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems), type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and hypertension ([HTN], high blood pressure). During a review of Resident 70's Minimum Data Set ([MDS] a resident assessment tool), dated 8/29/2024, the MDS indicated Resident 70 was moderately impaired in cognitive skills (thought process) for daily decision-making and was dependent (helper does all of the effort to complete the activity or the assistance of two or more helpers is required) on mobility such as rolling left and right, sit to lying position, lying to sitting on the side of the bed and self-care abilities such as eating, toileting, oral and personal hygiene. During a review of Resident 70's Order Summary Report, the Order Summary Report indicated enhanced barrier precautions, PPE required for high resident contact care activities. Indication was G-Tube every shift. During an observation on 11/12/2024 at 9:26 a.m., inside of Resident 70's room, the Certified Nursing Assistant (CNA) 1 did not have on proper PPE when tending to Resident 70's care in the room. The signage on the doorway indicated Resident 70 was on EBP and PPE needed to be worn when resident care was provided. CNA 1 only had gloves on when picking up Resident 70's blanket from the bed and adjusting the blanket on Resident 70. CNA 1 then stepped out of Resident 70's room and did not perform hand hygiene. During an observation on 11/12/2024 at 10:01 a.m., in Resident 70's room, Resident 70 was lying in bed in a supine (on the back) position. Resident 70 did not want to be interviewed and asked to be left alone. Resident 70 had a pillow underneath her right arm, a walker at the end of the bed and tube feeding machine next to the patient. During an interview on 11/15/2024 at 10:52 a.m., with Licensed Vocational Nurse (LVN) 2, LVN 2 stated Resident 70 was on EBP because Resident 70 had a G-Tube for feedings. LVN 2 stated residents with any openings in the body such as wounds, a foley catheter (a flexible tube that drains urine from the bladder into a collection bag), or G-Tube are on EBP. Staff are to wear PPE to protect other residents and themselves from infection. Staff who do not wear proper PPE when providing care to the residents are at risk for spreading infection and soiling their clothes when in contact with the openings from the residents. Infections can spread from resident to resident, resident to staff or resident to visitors. During an interview on 11/15/2024 at 2:47 p.m., with the Director of Nursing (DON), the DON stated the purpose of EBP was to protect the resident and staff from possible infections. The DON stated residents with wounds or devices such as a foley catheter, G-tube, or if the resident had a history of infection are on EBP. The proper PPE staff should have on are gloves, gown, mask when encountering anything that may belong to the resident such as their personal belongings or anything at the bedside. The DON stated when staff are not following PPE guidelines, infections can spread and be passed on to other staff members, residents and even visitors which can cause an outbreak. The correct way of donning (putting on) PPE was gown, mask, gloves. Gloves are put on last and should cover the sleeves of the gown. The correct way of doffing (taking off) PPE was gloves, gown, and mask and the perform hand hygiene. The DON stated all staff should perform hand hygiene before going into a resident's room and after leaving a resident's room. During a review of the facility's policy and procedure (P/P) titled IPCP Standard and Transmission-Based Precautions, revised 3/2024, indicated enhanced barrier protection used in conjunction with standard precautions and expand the use of PPE through the use of gown and gloves during high-contact resident care activities that provide opportunities for indirect transfer of MDROs to staff hands and clothes then indirectly transferred to residents or from resident to resident (e.g. residents with wounds and indwelling medical devices are at especially high risk of both acquisition and colonization with MDROs) examples of high contact resident care activities requiring gown and glove use for EBP include dressing, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use like central vascular line, indwelling urinary catheter, feeding tube, tracheostomy/ventilator. During a review of the facility's P/P titled, Hand Hygiene, dated 12/2022, indicated five moments of hand hygiene are before patient contact, before aseptic procedure, after patient contact, after body fluids, secretions contact, and after environment contact health care personnel must perform hand hygiene when it is needed during each five moments of hand hygiene. 49606

Based on interview and record review, the facility failed to ensure a resident, who was in severe back pain and was at the facility for pain management, received Hydrocodone-Acetaminophen ([Norco] a combination medication used to relieve moderate to severe pain) 10/325 milligram ([mg] a unit of weight measurement), for severe pain, for one of three sampled residents (Resident 1). The facility failed to: 1. Ensure licensed nurses ordered a refill of Norco 10/325 mg for Resident 1's moderate to severe pain management before its quantity was depleted, leaving Resident 1 in severe pain. 2. Ensure Registered Nurse Supervisor (RNS 1) contacted Resident 1's physician or the facility's Medical Director for authorization to take Norco 10/325 mg from the facility's emergency kit ([E-Kit] a kit that contains a small quantity of medications that can be dispensed when pharmacy service is not available) where six Norco 10/325 mg tablets were available, to administer to Resident 1 for severe back pain. 3. Ensure Resident 1 was medicated to control her severe pain as ordered by the physician and care planned. 4. Ensure licensed nurses followed the facility's Policy and Procedure (P&P) titled, Medication Orders, Controlled Substance Prescriptions, to refill Norco and send the request form to the pharmacy five (5) days in advance to assure an adequate supply of Norco was on hand for administration to Resident 1. These deficient practices resulted in Resident 1 experiencing uncontrolled severe back pain for approximately 22 hours without a relief. Resident 1 was eventually transferred to a General Acute Care Hospital (GACH) on 12/25/2023 at 10 a.m., for evaluation of uncontrolled back pain where she was administered intravenous ([IV] in the vein) Morphine (a medication used for severe pain) to relieve her uncontrolled severe pain. Findings: A review of Resident 1's Admission Record (Face Sheet) indicated Resident 1 was admitted to the facility on [DATE], with diagnoses that included orthopedic (a medical specialty that deals with the treatment of bones that did not grow correctly or sustained damaged) aftercare (care provided following a surgical procedure), arthrodesis status (orthopedic surgery in which two or more bones in a joint are fused (joined together) to become one larger bone), and difficulty in walking. A review of Resident 1's Minimum Data Set ([MDS] a standardized assessment and care planning tool), dated 12/19/2023, indicated Resident 1 was able to make independent decisions that were reasonable and consistent and was able to understand and be understood by others. The MDS indicated Resident 1 experienced severe pain frequently over the last five days making it hard to sleep. A review of Resident 1's Care Plan, dated 12/14/2023, indicated Resident 1 had acute/chronic pain related to lumbar stenosis (a narrowing of the spinal canal in the lower part of the back) with five prior lumbar surgeries with misplaced plates, rods, and screws, removal of hardware decompression (a release of physical pressure from plates, rods, and screws used to keep spine stable), laminectomy (a surgical procedure to relieve pressure on the nerves by removing the arched back piece of the vertebrae [backbone]) and fusion (surgery to connect two or more bones together) of the thoracic 11 (the middle section of the spine) vertebrae through the sacrum bone 1 (a triangle shaped bony structure at the base of the lumbar vertebrae). The care plan goal for Resident 1 was to verbalize adequate pain relief or the ability to cope with incompletely relieved pain. The Care Plan interventions included to anticipate Resident 1's need for pain relief and respond immediately to any complaint of pain and administer analgesics (pain medications) as ordered by the physician. A review of Resident 1's Physician's Orders indicated the following: 1. On 12/14/2023 - an order for Tylenol 325 mg, give two tablets by mouth every four hours as needed for mild pain (from 1 to 3) rated on a zero to 10 pain rating scale (a subjective [personal view] measure in which individuals rate their pain on an 11 point scale; 0=no pain, 1-3=mild pain, 4-6=moderate pain, and 7-10=severe pain, and 10=worst imaginable pain). 2. On 12/24/2023 - Norco 10/325 mg one tablet every four hours as needed for moderate pain (4-6) to severe pain (7-10). A review of Resident 1's Progress Note, dated 12/14/2023 and timed at 12:52 p.m., indicated Resident 1 was admitted to the facility from a GACH after an elective surgery to remove misplaced back hardware with severe stenosis, had hardware decompression with a history of multiple back surgeries. The Progress Note indicated Resident 1 was transferred to the facility (12/14/2023) for observation and management of physical condition/symptoms, and medication management for pain. A review of Resident 1's Controlled Medication Count Sheet, dated 12/23/2023 and timed at 9:20 a.m., indicated Resident 1 had one tablet of Norco 10/325 mg left. A review of Resident 1's Pharmacy Medication Order form, dated 12/23/2023 indicated, Resident 1's refill order for Norco 10/325 mg was faxed to the pharmacy on 12/23/2023 at 11:56 p.m., when Resident 1 had only one tablet (for one time dose) of Norco remaining available. A review of Resident 1's Medication Administration Record (MAR), dated 12/2023 indicated Resident 1's last (available at the facility) dose of Norco10/325 mg was administered at 1:01 p.m., on 12/24/2023. The MAR indicated Resident 1's pain level was a 10 on a pain scale of 1 to 10 and was administered Tylenol 650 mg (usually given for mild pain rating 1-3) on 12/25/2023, at 8:36 a.m. A review of Resident 1's Change in Condition Evaluation (COC), dated 12/25/2023 and timed at 10:05 a.m., indicated at 9:30 a.m., Resident 1 had an uncontrolled severe pain rated at 10. The COC indicated Resident 1 was tearful and had decreased mobility. The COC indicated there was no pain medication available, and the facility was waiting for Resident 1's pain medication (Norco 10/325 mg) to be delivered. The COC indicated Resident 1's physician was notified of Resident 1's pain level and an order was obtained to transfer Resident 1 to the GACH ' s emergency room (ER) for uncontrolled severe back pain. A review of Resident 1's physician order dated 12/25/2023, indicated to transfer Resident 1 to the GACH ER for uncontrolled severe back pain. A review of Resident 1's Transfer Form, dated 12/25/2024 indicated Resident 1 was transferred to the GACH on 12/25/2023 at 10 a.m. for uncontrolled severe back pain. A review of Resident 1's Narcotic Prescription Form Long Term Care Facility Patient, indicated a fax confirmation indicating the order for Norco (Hydrocodone-Acetaminophen) refill was faxed to the pharmacy on 12/25/2023 at 3:59 a.m. A review of Resident 1's GACH ER records, dated 12/25/2023 and timed at 11:13 a.m., indicated Resident 1's chief complaint was uncontrolled severe back pain that started on 12/24/2023, and radiated down Resident 1's right leg. The ER record indicated Resident 1 received IV Morphine to relief her uncontrolled severe pain. During a concurrent interview and record review, on 1/11/2024, at 3:34 p.m., with Registered Nurse Supervisor (RNS 1) Resident 1's MAR dated 12/2023 was reviewed. The MAR indicated on 12/25/2023 Tylenol 650 mg was given at 8:36 a.m., for a pain level of 10 out of 10. RNS 1 stated Tylenol 650 mg was administered to Resident 1 because Norco was not available. RNS 1 stated Norco had been ordered (12/24/2023) and was expected to be delivered to the facility at any time. RNS 1 stated there were six tablets of Norco available in the facility's E-Kit but because Resident 1 was being transferred to the GACH, she (RNS 1) did not think to call the Medical Director to obtain an order to retrieve Norco from the E-Kit and instead gave Resident 1 Tylenol 650 mg. RNS 1 stated she should have called the Medical Director to get authorization to access the Norco from the E-Kit earlier so that Resident 1's pain could have been under control sooner. During an interview on 1/11/2024 at 4:25 p.m., the Assistant Director of Nursing (ADON) stated, when medications are close to running out and get down to approximately 7-10 tablets, a medication order should be placed to refill the medication. The ADON stated in order to obtain a refill for a narcotic, the licensed nurse has to call the physician, the physician then calls the pharmacy to authorize the refill. Then ADON stated if the medication needed to be retrieved from the E-Kit, the licensed nurse has to call the physician, the physician then calls the pharmacy to authorize the medication to be taken from the E-Kit, then the pharmacy calls the facility to authorize the licensed nurse to retrieve the medication from the E-Kit. The ADON stated the nursing staff should have ordered Resident 1's pain medication before it was completely out of stock and called the physician and/or the Medical Director to get access to the Norco in the E-Kit so that Resident 1's pain could be controlled by preventing a delay in Resident 1's pain medication administration and transfer to the GACH. During an interview on 1/12/2024 at 4:24 p.m., a Certified Nurse Assistant (CNA 1) stated Resident 1 was in a lot of pain, (12/24/2023 during the night), she (Resident 1) was moaning, crying, and had shooting pain down both of her hips. CNA 1 stated he (CNA 1) approached the charge nurse (CN 1) three to four times during her shift (11 p.m.-7 a.m.) to ask if Resident 1's pain medication had been approved, and the charge nurse told him no it had not. During an interview on 1/12/2024 at 12:59 p.m., Licensed Vocational Nurse (LVN 2) stated, it was important to order the pain medication before its quantity became too low, so they did not run out of it, leaving Resident 1 in severe pain. LVN 2 stated she did not realize Resident 1's pain medication was running out. During an interview on 1/16/2024 at 3 p.m., the Director of Nursing (DON) stated the nurse should have sent the refill order for Norco at least three days ahead, so there was no delay in Resident 1 receiving pain medication. A review of the facility's P&P, titled Medication Orders, Controlled Substance Prescriptions, dated 8/2019 indicated emergency pharmacy service is available on a 24-hour basis. Emergency needs for medication are met by using the facility's approved emergency medication supply or by special order from Med-Plus Pharmacy LTC. Med-Plus Pharmacy LTC supplies emergency medications including emergency drugs, antibiotics, controlled substances, products for infusion in limited quantities in portable, sealed containers in compliance with applicable State regulation. To access medication from the emergency kit secondary to a new order or when medication for which there is a current prescription is not readily available, the nurse confers with the prescriber to determine whether the order is a true emergency., i.e., order cannot be delayed util the scheduled pharmacy delivery. If the medication is a controlled substance, the prescriber either faxes a complete prescription to the facility and pharmacy or communicates the verbal order to both the nurse and directly to the pharmacist along with details about the situation to verify that it meets the criteria of an emergency situation. A review of the facility's P&P, titled, Medication Orders, Controlled Substance Prescriptions, dated 8/2019, indicated, if a partial fill quantity of schedule II ([CIIs] drugs that require additional care because of the potential for the patient to intentionally or unintentionally abuse the drug) medication remains, refills are written on a medication order form or ordered by peeling the top label from the label and placing it in the appropriate area on the order form provided by the pharmacy for that purpose and requested from the pharmacy five (5) days in advance of need to assure an adequate supply is on hand.

Based on interview and record review, the facility failed to ensure a resident who had a history of back surgery, and was admitted to the facility for pain management with an order for Hydrocodone-Acetaminophen ([Norco] a combination medication used to relieve moderate to severe pain)10-325 milligrams ([mg] a unit of measurement) for severe pain, had the order for Norco refilled in time enough to ensure its availability for 1 of 3 sampled residents (Resident 1). The facility failed to: 1. Ensure licensed nurses ordered a refill of Norco 10/325 mg for Resident 1's moderate to severe pain management before its quantity was depleted, leaving Resident 1 in severe pain. 2. Ensure Registered Nurse Supervisor (RNS 1) contacted Resident 1's physician or the facility ' s Medical Director for authorization to take Norco 10/325 mg from the facility's emergency kit ([E-Kit] a kit that contains a small quantity of medications that can be dispensed when pharmacy service is not available) where six Norco 10/325 mg tablets were available, to administer to Resident 1 for severe back pain. 3. Ensure Resident 1 was medicated to control her severe pain as ordered by the physician and care planned. 4. Ensure licensed nurses followed the facility's Policy and Procedure (P&P) titled, Medication Orders, Controlled Substance Prescriptions, to refill Norco and send the request form to the pharmacy five (5) days in advance to assure an adequate supply of Norco was on hand for administration to Resident 1. These deficient practices resulted in Resident 1 experiencing uncontrolled severe back pain for approximately 22 hours. Resident 1 was eventually transferred to a General Acute Care Hospital (GACH) on 12/25/2023 at 10 a.m., for evaluation of uncontrolled back pain where she was administered intravenous ([IV] in the vein) Morphine (a medication used for severe pain) to relieve her uncontrolled severe pain. Findings: A review of Resident 1's Admission Record (Face Sheet) indicated Resident 1 was admitted to the facility on [DATE], with diagnoses that included orthopedic (a medical specialty that deals with the treatment of bones that did not grow correctly or sustained damaged) aftercare (care provided following a surgical procedure), arthrodesis status (orthopedic surgery in which two or more bones in a joint are fused (joined together) to become one larger bone), and difficulty in walking. A review of Resident 1's Minimum Data Set ([MDS] a standardized assessment and care planning tool), dated 12/19/2023, indicated Resident 1 was able to make independent decisions that were reasonable and consistent and was able to understand and be understood by others. The MDS indicated Resident 1 experienced severe pain frequently over the last five days making it hard to sleep. A review of Resident 1's Care Plan, dated 12/14/2023, indicated Resident 1 had acute/chronic pain related to lumbar stenosis (a narrowing of the spinal canal in the lower part of the back) with five prior lumbar surgeries with misplaced plates, rods, and screws, removal of hardware decompression (a release of physical pressure from plates, rods, and screws used to keep spine stable), laminectomy (a surgical procedure to relieve pressure on the nerves by removing the arched back piece of the vertebrae [backbone]) and fusion (surgery to connect two or more bones together) of the thoracic 11 (the middle section of the spine) vertebrae through the sacrum bone 1 (a triangle shaped bony structure at the base of the lumbar vertebrae). The care plan goal for Resident 1 was to verbalize adequate pain relief or the ability to cope with incompletely relieved pain. The Care Plan interventions included to anticipate Resident 1's need for pain relief and respond immediately to any complaint of pain and administer analgesics (pain medications) as ordered by the physician. A review of Resident 1's Physician's Orders indicated the following: 1. On 12/14/2023 - an order for Tylenol 325 mg, give two tablets by mouth every four hours as needed for mild pain (from 1 to 3) rated on a zero to 10 pain rating scale (a subjective [personal view] measure in which individuals rate their pain on an 11 point scale; 0=no pain, 1-3=mild pain, 4-6=moderate pain, and 7-10=severe pain, and 10=worst imaginable pain). 2. On 12/24/2023 - Norco 10/325 mg one tablet every four hours as needed for moderate pain (4-6) to severe pain (7-10). A review of Resident 1's Progress Note, dated 12/14/2023 and timed at 12:52 p.m., indicated Resident 1 was admitted to the facility from a GACH after an elective surgery to remove misplaced back hardware with severe stenosis, had hardware decompression with a history of multiple back surgeries. The Progress Note indicated Resident 1 was transferred to the facility (12/14/2023) for observation and management of physical condition/symptoms, and medication management for pain. A review of Resident 1's Controlled Medication Count Sheet, dated 12/23/2023 and timed at 9:20 a.m., indicated Resident 1 had one tablet of Norco 10/325 mg left. A review of Resident 1's Pharmacy Medication Order form, dated 12/23/2023 indicated, Resident 1's refill order for Norco 10/325 mg was faxed to the pharmacy on 12/23/2023 at 11:56 p.m., when Resident 1 had only one tablet (for one time dose) of Norco remaining available. A review of Resident 1's Medication Administration Record (MAR), dated 12/2023 indicated Resident 1's last (available at the facility) dose of Norco10/325 mg was administered at 1:01 p.m., on 12/24/2023. The MAR indicated Resident 1's pain level was a 10 on a pain scale of 1 to 10 and was administered Tylenol 650 mg (usually given for mild pain rating 1-3) on 12/25/2023, at 8:36 a.m. A review of Resident 1's Change in Condition Evaluation (COC), dated 12/25/2023 and timed at 10:05 a.m., indicated at 9:30 a.m., Resident 1 had an uncontrolled severe pain rated at 10. The COC indicated Resident 1 was tearful and had decreased mobility. The COC indicated there was no pain medication available, and the facility was waiting for Resident 1's pain medication (Norco 10/325 mg) to be delivered. The COC indicated Resident 1's physician was notified of Resident 1's pain level and an order was obtained to transfer Resident 1 to the GACH ' s emergency room (ER) for uncontrolled severe back pain. A review of Resident 1's physician order dated 12/25/2023, indicated to transfer Resident 1 to the GACH ER for uncontrolled severe back pain. A review of Resident 1's Transfer Form, dated 12/25/2024 indicated Resident 1 was transferred to the GACH on 12/25/2023 at 10 a.m. for uncontrolled severe back pain. A review of Resident 1's Narcotic Prescription Form Long Term Care Facility Patient, indicated a fax confirmation indicating the order for Norco (Hydrocodone-Acetaminophen) refill was faxed to the pharmacy on 12/25/2023 at 3:59 a.m. A review of Resident 1's GACH ER records, dated 12/25/2023 and timed at 11:13 a.m., indicated Resident 1's chief complaint was uncontrolled severe back pain that started on 12/24/2023, and radiated down Resident 1's right leg. The ER record indicated Resident 1 received IV Morphine to relief her uncontrolled severe pain. During a concurrent interview and record review, on 1/11/2024, at 3:34 p.m., with Registered Nurse Supervisor (RNS 1) Resident 1's MAR dated 12/2023 was reviewed. The MAR indicated on 12/25/2023 Tylenol 650 mg was given at 8:36 a.m., for a pain level of 10 out of 10. RNS 1 stated Tylenol 650 mg was administered to Resident 1 because Norco was not available. RNS 1 stated Norco had been ordered (12/24/2023) and was expected to be delivered to the facility at any time. RNS 1 stated there were six tablets of Norco available in the facility's E-Kit but because Resident 1 was being transferred to the GACH, she (RNS 1) did not think to call the Medical Director to obtain an order to retrieve Norco from the E-Kit and instead gave Resident 1 Tylenol 650 mg. RNS 1 stated she should have called the Medical Director to get authorization to access the Norco from the E-Kit earlier so that Resident 1's pain could have been under control sooner. During an interview on 1/11/2024 at 4:25 p.m., the Assistant Director of Nursing (ADON) stated, when medications are close to running out and get down to approximately 7-10 tablets, a medication order should be placed to refill the medication. The ADON stated in order to obtain a refill for a narcotic, the licensed nurse has to call the physician, the physician then calls the pharmacy to authorize the refill. Then ADON stated if the medication needed to be retrieved from the E-Kit, the licensed nurse has to call the physician, the physician then calls the pharmacy to authorize the medication to be taken from the E-Kit, then the pharmacy calls the facility to authorize the licensed nurse to retrieve the medication from the E-Kit. The ADON stated the nursing staff should have ordered Resident 1's pain medication before it was completely out of stock and called the physician and/or the Medical Director to get access to the Norco in the E-Kit so that Resident 1's pain could be controlled by preventing a delay in Resident 1's pain medication administration and transfer to the GACH. During an interview on 1/12/2024 at 4:24 p.m., a Certified Nurse Assistant (CNA 1) stated Resident 1 was in a lot of pain, (12/24/2023 during the night), she (Resident 1) was moaning, crying, and had shooting pain down both of her hips. CNA 1 stated he (CNA 1) approached the charge nurse (CN 1) three to four times during her shift (11 p.m.-7 a.m.) to ask if Resident 1's pain medication had been approved, and the charge nurse told him no it had not. During an interview on 1/12/2024 at 12:59 p.m., Licensed Vocational Nurse (LVN 2) stated, it was important to order the pain medication before its quantity became too low, so they did not run out of it, leaving Resident 1 in severe pain. LVN 2 stated she did not realize Resident 1's pain medication was running out. During an interview on 1/16/2024 at 3 p.m., the Director of Nursing (DON) stated the nurse should have sent the refill order for Norco at least three days ahead, so there was no delay in Resident 1 receiving pain medication. A review of the facility's P&P, titled Medication Orders, Controlled Substance Prescriptions, dated 8/2019 indicated emergency pharmacy service is available on a 24-hour basis. Emergency needs for medication are met by using the facility's approved emergency medication supply or by special order from Med-Plus Pharmacy LTC. Med-Plus Pharmacy LTC supplies emergency medications including emergency drugs, antibiotics, controlled substances, products for infusion in limited quantities in portable, sealed containers in compliance with applicable State regulation. To access medication from the emergency kit secondary to a new order or when medication for which there is a current prescription is not readily available, the nurse confers with the prescriber to determine whether the order is a true emergency., i.e., order cannot be delayed util the scheduled pharmacy delivery. If the medication is a controlled substance, the prescriber either faxes a complete prescription to the facility and pharmacy or communicates the verbal order to both the nurse and directly to the pharmacist along with details about the situation to verify that it meets the criteria of an emergency situation. A review of the facility's P&P, titled, Medication Orders, Controlled Substance Prescriptions, dated 8/2019, indicated, if a partial fill quantity of schedule II ([CIIs] drugs that require additional care because of the potential for the patient to intentionally or unintentionally abuse the drug) medication remains, refills are written on a medication order form or ordered by peeling the top label from the label and placing it in the appropriate area on the order form provided by the pharmacy for that purpose and requested from the pharmacy five (5) days in advance of need to assure an adequate supply is on hand.

Based on observation, interview and record review, the facility failed to follow its policy and a resident's plan of care to ensure assisted devices and supervision was provided to prevent falls and injuries during physical therapy for one of four sampled residents (Resident 1). Resident 1, who was overweight (weighing 244 pounds) was admitted to the facility for rehabilitation after undergoing bilateral knee surgery, was assessed as requiring a two-person extensive assist with transfer and locomotion but was not provided with adequate supervision and/or assistive devices to prevent falls and injury. This deficient practice resulted in Resident 1, who was status [REDACTED].) and a left knee tendon rupture (tendon separates in whole or in part from the tissue it is attached to). Resident 1 required a transfer to a general acute care hospital (GACH) and two days later, on 12/3/19, underwent two additional knee surgeries to repair the injuries after the fall. The facility staff continued to stair-train other residents in the basement after Resident 1 fell . On 3/26/19 at 4:12 p.m., an Immediate Jeopardy ((IJ), a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was declared under F689. The facility's administrator (ADM) and the Director of Nursing (DON) were notified of the immediacy and seriousness of the residents' health and safety being threatened. The facility submitted a Plan of Action (POA) for the correction of the IJ. The IJ was lifted and the POA was accepted on 3/27/19 at 4:48 p.m., after the team verified the POA which included the following: 1. To assure safety of the residents, all residents will be properly assessed by the physical therapy department prior to participation in stair training to ensure the resident has the capacity to be trained. 2. The director of rehabilitation (DOR) provided an in-service for the rehab department staff on 12/14/18, regarding patient safety while stair training in the stairway that leads down to the facility's basement. 3. The facility implemented a new policy that requires two therapists with a patient while being stair trained in the stairwell. 4. Ongoing in-services will be provided by the DOR as needed, but at least annually. 5. The DOR will monitor the rehab department to ensure safety of individual residents who participate in stair training in the basement. 6. A new set of mobile training stairs was purchased and is being used in the rehab gym as well. 7. A telephone was installed on 3/27/19 at the bottom of the basement stairs, which will allow any staff member who is providing stair training with residents to make a telephone call, in the event of an emergency. 8. The facility will provide a standardized training in writing regarding patient safety in the stairwell, which will be especially helpful for per-diem, on-call, weekend and registry therapist staff who are not as familiar with the facility. Findings: A review of Resident 1's Admission Face Sheet indicated the resident was admitted to the facility on [DATE]. Resident 1's [DIAGNOSES REDACTED]. A review of Resident 1's History and Physical (H/P), dated 11/12/18, indicated the resident had the capacity to understand, make decisions and be understood. According to the H/P, Resident 1 had an allergy to opiates (narcotic drugs used to treat pain) and was status [REDACTED]. According to the H/P, Resident 1 weighed 244 pounds. A review of Resident 1's admission Minimum Data Set (MDS), a resident assessment and care screening tool, dated 11/18/18, indicated Resident 1 had no memory problems, no impaired decision-making, was able to make needs known and able to understand others. According to the MDS, Resident 1 was assessed as requiring an extensive two-person physical assistance with bed mobility, transferring, locomotion on and off the unit, and extensive assistance with personal hygiene. The MDS indicated under Section G 300, balance during transfers and walking, that Resident 1 was not steady and was only able to stabilize with staff's assistance. The MDS under Section G 400, functional limitation in range of motion (ROM), that Resident 1 was assessed with [REDACTED]. A review of Resident 1's care plan initiated on 11/12/18, identified a problem with falls and/or injury. The goal indicated that Resident 1 would be free from fall and/or injuries. The staff's interventions included to keep close observation of the resident to minimize potential for falls during activity and to anticipate resident needs. A review of Resident 1's care plan initiated on 11/12/18, identified a problem with [MEDICAL CONDITION] joint disease (DJD) with a risk of joint pain, swelling, stiffness secondary to bilateral knee total joint replacement, with the potential for contractures (define) or limitations of extremities. The goal indicated Resident 1 will not have unresolved pain, joint swelling and joint stiffness daily. The staff's approach plan included gentle handling during care, assess for signs of joint swelling and pain and address in a timely manner. Provide gentle ROM during ADLs as tolerated, provide Physical therapy as ordered. A review of a physician's orders [REDACTED]. A review of the PT's evaluation and plan of treatment, dated 11/12/18-1/6/19, indicated aftercare following the bilateral joint replacement surgery with an onset date of 11/8/18 with the presence of bilateral artificial knee joints, and [MEDICAL CONDITION] arthritis. The plan of treatment short-term goals included Resident 1 would safely ascend/descend (climb up/down) one (1) stair using handrails bilaterally and tactile cues for proper sequencing, for task segmentation, for correct use of an assistive device, and for correct hand foot placement with the ability to right self to achieve /maintain balance with a target date of 11/25/18. The plan's long-term goals indicated Resident 1 will safely ascend/descend less than fifteen (15) stair using handrails bilaterally and tactile cues for proper sequencing, for task segmentation, for correct use of an assistive device, and for correct hand foot placement with ability to right self to achieve /maintain balance with a target date of 1/6/19. The PT evaluation and plan of treatment indicated Resident 1's current level of function and underlying impairment of pain 10 out of ten on the pain scale (10 being the worse pain) that was described as sharp and shooting upon movement. According to the PT Assessment, Resident 1 experienced pain at rest that was constant pain at 3 out of ten, which the resident described as gnawing and heavy in the right and left knees. The PT concluded that Resident 1's pain limits functional activities. A review of the modified barthel index (a scale used to measure one's performance in ADLs which assesses a resident's functional independence), dated 11/27/18 indicated Resident 1 had a score of 50 out of 100 indicating a moderate dependency level. The scale indicated that Resident 1 was unable to perform the task of stair climbing and required substantial help with ambulation. A review of a PT's treatment encounter note, dated 11/29/18, written by a physical therapy assistant (PTA 4), and co-signed by the physical therapist (PT 1) on 12/2/18 and timed at 7:57 a.m., indicated treatment as planned patient (Resident 1) transferred to wheelchair and stated right arm was flared up and feels pain in the left shoulder. Nursing administered pain medication. Patient (Resident 1) required step training 1-inch step three times with stand by assist, 4inch steps three times with contact guard assist, 6-inch steps three times to assimilate patient's (Resident 1's) home environment with contact guard assist and minimum cues for sequencing. Resident transferred into wheelchair with contact guard assist (one or two hands on one's body but provides no other assistance to perform the task). A review of Resident 1's PT treatment encounter note, dated 11/30/18, written by PTA 4, and co-signed by PT 1 on 12/2/18 at 7:57 a.m., indicated treatment emphasis included gait training, step training and therapeutic activities. Patient (Resident 1) required several seated therapeutic rests today after every functional task in general during treatment due to the patient (Resident 1) indicating her right arm had flared up and especially left shoulder, but was very determined to attempt 6-inch stairs in the basement today. Patient (Resident 1) was able to ascend and descend three steps three times with three therapeutic rests of 2-3 minutes due to the height of the step and patient's present [DIAGNOSES REDACTED]. Patient used non-reciprocating sequencing single rail left ascending. Gait training initiated after steps and seated rest. Patient completed therapy in good spirits after being able to complete therapy especially step training. Patient requires further training with steps, patient will have to be able to ascend approximately twenty steps to enter residence. Presently patient moves somewhat labored antalgic gait (a gait that develops as a way to avoid pain while walking) noted, but also requires several therapeutic rests due to patient's decreased functional endurance and stature, very pleasant and hard worker with therapy. A review of a Situation, Background, Assessment and Recommendation ((SBAR) internal communication form), dated 12/1/18 and timed at 2:30 p.m., indicated Resident 1 had an assisted fall while going up and down the stairs in the stairwell during physical therapy training. A review of a nurses' note, dated 12/1/18 and timed at 5:22 p.m., written by a Licensed Vocational Nurse 1 (LVN 1) indicated Resident (Resident 1) with family member (FM1) at the bedside complaining of knee pain status [REDACTED]. Administered [MEDICATION NAME] ([MEDICATION NAME]) 4 milligrams (mg) (muscle relaxant for muscle spasms) with relief. Administered all medications and tolerated well. Resident awaiting STAT (immediate) x-ray. The note indicated the resident (Resident 1) was alert and oriented, verbally responsive and able to make needs known. The note indicated to continue with PT/ OT services as tolerated; provide assistance with bathing, dressing, and transferring and keep clean at all times. The resident respirations were noted as even and unlabored with no shortness of breath (SOB). Call light within reach and will continue to monitor. All needs met and attended, no signs or symptoms of bleeding, bruising, or skin discoloration due to aspirin use. A review of the nurses' note, dated 12/1/18 and timed at 7:21 p.m., written by LVN 1 indicated x-rays completed x-ray at 6:35 p.m., awaiting results. A review of the right knee x-ray results, dated 12/1/18 and timed at 7:58 p.m., indicated status [REDACTED]. This x-ray was compared to the prior x-ray, dated 11/27/18, which indicated there was no periprosthetic fracture and the knee was anatomically aligned, before the fall incident. A review of a PT treatment encounter note, dated 12/1/18 and timed at 8:11 p.m., written by a physical therapy assistant (PTA 3) and co-signed by PT 1 on 12/2/18 and timed at 7:57 a.m., indicated Resident 1 was pre-medicated without complaint of pain and taken to the basement for stair training. According to the note, Resident 1 was able to ascend three steps up and down using left handrail with contact guard assist and instructions to adjust velocity and cues to clear foot every step to facilitate safety. The resident was able to take two steps using right lower extremity, but on the third step, decided to take a step using left lower extremity with instructions to use right lower extremity. Resident 1's left knee buckled and the resident immediately started yelling. Stayed with patient and called for help, nursing and rehab staff transferred patient onto wheelchair, provided cold packs on both knees, and transferred patient using sliding board post pain medication administration. A review of the nurses' note, dated 12/1/18 and timed at 10:36 p.m., indicated Resident 1's x-ray results were abnormal for an acute fracture of inferior right patella (knee) with significant distraction of the fracture fragment. The note indicated that the primary physician and the orthopedic surgeon were notified, received new orders for an immobilizer (medical device applied to a part of the body to keep from moving) and apply ice to the area four times a day. No flexion exercise to the right knee. On 3/18/19 at 10:19 a.m., during an interview, PT 2 stated that the basement stairs are typically used for high level residents. PT 2 stated that the resident walks up or down the stairs two to three at a time and then the resident would rest. PT 2 indicated that the stair training was used to mimic the surroundings once the resident was discharged from the facility and back at home. At 10:29 a.m., on 3/18/19, during a subsequent interview and concurrent observation of the basement stairs with the DOR, she stated that Resident 1's fall incident occurred over the weekend and that PTA 3 had called and reported what happened. The DOR stated that when a resident received stair training in the basement they have already had training using blocks before transitioning to the stairs. The DOR stated that the rehabilitation training stairs were damaged by the rainy weather because they were kept outside in the element and that a new set of training stairs were ordered in (MONTH) 2019 and received in (MONTH) 2019. The DOR stated that Resident 1 was trained in the basement stairwell for the first time a day prior to the fall by two physical therapy staff members, and it was the resident's first time working with PTA 3. The DOR stated that PTA 3 was a part time staff member, because of another job obligation during the week. On 3/18/19 at 10:32 a.m., during an interview the DOR was questioned regarding ensuring safety for residents during stair training and the DOR replied that during training a gait belt should be used during training. The DOR attempted to use her personal cell phone to make a telephone call from the basement and the call was unsuccessful. The DOR stated that due to the fall incident and PTA 3 being unable to call for help, the facility implemented a new protocol for two physical therapy staff members to assist a resident during stair training for safety. On 3/18/19 at 10:36 a.m., the Maintenance director (MTA) stated that there was a phone in his office located in the basement but that the office was usually locked to protect the equipment inside. At 10:39 a.m., on 3/18/19, the MTA measured the height of the basement stairs and stated that the height of the first stair was 8 inches and the other stairs going up were 7 inches. The MTA stated that the door at the top of the stairs remains locked for resident's safety and that the maintenance staff and charge nurses have a key to the door leading to the basement. The other staff use the elevator to get to the basement. On 3/20/19 at 3:42 p.m., during an interview, PTA 3 stated that she reviewed the stair training notes for Resident 1 for three days prior and was repeating the training from the day before. PTA 3 stated that it was her first time working with Resident 1 and she ensured that the resident received pain medication prior to the physical therapy. PTA 3 stated that she was not sure of the basement stair height, but had taken other residents to the basement for training before. PTA 3 stated that Resident 1 was descending the basement stairs using the left handrail and the resident was told to rest after three stairs was completed. PTA 3 stated that Resident 1 was excited and wanted to continue stair training, and on the fourth stair a loud crack noise was heard, and Resident 1 immediately yelled. PTA 3 stated Resident 1 was yelling in pain and that while being held she was guided, and the resident used her hands to sit on the stairs. PTA 3 stated that she was unsure if a gait belt was used because the resident was either contact guard assist or minimum assist. PTA 3 stated she tried to call the facility's front desk for help using her personal cell phone, but there was no service in the basement and the call was unsuccessful. PTA 3 stated she left Resident 1 and went and found a housekeeping staff member and told the person to go upstairs for help. PTA 3 stated that she waited with Resident 1 for a few minutes and that various staff members from the Physical therapy department responded (PTA 1 and PTA 2) came to the basement, but was unsure exactly who from the nursing department responded, because she does not work at the facility often. PTA 3 stated that emergency paramedics were not called and the physical therapy staff used linen sheets to pick up Resident 1 to place her in a wheelchair to take her back to her room. PTA 3 stated that she was traumatized by the incident and the nursing staff took over the resident's care. PTA 3 stated that she called the DOR and reported what happened. On 3/21/19 at 11:11 a.m., during an interview, Resident 1 stated that PTA 3 brought her to the basement for stair training on (MONTH) 1, (YEAR) and that she had only climbed three stairs the day prior and it was with two other physical therapy staff members. Resident 1 stated she had concerns initially about the stair training because the therapist (PTA 3) did not use a gait belt and did not assist her physically at all during the training. Resident 1 stated that after going up three steps she needed to rest, but PTA 3 told her to continue. Resident 1 stated that PTA 3 was standing at the bottom of the stairway during the therapy looking at her telephone without any hands on technique with her. Resident 1 stated that she felt her right knee get weak and used her to left leg to stabilize and suddenly both legs collapsed and she fell on the stairs. She (Resident 1) stated she started crying and took a deep breath. Resident 1 stated that the handrails on the basement stairwell were too wide to hold both at the same and she was only able to hold on to one handrail during the training. Resident 1 stated that she felt an excruciating pain on both knees and her legs were pinned underneath her and she felt her heels touching her buttocks. Resident 1 stated that she screamed out and in pain because it was unbearable that it felt as if her surgical wounds had reopened. Resident 1 stated that PTA 3 was also started screaming and she had to yell at PTA3 to help pull her legs from underneath her while grasping onto the single rail unable to reach the other. Resident 1 stated that as soon as her legs were pulled from underneath her buttocks by PTA 3, she passed out from the horrible pain while clenching onto the handrail. Resident 1 stated that she awoke and felt the cold wall against her cheek and opened her eyes and observed PTA 3 attempting to use her personal cell phone to call for help and the calls did not go through. Resident 1 stated she waited on stairs until a few staff members along with FM1 came to the basement. Resident 1 stated that PTA 1 and PTA 2 placed a linen sheet under her armpits and under her legs to lifted her into the wheelchair and took her back to her room. Resident 1 stated she was administered synthetic opiate pain medication due to her allergies [REDACTED]. Resident 1 stated that she asked the nursing staff to call emergency paramedics to be transferred to the GACH right away but that she was told to wait for her orthopedic surgeon orders. Resident 1 stated an x-ray of her legs were taken at the facility four hours after the fall. Resident 1 stated that since the fall she has been unable to stand or walk, and fears that the fall may negatively impact her ability to walk again. Resident 1 stated that since the fall she has had a lot of emotional distress and depression with crying spells. Resident 1 stated she stayed at the facility a couple of days before being transferred to the GACH and once transferred she underwent surgery the following day (12/4/18). Resident 1 stated that since the fall she has had to receive two additional surgeries to repair the fracture and a ruptured tendon due to the fall. Resident 1 stated that the facility Administrator (ADM) offered her money after the fall incident, and that he kept pressuring her to sign a contract for the money. Resident 1 stated she wanted to focus on her recovery and refused to sign the contract. On 3/26/19 at 4:18 p.m., the DOR provided a list of four current residents who are currently receiving basement stair training. On 3/27/19 at 3:48 p.m., during an interview PTA 2 stated that he was called down to the basement by a nurse to assist with Resident 1. PTA 2 stated that when he arrived to the basement he saw Resident 1 and PTA 3 on the basement stairs. PTA 2 stated that it was suggested by a nurse to call emergency paramedics to remove Resident 1, but the he did not think it was necessary. PTA 2 stated with the help of PTA 1 and PTA 3, two linen sheets were used to wrap Resident 1's upper body and lower body to lift into the wheelchair. PTA 2 stated that he does not remember Resident 1 having a gait belt on her when he transferred her into the wheelchair. PTA 2 stated a nurse brought Resident 1's daughter down to the basement to comfort the resident. PTA 2 stated Resident 1 was escorted to her room and was left in the care of the nurses. PTA 2 stated he returned to assist with transferring Resident 1 into bed. On 3/27/19 at 4:14 p.m., during an interview in the presence of the DOR, Resident 2 stated that she had been admitted to the facility three times, and every time she has been a resident at the facility she received basement stair training at least two times a week. Resident 2 stated that the stair training was necessary because her residence has a second floor. In a subsequent interview at 4:22 p.m., in the presence of the DOR, Resident 3 stated that the stair training was done frequently and during her therapy. Resident 3 stated that she has received this type of therapy since her admission. A review of the facility's document titled, Physical therapy job description, indicated associated responsibilities were to use professional judgement to ensure safety of self, patients, and others at all times. A review of the facility's undated policy titled, Falling star program, indicated all residents would be closely monitored by staff for safety, and proper positioning of the resident. A review of the facility's undated policy titled, Gait Belt Policy, indicated gait belts were to be used to transfer and ambulate all residents who needs hands on or assistance in moving from one place to another. The policy indicated the belt was primarily used for safety purposes for the resident and staff.