Every finding on record at Alhambra Post Acute

Based on observation, interview and record review, the facility failed to ensure it kept accurate records of controlled medications (medication with a potential for abuse) as evidenced by: 1. The facility failed to ensure, for Residents 1-3, the scheduled (controlled medication, narcotic) medication system was complete (all documents available) and accurate (information matched). The record system included Shipping Manifests (pharmacy delivery receipt), Controlled Substance Accountability Sheets (CDR, Controlled Drug Record), Medication Administration Records (MAR, record of medication administration) and destruction logs. The facility records were incomplete. The facility records were inaccurate. These failures had the potential to result in undetected loss and diversion of scheduled medications. In addition, these failures had the potential to result in preventable medication errors (medication not given as ordered). 2. The facility failed to ensure, between 6/23-12/23, the Consultant Pharmacist identified the scheduled (controlled medication, narcotic) medication system was incomplete (all documents available) and inaccurate (information matched). The record system included Shipping Manifests (pharmacy delivery receipt), Controlled Substance Accountability Sheets (CDR, Controlled Drug Record), Medication Administration Records (MAR, record of medication administration) and destruction logs. The facility records were incomplete. The facility records were inaccurate. These failures had the potential to result in undetected loss and diversion of scheduled medications. In addition, these failures had the potential to result in preventable medication errors (medication not given as ordered). Findings:1. During an interview, on 3/3/26 at 11 a.m., Director of Nursing (DON) and Medical Record Director (MRD), were asked to describe the scheduled medication record system. Their description included that scheduled medication Shipping Manifests were retained by the facility. The MRD was requested to provide the scheduled medication Shipping Manifests for the months of 6/23 through 12/23. The facility was requested to provide the corresponding CDRs. During a concurrent tour and interview on 3/3/26 at 11:45 a.m., at the north nursing unit, Registered Nurse (RN 1) identified the medication cart. RN 1 was requested to describe the scheduled medication documentation process. RN 1's description included scheduled medications were delivered with a Shipping Manifest and a corresponding CDR. The medication was locked in the medication cart.The CDR was filed at the medication cart. The CDR was used to document removal of patient medications. Administration of the medication was documented on the MAR. Completed CDRs were sent for retention. If there were scheduled medications remaining upon discontinuation, the remailing medications and the CDR were sent to the DON. During a concurrent interview and record review, on 3/4/2 at 9:45 a.m., DON and MRD provided the requested Shipping Manifests and CDRs. During a concurrent interview and medical record review, on 3/9/26 at 10:15 a.m., DON identified Shipping Manifest #2581880 Resident 1 prescription 5893500 Hydrocodone (narcotic pain reliever) /APAP (acetaminophen, pain reliever) 5/325 mg (milligram) tablet #39. DON stated the facility did not have a corresponding CDR. During a concurrent interview and medical record review, on 3/9/26 at 10:15 a.m., DON identified 50 CDRs that the facility did not have a corresponding Shipping Manifest.The missing Shipping Manifests included the following:33 manifests for Hydrocodone-Acetamin (acetaminophen, pain reliever) 5-325 mg tablets4 manifests for Oxycodone (narcotic pain reliever)-APAP 10-325 mg tablets5 manifests for Hydrocodone-Acetamin 10-325 mg tablets During a concurrent interview and record review, on 3/10/26 at 1 p.m., DON identified Resident 2's MAR. She compared the 6223024 Oxycodone 5 mg capsule #60 date 11/21/23 CDR against the MAR. DON acknowledged the CDR removals did not have a corresponding MAR administration on the dates and times listed below.- 11/21/23 1500- 11/24/23 0400- 11/25/23 1500 During a concurrent interview and record review, on 3/10/26 at 1 p.m., DON identified Resident 3's MAR. She compared the 6158952 Hydrocodone/APAP 10/325 mg tablet #18 against the MAR. DON acknowledged the CDR removals did not have a corresponding MAR administration on the dates listed below.11/11-11/14/23 An administrative record review, of the Policy for Controlled Substances (Revision Date November 2022) showed, Dispensing and Reconciling Controlled Substances, 1. Controlled substance inventory is monitored and reconciled to identify loss or potential diversion in a manner that minimizes the time between loss/diversion and detection/follow-up.2. The system of reconciling the receipt, dispensing and disposition of controlled substances includes the following: a. Records of personnel access and usage; b. Medication administration records (MAR); c. Declining inventory records (CDR). 2. During an interview, on 3/3/26 at 11 a.m., Director of Nursing (DON) and Medical Record Director (MRD), were asked to describe the scheduled medication record system. Their description included that scheduled medication Shipping Manifests were retained by the facility. The MRD was requested to provide the scheduled medication Shipping Manifests for the months of 6/23 through 12/23. The facility was requested to provide the corresponding CDRs. During a concurrent tour and interview on 3/3/26 at 11:45 a.m., at the north nursing unit, Registered Nurse (RN 1) identified the medication cart. RN 1 was requested to describe the scheduled medication documentation process. RN 1's description included scheduled medications were delivered with a Shipping Manifest and a corresponding CDR. The medication was locked in the medication cart.The CDR was filed at the medication cart. The CDR was used to document removal of patient medications. Administration of the medication was documented on the MAR. Completed CDRs were sent for retention. If there were scheduled medications remaining upon discontinuation, the remailing medications and the CDR were sent to the DON. During a concurrent interview and record review, on 3/4/2 at 9:45 a.m., DON and MRD provided the requested Shipping Manifests and CDRs. During a concurrent interview and medical record review, on 3/9/26 at 10:15 a.m., DON identified Shipping Manifest #2581880 Resident 1 prescription 5893500 Hydrocodone (narcotic pain reliever) /APAP (acetaminophen, pain reliever) 5/325 mg (milligram) tablet #39. DON stated the facility did not have a corresponding CDR. During a concurrent interview and medical record review, on 3/9/26 at 10:15 a.m., DON identified 50 CDRs that the facility did not have a corresponding Shipping Manifest.The missing Shipping Manifests included the following:33 manifests for Hydrocodone-Acetamin (acetaminophen, pain reliever) 5-325 mg tablets4 manifests for Oxycodone (narcotic pain reliever)-APAP 10-325 mg tablets5 manifests for Hydrocodone-Acetamin 10-325 mg tablets During a concurrent interview and record review, on 3/10/26 at 1 p.m., DON identified Resident 2's MAR. She compared the 6223024 Oxycodone 5 mg capsule #60 date 11/21/23 CDR against the MAR. DON acknowledged the CDR removals did not have a corresponding MAR administration on the dates and times listed below.- 11/21/23 1500- 11/24/23 0400- 11/25/23 1500 During a concurrent interview and record review, on 3/10/26 at 1 p.m., DON identified Resident 3's MAR. She compared the 6158952 Hydrocodone/APAP 10/325 mg tablet #18 against the MAR. DON acknowledged the CDR removals did not have a corresponding MAR administration on the dates listed below.11/11-11/14/23 During a concurrent interview and record review, on 3/10/26 at 1:10 p.m., DON identified the Consultant Pharmacist reports 6/23-12/23. DON inspected the reports and stated that incomplete/inaccurate issues with Shipping Manifest, CDR and MAR were not documented. An administrative record review, of the Policy for Controlled Substances (Revision Date November 2022) showed, Dispensing and Reconciling Controlled Substances, 1. Controlled substance inventory is monitored and reconciled to identify loss or potential diversion in a manner that minimizes the time between loss/diversion and detection/follow-up.2. The system of reconciling the receipt, dispensing and disposition of controlled substances includes the following: a. Records of personnel access and usage; b. Medication administration records (MAR); c. Declining inventory records (CDR). An administrative record review, of the Policy for Pharmacy Services-Role of the Consultant Pharmacist (Revision Date April 2019) showed, Polic Interpretation and Implementation, 3. The consultant pharmacist shall provide consultation on all aspects of pharmacy services in the facility, and collaborate with the facility and medical director to:, a. develop, implement, evaluate, and revise (as necessary) the procedures for the provision of all aspects of pharmacy services.

Based on observation, interview and record review, the facility failed to follow state Title 22 regulations and ensure the social services department was staffed and supervised by a qualified social worker which affected all 20 residents for at least 3 months.This failure resulted in all residents receiving social services from unqualified staff.During an interview on 2/4/26 at 2:48 p.m., with social services director (SSD), SSD stated they had been in the position since December 2025. SSD stated they were a certified nursing assistant prior to taking the position.During a review of facility assessment titled, Facility Assessment Tool, dated 10/13/2025, the assessment indicated the facility identified resources needed to provide competent support and care for our resident population every day and during emergencies.staff type.therapy services.social worker, mental health social worker.During a concurrent interview and record review on 3/3/26 at 10:15 a.m., with Human Resources (HR), SSD's resume titled, [SSD] Certified Nursing Assistant, undated, was reviewed. HR stated SSD's resume indicated high school was the highest education completed and SSD has not completed any other education granting a Bachelor's degree.During a concurrent interview and record review on 3/3/26 at 12:15 p.m., with HR, SSD's job description titled, Job Description: Social Services Director, dated 2/2024, was reviewed. The job description was signed by SSD. HR stated the job description indicated a minimum education requirement of Bachelor's Degree in Social Work or Human Services and 2 years of supervised social work experience in a health care setting working directly with individuals. MSW preferred. HR stated SSD did not meet the educational requirements of the position of social services director.A review of facility policy and procedure (P&P) titled, Social Services End of Life Care Section: Medically Related Social Services, dated 12/2015, indicated social service staff will participate.in assessing and evaluating the benefits of outside resources for residents diagnosed with a terminal condition.the social worker will review any Advance Directive on file and communicate with the resident.to assure resident's wishes are honored.A review of facility P&P titled, Social Services Behavioral Management Section: Medically Related Social Services, dated 12/2015, indicated the facility would identify and address resident's behavior patterns that may impede their capability to relate to others and which may interfere with their functional capacity.the social worker will coordinate arrangement of the services.During a review of California state regulation titled, Title 22 S72433, the state regulation indicated 'Social Work Service' means those services which assist.a patient and a patient's family to understand and cope with.personal, emotional and related health and environmental problems.During a review of California state regulation titled, Title 22 S72105, the state regulation indicated a Clinical Social Worker was person who is a licensed clinical social worker by the Board of Behavioral Sciences.During a review of California state regulation titled, Title 22 S72437, the state regulation indicated Social Work Service Unit-Staff.the social work service unit shall be organized, directed and supervised by a social worker, who is responsible for supervision of other social work staff, including social work assistants.

Based on observation, interview, and record review, the facility failed to ensure the pacemaker defibrillator monitor (a remote monitor that automatically collects device data and sends it to the healthcare team) for one of four residents (Resident 1) was adequately monitored at the nurse's station when Resident 1's pacemaker defibrillator monitor was unable to be located.This failure had the potential to increase Resident 1's risk of cardiovascular accidents and decline in health condition.During record review of admission record, printed on 6/2/26, Resident 1 was admitted on [DATE].During record review of Resident 1's Minimum Data Set (MDS, an assessment tool used to guide care), dated 4/14/26, indicated Resident 1's Brief Interview for Mental Status (BIMS, an assessment tool used to assess mental status) score was 15 out of 15, which indicated Resident 1's cognition was intact. During an interview on 6/2/26, at 11:47 a.m., with Resident 1, Resident 1 stated their pacemaker defibrillator monitor was serviced by a technician due to poor signal, interfering with remote physician monitoring and accurate readings from device. Resident 1 stated days after technician came to service pacemaker defibrillator monitor, they were unable to find the device, even though Resident 1 was instructed to remain close to the device once a day for a few minutes to allow readings to transfer to physician. Resident 1 stated they called the Ombudsman (OMB) because monitor was not being monitored by staff and they could not find it at the nurse's station. Resident 1 stated the technician placed the device to the right of the closet in a specific area that had a good signal and staff moved it stating the signal was not good in that area. Resident 1 stated the monitor was found under papers, on the floor of nurse's station and out of nurses' view at times, and Resident 1 felt ignored when they expressed concerns regarding the pacemaker defibrillator monitor device. During a phone interview on 6/2/26, at 12:51 p.m., with OMB, OMB stated on 5/7/26, Resident 1 informed OMB of recent pacemaker technician visit due to pacemaker not functioning properly for several months and expressed pacemaker defibrillator monitor was not being properly monitored by nursing staff. OMB stated on 5/7/26 during an onsite visit she found the pacemaker defibrillator monitor to be missing from the nurse's station. OMB stated the Director of Nursing (DON) could not find the pacemaker defibrillator monitor and believed it had gone missing the night before OMB's visit but DON was unsure. OMB stated after twenty minutes of searching the skilled nursing unit the pacemaker defibrillator monitor was found in a supply closet near the nurse's station, not plugged in or in nurse's view for monitoring. During a concurrent observation and interview on 6/2/26, at 3:26 p.m., with the DON, the DON stated Resident 1's pacemaker defibrillator monitor was at the nurses' station within the nurse's view for monitoring. DON stated Resident 1 checked nurses' station daily to ensure device was in place and functioning properly, indicating a green light. DON stated Resident 1's pacemaker defibrillator monitor was found in the supply room near the nurses' station unplugged and out of nurses' view after the nurses' station was cleaned. DON stated they were unsure how long the device was in the supply closet, but likely it was moved from the nurses' station the day before it went missing when night shift was cleaning. DON stated it was important the pacemaker defibrillator monitor was visible at the nurses' station to ensure staff were monitoring the device appropriately and were able to intervene when necessary. During an interview on 6/3/26, at 11:00 a.m., with Director of Staff Development (DSD), DSD stated they were in the facility when OMB visited and found Resident 1's pacemaker defibrillator monitor was missing from the nurses' station and later found by a staff member in the supply closet near the nurses' station. DSD stated they were unsure of how the pacemaker defibrillator monitor ended up in the supply closet but it could have been due to a nursing student cleaning the nurses' station as the monitor looked like a router. DSD stated it was important that nurses monitor Resident 1's pacemaker defibrillator monitor as the monitor would alert staff of a cardiac emergency. During record review of Resident 1's Cardiac Device Interrogation Report Progress Note, dated 4/21/26, the Cardiac Device Interrogation Report progress note indicated Resident 1 had a Cardiac Resynchronization Therapy Defibrillator (CRT-D; an implantable device that combines a pacemaker and a defibrillator. It is primarily used for heart failure patients whose lower heart chambers pump out of sync, and who are also at high risk for sudden cardiac arrest) that was last checked on 12/9/24 and programmed to normal function on the service date. During record review of Resident 1's Order Audit Report, order date 6/2/26, the order audit report indicated, monitor pacemaker status and report abnormalities or signs of malfunction to [the medical doctor] MD, every shift for pacemaker use.During a review of the facility's undated policy and procedure (P&P) titled, Neglect, the P&P indicated, Neglect occurs when the facility is aware of, or should have been aware of, goods or services that a resident requires but the facility fails to provide them and this has resulted in (or may result in) physical harm, pain mental anguish or emotional distress .Goods and services that the resident needs are identified and addressed though the following: The facility assessment to determine what resources are necessary to care for residents competently; The provision of sufficient numbers of qualified, trained staff based upon the facility assessment and as needed to meet resident needs; An effective orientation, training, and evaluation program; Oversight and monitoring of staff performance; Oversight and monitoring of contracted services or services provided under arrangement; The provision and implementation of a resident-specific care plan including the ongoing evaluation and revision of the care plan as necessary; and Ongoing monitoring and supervision of staff to assure the implementation of the care plan as written.Examples of failures to provide care and services to the resident that result in neglect include: Failure to provide sufficient, qualified, competent staff, to meet resident's needs; Failure to provide orientation and/or training to staff; Failure to provide training on new equipment or new procedures or medications required for the care of a specified resident or required due to changes in acceptable standards of practice.

Based on observation, interview and record review, the facility failed to ensure that it was free of medication error rate of five percent (5%) or greater, as evidenced by the identification of five medication errors out of 27 opportunities, to yield a facility error rate of 18.5 % as evidenced by:1.For Resident 1, Registered Nurse (RN) 1 crushed four different medications, mixed them together in one cup, and administered them in a single administration via resident's gastrostomy tube (also called G-tube, is a tube surgically inserted through the abdomen into the stomach to administer nutrition and medications).2.RN 2 did not administer Cholecalciferol (Cholecalciferol is Vitamin D3, a supplement essential for bone health) as ordered by the physician, to Resident 8.These failures had the potential to compromise the residents' medical health.Findings:Review of Resident 1's physician order dated April 2026 indicated the following medication orders to be given via G-tube:Apixaban oral tablet 5 milligrams, give one tablet two times a day (apixaban is a medication that thins the blood and prevents stroke; milligrams or mg. is a form of measurement).Ascorbic acid liquid 500 mg. per 5 ml., give 5 ml. one time a day (ascorbic acid is vitamin C, a supplement; milliliters or ml. is a form of measurement).Atorvastatin calcium oral tablet 40 mg. give one tablet one time a day (atorvastatin is a medication that lowers cholesterol).Spironolactone oral tablet 25 mg., give one tablet one time a day (spironolactone is a medication that lowers blood pressure and decreases body swelling).During a medication pass observation on 4/21/26 at 8:43 a.m., RN 1 placed Apixaban 5 mg one tablet, Ascorbic acid 500 mg one tablet, Atorvastatin calcium 40 mg one tablet and Spironolactone 25 mg one tablet in an individual plastic pouch and crushed each medication into powder and mixed all four medications in one small medication cup. At Resident 1's bedside, RN 1 added a small amount of water about 10 ml. to the medication cup and dissolved the four medications. RN 1 attached a syringe to Resident 1's G-tube and flushed it with about 30 ml. of water. RN 1 then poured the contents of the medication cup to the G-Tube. After administering the medications, RN 1 flushed the Resident 1's G tube with 30 ml. water.During a review of Resident 1's physician's order printed on 4/22/26, the record indicated an order with a start date of 3/26/26 of .Prior to medication administration, flush tubing with 15-30 ml of water. Before medication administration, flush tube with 5-10 ml between each medication. Flush with 15-30 ml of water after medication administration.During an interview on 4/21/2026 at 3:35 p.m., with Director of Staff Development (DSD), DSD stated that medications should have been given separately administered to Resident 1's G-tube and not mixed together in one medication cup, to prevent the G tube from clogging and to avoid drug interactions.During a concurrent interview and record review on 4/22/2026 10:55 a.m., with RN 1, Resident 1's physician order was reviewed, RN 1 stated she should have followed the physician's order of giving liquid Vitamin C instead of giving the tablet form via Resident 1's G tube.During a review of the facility's policy and procedure (P&P) titled, General Guidelines for Administering Medication via Enteral Tube, dated May 2022, the P&P indicated, .Procedures.D. Enteral tubes are flushed with at least 15-30 ml. ( or prescribed amount) of room temperature or warm tap water before administering medications, and 10-15 ml. ( or prescribed amount) between each medication .(an enteral tube or feeding tube is a soft, flexible plastic tube used to deliver liquid nutrition, fluids and medications directly into the stomach or small intestine. G-tube is considered an enteral tube).2. Review of Resident 8's Facesheet (information containing contact details, brief medical history at a glance) indicated, Resident 8 was admitted to the facility on [DATE], with diagnoses that included right shoulder osteoarthritis (a common wear and tear disease where the cushion at the ends of bones gradually breaks down, leading to joint pain, stiffness, and reduced movement).Review of Resident 8's physician order, indicated an order of Cholecalciferol tablet, give 1000 units one time a day.During a medication pass observation on 4/21/26 at 9:39 a.m., RN 2 was observed giving Vitamin D 400 IU one tablet orally to Resident 8 (IU means international units or units). During a concurrent interview and record review on 4/22/2026 at 10:52 a.m., Resident 8's physician orders were reviewed. RN 2 acknowledged that he gave the wrong form and dosing to Resident 8. RN 2 stated he should have followed the physician's cholecalciferol's order for the resident. RN 2 further stated that the risk of not giving the correct form and dosage of cholecalciferol was for the resident not receiving the proper amount of nutrients.During an interview on 4/22/2026, at11:08 a.m., with the Director of Nursing (DON), DON stated the nurse should have followed the physician's order for cholecalciferol or vitamin D3. DON stated the risk of not giving the correct form and dose was for the resident to be underdosed. During an interview on 4/23/26, at 10:15 a.m., with Pharmacist Consultant (PC), stated not giving the correct dosage of cholecalciferol was a medication error because the resident was underdosed and was given less cholecalciferol to the resident's bones.During a review of the facility's P&P titled, Administering medications, dated 2001, the P&P indicated, .Medications are administered in a safe and timely manner, and as prescribed. Medications are administered in accordance with prescriber orders.10. The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication.

Based on observation, interview and record review, the facility failed to ensure:1.Expired medications for one of 14 sampled residents (Resident 6) were properly disposed.2. An opened, full box of expired one ml. needles (ml. or milliliters is a form of measurement) was not stored in the facility medication storage room.3. An opened, multidose PPD vial (PPD is purified protein derivative. PPD vial is used for PPD test, a skin test used to check if you have been infected with the bacteria that causes tuberculosis- an infectious lung disease; multidose vial is a small bottle of medicine designed to be punctured multiple times, allowing healthcare professionals to draw out several doses over a period of time) in the medication storage room refrigerator, had no date opened label. These failures had the potential of exposing residents to drugs and biologicals with questionable potency and efficacy.Findings:1.A review of Resident 6's admission Record (AR), dated 4/22/26, indicated Resident 6 was admitted on [DATE] with diagnoses that included dementia (dementia is a decline in mental ability severe enough to interfere in daily life, such as memory loss, confusion, and personality changes) mood disturbance and anxiety. A review of Resident 6's Minimum Data Set, (MDS, a standardized resident assessment and care screening tool) dated 1/23/26, indicated the resident had severe cognitive impairment.During a concurrent observation and interview on 4/20/2026 at 2:33 p.m., with the Director of Staff Development (DSD), during an inspection of the south medication cart, expired medications for Resident 6 were found. The following expired medications were: One bottle that contained 12 Haldol 1 mg. tablets, expired on 4/4/26.One bottle that contained 14 Olanzapine 2.5 mg. tablets, expired on 4/4/26.One bottle that contained 14 Amlodipine 5 mg. tablets, expired on 4/4/26.One bottle that contained six Hyoscyamine 0.125 mg. tablets- expired on 4/3/26One bottle that contained six Ondansetron 4 mg. tablets- expired on 4/3/26.The DSD stated that Resident 6's expired medications should have been disposed to eliminate the risk of administering less effective medication. (Haldol and Olanzapine are strong medications used to treat serious mental health conditions, Amlodipine is a medication for high blood pressure, Hyoscyamine is a medication that calms stomach muscles and Ondansetron is a medication to prevent nausea and vomiting; mg. or milligrams is a form of measurement). 2. During an observation and interview on 4/20/2026 at 11:28 a.m., with the Director of Nursing (DON), in the medication storage room, a full box of opened 1 ml syringes were found with an expiry date of 3/3/26. The DON stated that the box of expired syringes should have been disposed and should not be in the medication storage room.3. During an observation and interview on 4/20/2026 at 11:35 a.m., an opened PPD vial was found stored in the medication storage room refrigerator with no open date label. The DON stated the PPD vial should have been labeled with the open date label to know when the expiry date was.During an interview on 4/23/26, at 10:15 a.m., with the Pharmacist Consultant (PC), PC stated the PPD vial should have been labeled with the open date when first opened and used the first time and the vial was only good for 30 days from the date it was opened.A review of facility's policy and procedure (P&P), titled Medication Labeling and Storage, dated 2001, the P&P indicated, . 3. If the facility has discontinued, outdated or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items. 5.Multi dose vials that have been opened or accessed (e.g. needle punctured) are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial. (e.g. is an abbreviation for the Latin phrase exempli gratia, which translates to for example).

Based on observation, interview, and record review, the facility failed to ensure safe food handling and storage practices when three bottles of [NAME] Designer Dessert Sauce were found past their use-by dates at the dry food storage area. This failure had the potential to cause foodborne illnesses when consumed by residents.Findings:During the initial tour of the kitchen on 4/20/26 at 9:13 a.m., one opened bottle of [NAME] Designer Dessert Sauce, Kiwi Lime flavor, with a use-by date of 4/4/26, was observed in the dry food storage area. Additionally, one unopened bottle of [NAME] Designer Dessert Sauce, Mango flavor, with a use-by date of 3/14/26, and one unopened bottle of [NAME] Designer Dessert Sauce, [NAME] Chocolate flavor, with a use-by date of 4/2/26 were observed.During a follow-up tour of the kitchen on 4/21/26 at 9:26 a.m., the Dietary Manager (DM) stated they check the dry food shelves every day to ensure expired and past use-by date food items are removed; however, staff missed checking the three past use-by date dessert sauces. The DM was unable to provide evidence or logs demonstrating that daily checks in the dry food shelves were performed.During a concurrent interview and record review on 4/22/26 at 9:39 a.m., the Registered Dietitian (RD) stated that they inspect the kitchen monthly and submit Nutrition Therapy Essentials (inspection report) to the Administrator (ADM), Director of Nursing (DON), and DM. The March 2026 inspection report indicated there were Multiple foods passed use by date.During an interview on 4/22/26 at 1:50 p.m., the DM stated that dessert sauces past their use-by dates should not be kept in the storage area because they could be mistakenly consumed by residents and potentially cause foodborne illnesses.During an interview on 4/23/26 at 8:09 a.m., the ADM stated that it is the DM's responsibility to ensure that there are no expired or past use-by date food items in the kitchen.During a review of facility's Policy and Procedure (P&P), titled, Food Receiving and Storage, revised [DATE], the P&P indicated, Foods shall be received and stored in a manner that complies with safe food handling practices.During an interview on 4/23/26 at 10:30 a.m., the ADM stated that the facility did not have a P&P for specifically addressing monitoring of food expiration dates.

Based on observation, interview, and record review, the facility failed to ensure a safe and sanitary method for storing residents' food brought from outside for one of six sampled residents (Resident 42) when a jar of jam and fruit preserve and fruit cups were stored in a rectangular plastic container with ice and ice water.This failure has the potential to place the resident at risk for foodborne illnesses.Findings:During a review of Resident 42's admission Record (AR) printed on 4/22/26, the AR indicated, Resident 42 was admitted to the facility in March 2026.During an observation on 4/20/26 at 10:55 a.m., in Resident 42's room, one unopened jar of Smucker's Blueberry Preserves, one opened jar of Sunny Select Grape Jam, and two sealed fruit cups were observed stored in a rectangular plastic container filled with ice chips.During an interview on 4/20/26 at 11:00 a.m., Resident 42 stated that she uses the jams for her peanut butter crackers and had requested that the jam be placed in a refrigerator. Resident 42 stated she was informed that there was no refrigerator for residents to store their food.During an interview on 4/21/26 at 1:50 p.m., with the Director of Staff Development (DSD), DSD stated that due to space limitations, the facility does not provide a refrigerator for residents to store their food including leftovers or food brought from outside. DSD stated the facility educates residents to either consume food brought from outside within two hours or throw it away after two hours.During a concurrent observation and interview on 4/22/26 at 10:06 a.m., with the Director of Nursing (DON), in Resident 42's room, two jars of jam were observed stored in a plastic rectangular container containing melted ice water, and one fruit cup was observed submerged under the water. DON asked staff to move the container away.During an interview on 04/22/2026 at 10:08 a.m., with Certified Nursing Assistant (CNA) 1, CNA 1 stated that Resident 42 always asks for ice to keep the jam cold. CNA 1 further stated that they did not pay attention to or notice when the ice had melted into water.During an interview on 04/22/26 at 1:07 p.m., Resident 42 stated that she was upset that the facility did not provide a refrigerator for residents to keep their food and that staff had removed her ice container, leaving her unsure of what to do.During an interview on 04/23/26 at 9:37 a.m., with Registered Nurse (RN) 2, RN 2 stated that there was no system or log in place to monitor the temperature or ensure that ice is consistently maintained in the container. RN 2 further stated that, in practice, they check to ensure there is still ice in the container whenever they enter the resident's room. A review of facility's policy and procedure (P&P) titled, Food Brought by Family/Visitors, revised in March 2022, the P&P indicated, food brought to the facility by visitors and family is permitted. 5. Food brought by family/visitors that is left with the resident to consume later is labeled and stored in a manner that it is clearly distinguishable from facility-prepared food. a. Non-perishable foods are stored in re-sealable containers with tight-fitting lids. Intact fresh fruit may be stored without a lid. b. Perishable foods are stored in re-sealable containers with tightly fitting lids in a refrigerator.

Based on observation, interview, and record review, the facility failed to ensure one of 14 sampled residents (Resident 51) dignity was maintained when staff referred to the resident as a feeder in the lunchroom. This failure had the potential to result in Resident 51 feeling disrespected, demeaned, embarrassed, or devalued, thereby negatively affecting the resident's sense of self worth and well being.Findings:During a record review of Resident 51's admission Record (AR) printed on 4/22/26, the AR indicated, Resident 51 was admitted to the facility on [DATE].During a record review of Resident 51's Brief Interview for Mental Status (BIMS, an assessment for mental status) assessment dated [DATE], Resident 51's BIMS score was nine (9) out of 15, indicating moderate impaired cognition (mental status).During a record review of Resident 51's Care Plan Report Special Instruction (CPRSI) dated 4/10/26, CPRSI indicated, Resident 51 required 1:1 feeding (requires one staff member to stay with resident the whole time they are eating and help them with every bite and sips) and Aspiration Precautions (steps staff take to help keep food or drinks from going into the resident's airway).During an observation on 4/20/26, at 12:38 p.m., in the lunchroom, Resident 51 was sitting at the dining table. Activity Coordinator (AC 1) was heard referring to Resident 51 as a feeder when describing the resident during the meal service.During an interview on 4/20/26 at 12:50p.m., AC 1 stated the wording came out wrong. AC 1 stated that the appropriate way to refer to the resident is simply to indicate whether the resident needed assistance with meals.During an interview on 4/20/26 at 1:15p.m., with the Director of Staff Development (DSD), DSD stated the term feeders should not be used when referring to residents. DSD stated that staff are expected to address individuals as residents, clients, or patients. DSD stated the term feeder was not an appropriate term, and using it would be insulting and demeaning for the residents.During a record review of the facility's policy and procedure (P&P), titled, Dignity, dated February 2021, the P&P indicated, Each resident shall be cared for in a manner that promotes and enhances his or her sense of well being, level of satisfaction with life, and feelings of self worth and self esteem. The P&P further indicated, that staff must speak respectfully to residents at all times, including addressing residents by their name of choice and not labeling them by referring to the resident by their room number, diagnosis, or care needs.

Based on observation, interview and record review, the facility failed to ensure that one of 14 sampled residents (Resident 6) had adequate indications for the use of Haloperidol (or Haldol, is a strong antipsychotic. An antipsychotic is a medication that is used for the mind to manage delusions, hallucinations, and disordered thoughts. Antipsychotic medications can cause severe side effects).This failure had the potential for increased risks associated with the use of psychotropic (psychotropic medications are prescription drugs that affect how the brain works, changing a person's mood thoughts, feelings or behavior. Antipsychotic medication like Haldol is a psychotropic medication) medications that could negatively affect the residents' physical, mental and psychosocial well-being.Findings:During a review of the facility's policy and procedure (P&P) titled, Antipsychotic Medication Use, dated 2001, the P&P indicated, Policy statement: Residents will not receive medications that are not clinically indicated to treat a specific condition.7. Antipsychotic medications should generally be used for the following conditions /diagnoses .: a. Schizophrenia .f. psychosis in the absence of dementia . 8. Diagnosis alone do not warrant the use of antipsychotic medication. In addition to the above criteria, anti-psychotic medications will generally only be considered if the following conditions are also met: a. The behavioral symptoms present a danger to the resident or others. (schizophrenia is a brain disorder that causes people to lose touch with reality; dementia is loss of memory, language, problem-solving and other thinking abilities).During an observation on 4/20/26, Resident 6 was awake, quiet, and lying in bed. During another observation, on 4/21/2026 at 10:00 a.m., Resident 6 was sleeping in her bed. A review of Resident 6's admission record indicated, the resident was admitted on [DATE], with diagnoses that included, dementia without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety (psychotic disturbance or psychosis means a person has temporarily lost touch with reality. It is a collection of symptoms where the brain has trouble distinguishing between what is real and what is not.) The resident's diagnosis indicated the resident had dementia without psychotic disturbance.A review of Resident 6's Minimum Data Set (MDS, a standardized resident assessment and care screening tool) dated 1/23/26, indicated, the resident had severe cognitive impairment.A review of Physician's orders dated 4/23/26, indicated, an order with a start date of 1/16/26 of Haloperidol 1 mg tablet by mouth every morning and at bedtime for agitation, and Haloperidol 1 mg tablet give 2 mg. by mouth in the afternoon for agitation before lunch.During an interview on 4/22/26 10:14 a.m., with Certified Nursing Assistant (CNA) 2, stated Resident 6 had no behavior of being a danger to herself or to others. CNA 2 stated that the resident's behavior was yelling at times but stated the resident would eventually calm down when the staff talked to her.A review of the Consultant Pharmacist's (CP) Medication Review Recommendation, for Haldol, dated 1/29/26, indicated the CP was asking the facility for an approved indication for the Haldol use for Resident 6.A review of another CP Medication Review Recommendation, for Haldol, dated 3/26/26, indicated the CP was asking the facility again for an approved indication for the Haldol use for Resident 6.During a concurrent interview and record review on 4/23/2026 at 9:20 a.m., with Director of Nursing (DON), Resident 6's Antipsychotic Medication care plan dated 4/22/26 was reviewed. The care plan indicated that the resident had a diagnosis of schizophrenia. DON stated that the resident did not have a diagnosis of schizophrenia and was just probably a mistake in documentation. DON further stated that agitation was not an appropriate indication for Haldol. DON also stated that Haldol should be given to the resident with the correct diagnosis and indication. Resident 6's Medication Administration Record (MAR) for April 2026 was also reviewed. On 4/1/26- 4/22/26, the MAR indicated a behavior monitoring of increased anxiety and paranoid behavior for the Haldol use. The MAR did not indicate that the behaviors were observed.During an interview on 4/23/2026 at 10:15 a.m., with the CP, CP stated that agitation was not an appropriate indication to give Haldol to Resident 6.

Based on interview and record review, for one of three sampled residents (Resident 36) the facility failed to ensure that an arbitration agreement (Arbitration is a method of settling disputes between individuals, the two parties choose some disinterested and qualified person or people-the arbitrator-to judge the matter) was explained to the resident or resident representative in a manner that they understood.This failure had the potential for Resident 36's rights to be compromised by preventing the resident and the resident's representative from making fully informed choices about matters affecting the resident's care and well being.Findings:During a record review of Resident 36's admission Record printed on 4/21/26, the record indicated Resident 36 was admitted to the facility on [DATE].During a record review of Resident 36's History and Physical, dated 3/24/26, the record indicated Resident 36's Durable Power of Attorney (DPOA, A legal document that gives one person the authority to make medical, legal, or financial decisions for another person.) was listed as Resident Representative (RR 1).During a record review of Resident 36's Minimum Data Sheet (MDS, a standardized assessment tool used to evaluate a resident's functional capabilities, health needs, and clinical status) dated 4/1/26, the MDS indicated a Brief Interview for Mental Status (BIMS, an assessment for mental status) score was seven (7) out of 15, indicating that Resident 36 had severe cognitive impairment.During an interview and record review on 4/22/26 at 10:06 a.m. with the Infection Preventionist (IP), Resident 36's physician order summary in electronic health record was reviewed. The physician order dated 3/28/26, indicated, that the IP documented a telephone order (obtained from the doctor via phone) that Resident 36 did have the capacity to sign documents. IP stated he had entered the order based on the nursing admission assessment dated 3/28/26, which indicated Resident 36 was alert and oriented to time, place and person. IP stated, however, the physician should be the one to determine a resident's capacity.During an interview on 4/21/26 at 8:50 a.m. Resident 36 was lying in bed in her room. Resident 36 stated Resident Representative (RR 1) signed all documents upon her admission to the facility.During a phone interview on 4/21/26 at 9:10 a.m., RR 1 stated she did not remember being explained the arbitration process and/or signing an arbitration agreement for Resident 36 upon her admission to the facility on 3/28/26.During an interview and record review on 4/21/26 at 10:20 a.m., with the Marketing Director 1 (MD 1), Resident 36's arbitration agreement dated 3/30/26 was reviewed. MD 1 stated he and facility's admission Director (AD 1) were responsible for explaining the arbitration process and getting the agreements signed from residents or their responsible representatives. MD 1 stated Resident 36's arbitration agreement indicated facility's AD 1 and Resident 36 signed the agreement on 3/30/26.AD 1 remained unavailable for an interview throughout the survey.During an interview and record review on 4/21/26 at 12:55 PM, with the Director of Nursing (DON), Resident 36's physician progress note dated 3/31/26 were reviewed. The notes indicated that Resident 36's doctor noted, patient does not have the capacity to make medical decisions. The DON stated based on doctor's note and Resident 36's impaired mental status, Resident 36 should not have signed her arbitration agreement. The DON stated residents could feel misled if they were signing something that they didn't understand.During a record review of the facility's policy and procedure (P&P) titled, Binding Arbitration Agreements, dated 2001, the P&P indicated, The terms and conditions of a binding arbitration agreement are explained to the resident (or representative) in a way that ensures his or her understanding of the agreement.The record also indicates, The terms and conditions of a binding arbitration agreement are explained to the resident (or representative) in a form and manner that he or she understands.

Based on observation and interview, the facility had sixteen resident rooms (Rooms 1, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 14, 15, 16, 17 and 18) with multiple beds that provided less than 80 square foot (sq. ft) per resident who occupied these rooms. This deficient practice had the potential to result in inadequate space for the delivery of care to each of the residents in each room or for storage of residents' belongings. Findings:During an observation on 4/22/26 at 1:31 p.m., the following rooms and corresponding sq. ft per bed were identified: room [ROOM NUMBER] was observed with three beds. The room measured a total of 200 square feet. This size only provided 66 square feet per resident space. room [ROOM NUMBER] was observed with three beds. The room measured a total of 200 square feet. This size only provided 66 square feet per resident space. room [ROOM NUMBER] was observed with two beds. The room measured a total of 140 square feet. This size only provided 70 square feet per resident space. room [ROOM NUMBER] was observed with three beds. The room measured a total of 200 square feet. This size only provided 66 square feet per resident space. room [ROOM NUMBER] was observed with two beds. The room measured a total of 140 square feet. This size only provided 70 square feet per resident space. room [ROOM NUMBER] was observed with three beds. The room measured a total of 200 square feet. This size only provided 66 square feet per resident space.room [ROOM NUMBER] was observed with two beds. The room measured a total of 140 square feet. This size only provided 70 square feet per resident space. room [ROOM NUMBER] was observed with two beds. The room measured a total of 140 square feet. This size only provided 70 square feet per resident space. room [ROOM NUMBER] was observed with three beds. The room measured a total of 200 square feet. This size only provided 66 square feet per resident space. room [ROOM NUMBER] was observed with two beds. The room measured a total of 140 square feet. This size only provided 70 square feet per resident space. room [ROOM NUMBER] was observed with three beds. The room measured a total of 200 square feet. This size only provided 66 square feet per resident space. room [ROOM NUMBER] was observed with three beds. The room measured a total of 200 square feet. This size only provided 66 square feet per resident space.room [ROOM NUMBER] was observed with two beds. The room measured a total of 140 square feet. This size only provided 70 square feet per resident space. room [ROOM NUMBER] was observed with three beds. The room measured a total of 200 square feet. This size only provided 66 square feet per resident space. room [ROOM NUMBER] was observed with two beds. The room measured a total of 140 square feet. This size only provided 70 square feet per resident space.room [ROOM NUMBER] was observed with three beds. The room measured a total of 200 square feet. This size only provided 66 square feet per resident space. During random observations of care and services from 04/20/26 to 04/23/26, there were sufficient space for the provision of care for the residents in the rooms. There was no heavy equipment in the room that might interfere with residents' care and each resident had adequate personal space and privacy. There were no complaints from the residents regarding insufficient space for their belongings. There were no negative consequences attributed to the decreased space and/or safety concerns in the 16 rooms. Granting of room size waiver recommended.

Based on observation, interview, and record review, the facility failed to provide timely treatment to one of five sampled residents (Resident 1) when Resident 1 had asked for psychological therapy on 1/14/26. The facility did not start the referral for treatment for Resident 1 until 2/25/26. Resident 1 was not seen by a psychiatrist or psychologist until 3/2/26. Resident 1 waited 45 days before receiving mental health services. This failure placed Resident 1 at risk for worsening depressive symptoms and decline in overall well-being while awaiting mental health services.A review of Resident 1 's admission Record (AR) printed on 3/5/26, the AR indicated Resident 1 was admitted to the facility on [DATE], with diagnosis that included muscular dystrophy (a group of diseases that cause muscle to become weaker and lose mass over time, ultimately leading to loss of function).A review of Resident 1's Minimum Data Set (MDS, resident assessment tool to evaluate each resident's physical, mental, and functional status) dated 2/2/26, indicated Resident 1's Brief Interview for Mental Status (BIMS, a scoring system used to determine the resident's cognitive status regarding attention, orientation, and ability to register and recall information) score was 15. A BIMS score of 13 to 15 indicates that residents are cognitively intact.A review of Resident 1's MDS comprehensive assessment dated [DATE], indicated that Resident 1's Patient Health Questionnaire-9 (PHQ-9) score was 17. A PHQ-9 score of 17, indicates moderately severe depression.During an observation on 3/5/26 at 1:47 p.m., Resident 1 was observed sitting by a table in the activity room and staring at a book.During an interview on 3/5/26 at 2:07 p.m., Resident 1 stated he felt like he was going crazy, hearing things very loudly and being unsure whether the voices were real. Resident 1 stated he was unable to sleep at night and had no energy during the day. Resident 1 stated that in mid-January 2026, he told the Ombudsman that he wanted to receive talk therapy.During an interview on 3/5/26 at 2:30 p.m., the Activity Director (AD) stated that Resident 1 usually attends activities but most of the time, Resident 1 sits quietly and does not interact with other residents.During an interview on 3/5/26 3:07 pm, the Social Services Director (SSD) stated the Ombudsman told her that Resident 1 wanted talk therapy during a visit to the facility in January 2026. SSD stated she informed the Director of Nursing (DON) verbally on the same day, that Resident 1 was asking for psychological therapy.During an interview on 3/9/26 at 10:43 a.m., the Director of Nursing (DON) stated she was not aware that Resident 1 had asked to see a psychologist or psychiatrist on 1/14/26. DON stated she became aware of Resident 1's request on 2/19/26. DON stated she learned of Resident 1's request after receiving an email from the Ombudsman to the SSD stating that Resident 1 wanted psychological treatment. DON stated that without timely intervention, Resident 1 could escalate to severe depression, which could lead to loss of motivation, extreme hopelessness, and a decline in activities of daily living (ADL) function.During a concurrent record review of Resident 1's medical records and interview on 3/9/26 at 10:45 a.m. with DON, DON stated that Resident 1 had been seen by a psychologist from March through August 2025 for adjustment disorder with mixed anxiety and depressed mood. DON could not provide a reason why the psychological therapy was discontinued after August 2025.A review of the facility's Policy and Procedures (P&P), titled, Behavioral Health Services, revision dated 2/2019, indicated, the facility will provide and residents will receive behavioral health services as needed to attain or maintain the highest practicable physical, mental and psychosocial well-being in accordance with the comprehensive assessment and plan of care.

Based on interview and record review, the facility failed to promote and support the resident's choice when Resident 1 asked for assistance with transferring to another skilled nursing facility on 1/15/26, but the facility did not provide evidence that it actively helped the Resident 1 to locate an alternative placement.This failure placed Resident 1 at risk for emotional distress, reduced control over decisions about their living arrangement, and delays in accessing a facility that could better meet the resident's preferences and needs. A record review of Resident 1 's admission Record (AR) printed on 3/5/26, indicated, Resident 1 was admitted to the facility on [DATE].A review of Resident 1's Minimum Data Set (MDS, resident assessment tool to evaluate each resident's physical, mental, and functional status) dated 2/2/26, indicated Resident 1's Brief Interview for Mental Status (BIMS, a scoring system used to determine the resident's cognitive status regarding attention, orientation, and ability to register and recall information) score was 15. A score of 13 to 15 indicates that residents are cognitively intact.During an interview on 3/5/26 at 2:10 p.m., Resident 1 stated that he had informed the Administrator (ADM) and the Interdisciplinary Team (IDT, a team of staff members from different departments who collaborate with the resident to assess needs, plan care, and make decisions that support the resident's well-being and preferences), approximately two months earlier, of his desire to transfer to a skilled nursing facility in Solano County, to be closer to his son and sister. However, Resident 1 stated that he had not received any updates regarding efforts to locate another placement. Resident 1 stated that he did not like residing in the current facility and reported feeling sad and stuck there.A record review of IDT conference note, dated 1/15/26 indicated, that Resident 1 expressed dissatisfaction with remaining at the facility and preferred to reside in a skilled nursing facility located in Solano County. During a concurrent record review of Resident 1's chart, and interview on 3/5/26 at 3:03 p.m., with the Social Services Director (SSD), SSD stated that she was aware that Resident 1 had requested a transfer to another nursing facility. The SSD stated that she had contacted two skilled nursing facilities regarding possible placement for Resident 1. However, when asked to provide documentation to support these efforts, the SSD was unable to provide or show any records, notes, referral forms, emails, or other documentation demonstrating that outreach had been made.A review of the facility's Policy and Procedures (P&P), titled Resident Rights, undated, indicated, Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to .Be informed about rights and responsibilities he or her has. Residents are entitled to exercise their rights and privileges to fullest extent possible.

Based on observation, interview and record review, the facility failed to ensure garbage and refuse storage area was maintained in a sanitary condition when the dumpster was overflowed with bags of trash and not properly contained with lid. This failure had the potential of harborage and feeding of pest. Findings: During an observation on 11/19/24 at 7:12 a.m., with Dietary Services Manager (DSM) one dumpster located by the side of the facility overflowed with trash bags was not contained with lid. During an interview on 11/19/24 at 7:18 a.m. with Administrator (Admin) stated contracted company staff came and left without empty the dumpster. Admin stated house keeping staff assist with making sure dumpster was emptied. During an interview on 11/19/24 at 7:23 a.m. with Housekeeping Supervisor (HKS), HKS stated someone blocked the path to the dumpster and the dumpster was not emptied. During a review of the facility's policy and procedure (P&P) titled, Waste Disposal, revised January 2022, the P&P indicated, All infectious and regulated waste shall be handled and disposed of in a safe and appropriate manner.

Based on observation, interview and record review, the facility failed to ensure three (Resident 27, 31 and 145) of five sampled residents were free from unnecessary drugs when; 1. Resident 27 was administered Seroquel (an antipsychotic - drugs used to treat schizophrenia and bipolar serious mental health conditions and not approved for use in psychotic conditions related to dementia.) medication for wandering; 2. Resident 31 had a new diagnosis of schizophrenia (a serious mental health conditions capable of affecting the mind, emotions, and behavior); 3. Resident 31 with diagnosis of dementia was administered Zyprexa (an antipsychotic) medication for yelling and screaming; 4. Resident 145 was administered antipsychotic medication without adequate indication for use. These failures had the potential for residents to receive unnecessary medications and had the potential for the residents to suffer adverse medication side effects. Findings: 1. During a review of Resident 27's Annual Minimum Data Set (MDS), Resident Assessment and care guide tool, dated 3/8/24, indicated Resident 27's Basic Interview of Mental status (BIMS, a scoring system used to determine the resident's cognitive status regarding attention, orientation, and ability to register and recall information. A BIMS score of thirteen to fifteen is an indication of intact cognitive status.). Resident 27's score was 01 meaning poor cognition. Resident 27 had no behavior of wandering. Resident 27 had no physical or verbal behavioral symptoms directed towards others e.g., hitting, kicking, pushing, scratching, grabbing or screaming at others, verbal/vocal symptoms like screaming or disruptive sounds. Resident 27 had no potential indicators of psychosis. Resident 27's diagnoses included Non-Alzheimer's Disease (a group of diseases characterized by progressive deficits in behavior, executive function or language). During a review of Resident 27's Order Summary Report dated 11/12/24, indicated the physician prescribed Resident 27, Seroquel oral tablet 25 mg give 0.5 tablet by mouth in the afternoon for wandering and behavioral disturbances. During a review of Resident 27's Medication Administration Record (MAR), dated 11/12/24 to 11/18/24 indicated Resident 27 was administered seroquel 25 mg give 0.5 tablet by mouth in the afternoon for wandering and behavioral disturbances. Further review of Resident 27's MAR dated 10/1/24 to 10/31/24 indicated Resident 27 was administered seroquel 25 mg give 0.5 tablet by mouth in the afternoon for agitation and tearfulness. During a review of Resident 27's Pre-Admission Screening Resident Review (PASRR) evaluation, dated 4/15/22, the PASRR indicated Resident 27 has no serious mental illness. During an observation on 11/18/24 at 10:48 a.m. in the hallway south station Resident 27 appeared well groomed wanders up and down the hallway and was redirected by staff to her bed. During an interview on 11/19/24 at 9:08 a.m. with Certified Nursing Assistant (CNA) 1, CNA1 stated Resident 27 was redirectable and nice. CNA 1 said Resident 27 liked to sit outside her room. During a review of Resident 27's Consultant Pharmacist's Medication Regimen Review (MRR), dated 8/13/24, the MRR indicated to please review indication for seroquel use. MRR indicated Resident 27 has a diagnosis of dementia . 2. During a review of Resident 31's Discharge Summary (D/S), dated 7/11/23, the D/S indicated, Resident 31's principal diagnoses was dementia and secondary diagnoses included dementia, severe protein-calorie malnutrition, ground level fall, subdural hematoma, subarachnoid hemorrhage. During a review of Resident 31's Admission Record (AR), the AR indicated, Resident 31's was an [AGE] year old female admitted to the facility on [DATE]. Resident 31's primary diagnoses included non traumatic subdural hemorrhage and Dementia without behavioral disturbance. The AR did not show that Resident 31 had a diagnosis of schizophrenia upon admission to the facility. During a review of Resident 31's Admission Minimum Data Set (MDS), Resident Assessment and care guide tool, dated 7/18/23, indicated Resident 31's active diagnoses did not include diagnosis of schizophrenia. During a concurrent interview and record review on 11/20/24 at 9:01 a.m. with the Director of Nursing (DON), Resident 31's D/S, AR and order summary report were review. The physician order indicated Resident 31 was prescribed Zyprexa oral tablet 2.5 mg by mouth at bed time for schizophrenia manifested by disorganized thought process. DON stated Resident 31 had dementia. DON said Resident 31 was not admitted with schizophrenia diagnosis. DON stated the psychiatry added the schizophrenia diagnosis with consultation. DON stated Resident 31 wanders around the facility. DON said somehow along the way Resident 31 was diagnosed with schizophrenia. DON said she did not know why Resident 31 was diagnosed with schizophrenia. During a review of Resident 31's Psychiatric Progress Report, dated 2/9/23, the Nurse Practitioner notes indicated Resident 1 had unclear confusion vs possible psychotic and disorganized thinking. Resident 31 diagnostic impression included other specified schizophrenia spectrum and dementia without behavior. During an interview on 11/21/24 at 10:44 a.m. with Resident 31's Medical Doctor (MD) 1, MD 1 stated Resident 31 had profound dementia and subdural hematoma. MD 1 stated he did not diagnosed Resident 31 with schizophrenia. MD 1 stated Resident 31 was on Zyprexa for agitation. MD 1 stated Resident 31's dementia was so severe that he was not capable of diagnosing Resident 31 with schizophrenia. MD 1 stated Resident 31 was seen by psychiatry. MD 1 stated Resident 31 will benefit from a dementia unit. 3. During a review of Resident 31's Annual Minimum Data Set (MDS), Resident Assessment and care guide tool, dated 7/17/24, indicated Resident 31's Basic Interview of Mental status (BIMS, a scoring system used to determine the resident's cognitive status regarding attention, orientation, and ability to register and recall information. A BIMS score of thirteen to fifteen is an indication of intact cognitive status.). Resident 31's score was 03 meaning poor cognition. Resident 31 had no potential indicators of psychosis, no hallucination, no delusions. Resident 31 exhibited wandering and rejection of care behavior. Resident 31's diagnoses included Non-Alzheimer's Disease (a group of diseases characterized by progressive deficits in behavior, executive function or language). During a review of Resident 31's Order Summary Report dated 2/14/24, indicated the physician prescribed Resident 31 zyprexa oral tablet 2.5 mg give 2.5 mg by mouth at bedtime for schizophrenia manifested by disorganized thought process. Further review of Resident 31's physician order dated 7/4/24 indicated behavior monitoring for antipsychotic seroquel and zyprexa medication, document number of episodes per shift of target behavior; screaming, yelling, pacing, refusing care every shift for behavior monitoring for zyprexa. During a review of Resident 31's Medication Administration Record (MAR), dated 11/1/24 to 11/18/24 indicated Resident 31 was administered zyprexa 2.5 mg give 2.5 mg tablet by mouth at bedtime. During a review of Resident 31's Behavior Management care plan initiated 11/28/23, indicated use of psychotropic medication related to episodes of yelling out, refusal of care, pacing, unable to redirect, interventions included monitor/record occurrence of target behavior symptoms i.e. pacing, wandering, disrobing, inappropriate response to verbal communication. During an observation on 11/19/24 at 11:09 a.m. Resident 31 wandered up and down the hallways alert with incomprehensible conversation. During an interview on 11/20/24 at 1:14 p.m. Certified Nursing Assistant (CNA2), CNA2 stated Resident 31 wanders around goes to other residents' rooms and closet. CNA2 stated Resident 31 was very confused and difficult to redirect. During an interview on 11/20/24 at 2:39 p.m. DON stated despite interventions Resident 31 continued to wanders into other residents rooms. During a review of the facility's policy and procedure (P&P) titled, Antipsychotic Medication Use, revised 2022, the P&P indicated, Antipsychotic medications will not be used if the only symptoms are one or more of the following: a. Wandering; b. Poor self care; c. Restlessness; d. impaired memory; e. Mild anxiety; f. Insomnia; g. Inattention or indifference to surroundings; i. Fidgeting; j. Nervousness; or k. Uncooperativeness. 46487 Findings: 4. During a review of Resident 145's admission record, the admission record indicated the resident was admitted on [DATE] with diagnoses that included Alzheimer's Disease (a brain disorder that gradually destroys memory and thinking skills) and Dementia (loss of memory, language, problem-solving and other thinking abilities). During a review of Resident 145's Minimum Data Set (MDS, a standardized resident assessment and care screening tool), dated 11/11/24, indicated the resident had severe cognitive impairment. During a review of Physician's orders dated 11/9/24, indicated, an order of Seroquel oral tablet 25 milligrams (mg., a form of measurement), give 0.5 tablet by mouth every 12 hours as needed for Alzheimer's Dementia manifested by depression and anxiety for 14 days (Seroquel is an antipsychotic medication; an antipsychotic is a medication that is used for the mind to manage delusions, hallucinations, disordered thought. Antipsychotic medications can cause severe side effects; depression is a mood disorder that causes persistent feelings of sadness). A review of Physician's orders dated 11/9/24, indicated, no target behaviors were specified to be monitored for the use of the antipsychotic drug Seroquel (target behaviors for antipsychotics refer to the specific, undesirable behaviors that a patient is exhibiting which a doctor aims to reduce or manage with the use of antipsychotic medication, such as aggression, agitation, hallucinations, delusions, or other disruptive behaviors). During an interview on 11/21/24, at 10:00 a.m., with the Director of Nursing (DON), DON stated that there should be target behaviors to be monitored for the use of Seroquel. Also stated this would help in surveilling the medication's effectiveness in controlling the undesirable behaviors. During a telephone interview on 11/21/24 11:24 a.m., with the Consultant Pharmacist (CP), CP stated that there should be target behaviors to be observed for the use of Seroquel. Further stated the behavior monitoring would have helped to determine if Seroquel was effective and if the resident still needed this medication. During a telephone interview on 11/21/24, at 10:36 a.m., with the Medical Doctor (MD) 1, MD 1 stated there should be target behaviors specified to be monitored for the use of Seroquel. During a review of the resident's Pre-Admission Screening Resident Review (PASRR) for serious mental illness screening dated 11/9/24 indicated, Resident 145 did not have a serious mental illness. During a review of the facility's policy and procedure (P&P) titled, Antipsychotic Medication Use, dated 2001, the P&P indicated, . The attending physician will identify, evaluate, and document, with input from other disciplines and consultants as needed, symptoms that may warrant the use of antipsychotic medications . The staff will observe, document, and report to the attending physician information regarding the effectiveness of any interventions, including antipsychotic medications .

Based on interview and record review, the facility failed to act promptly upon the grievances and recommendations from the residents' group meetings concerning residents care and life in the facility. This failure had the potential to cause residents' emotional distress. Findings: During a review of the facility's residents group meeting, titled, Resident Council Minutes/Resident Council Resolution Form, dated 8/5/24, indicated residents reported concerns included: Certified Nursing Assistants (CNAs) making too much noise at night whereby residents can't sleep, rooms too hot, cold food and food doesn't look good, request bigger room for activities. Further review of the residents' council minutes dated 9/26/24 indicated residents reported delays in receiving assistance, CNAs lack of courtesy and professionalism, feeling of neglect and no dignity or respect, not feeling safe because other resident going into their rooms, cold food. During a concurrent interview and record review on 11/19/24 at 9:41 a.m. with the Activities Director (AD), the facility's residents council minutes notes dated 8/5/24 and 9/26/24 were reviewed. AD stated she did not communicate residents concerns reported during August and September 2024 residents group meeting to the appropriate department for follow up. During a concurrent interview and record review on 11/20/24 at 12:28 p.m. with Administrator (Admin), the facility's residents council minutes notes dated 8/5/24 and 9/26/24 were reviewed. Admin stated he cannot say for certain if he addressed grievances from the resident group meetings. Admin stated he did not have a good paper trail for residents' grievances follow up. Admin said facility has a plan to follow up with reported grievances from resident group meetings. During a review of the facility's policy and procedure (P&P) titled, Resident Council, revised February 2021, the P&P indicated,The purpose of the resident council is to provide a forum for residents, families and resident representatives to have input in the operation of the facility and discussion of concerns and suggestions for improvement, a resident council response form will be utilized to track issues and their resolution. During a review of the facility's policy and procedure (P&P) titled, Grievances/Complaints, Filing revised 2024, the P&P indicated Residents and their representatives have the right to file grievances, either orally or in writing, to the facility staff or to the agency designated to hear grievances. The administrator and staff will make prompt efforts to resolve grievances to the satisfaction of the resident and/or representative.

Based on observation, interviews and record review, the facility failed to ensure storage of food under sanitary conditions when the following food items in the refrigerator were not dated and labeled with received, open and use-by dates : - One bag of cauliflower with brownish black discoloration - One bag of parsley moist and withered - Three cut up watermelon not labeled with date - One chest freezer had no temperature log. - Refrigerator temperature log missing entries - Trash can lid with brownish discoloration - Kitchen floor tiles with brownish stain and discoloration These failures had the potential to result in food borne illnesses. Findings: During the initial tour of the kitchen on 11/18/24 at 8:20 a.m. with Dietary Aide (DA)1, the following were observed in the refrigerator; one bag of cauliflower with brownish black discoloration, one bag of parsley moist and withered, three cuts up watermelon not labeled with use by date. DA 1 stated food items in refrigerator are labeled with use-by-date. DA 1 stated the bag of cauliflower and parsley were no longer good for use . DA 1 said she will disposed these food items. Further tour with DA 1 indicated refrigerator/freezer temperature log was missing entries from 11/13/24 to 11/17/24. Trash can located under hand washing sink lid had brownish discoloration. Kitchen floor tiles with brownish stain discoloration. During a follow up tour of kitchen on 11/19/24 at 12:24 p.m. with Dietary Supervisor (DS), one stand alone chest freezer had no temperature log, DS stated the temperature log for the chest freezer was missing and she will start a new log. DS stated she had new staff in the kitchen that are in training. During an interview on 11/19/24 at 2:34 p.m. with DA 2, DA 2 stated she received training on her job function including dating and labeling food in the refrigeration. During an interview on 11/19/24 at 2:42 p.m. with [NAME] (CK), CK stated he was a new hire. CK said he received training that included checking food temperature, dating and labeling of food in refrigerator and check and documentation of fridge and freezer temperature. During a review of the facility's policy and procedure (P&P) titled, Food receiving and storage of cold food, dated 2023, the P&P indicated, All perishable food items purchased by the department of food and dining services will be stored properly. All open food items will have an open date and use-by-date per manufacturer's guidelines.

Based on observation and interview, the facility failed to provide a dining/activity room with adequate space for 42 residents. This failure resulted in limiting the independent functioning and task performance of the residents during mealtime and activity time. Findings: The facility census on 11/18/24 was 42 residents. On 11/21/24 at 12:04 p.m., observation of dining/activity room was conducted. The room which served as the residents' dining room and activity room had three square tables and accommodated five residents in wheelchairs and two ambulatory residents who used a walker as an assistive device. The dining room was observed to be crowded for the seven residents. The dining room staff were observed to push the tables to the side to be able to push and position some of the residents in wheelchairs in the dining tables. During an interview on 11/21/24 at 8:17 a.m., with Certified Nursing Assistant (CNA) 2 , CNA 2 stated the dining room was crowded at mealtimes and stated some of the ambulatory residents could slip and fall due to the tight space in the dining room. During an interview on 11/21/24 12:16 p.m., with Resident 16, stated the dining room was small and sometimes she had to dine in her room because the dining room space was limited. During an interview on 11/21/24 at 8:30 a.m., with Resident 17, stated the dining room was congested at mealtimes. Also stated it was difficult for the staff to position the residents in wheelchairs in the dining tables because of the small space of the dining area.

Based on observation, interview, and record review, the facility failed to ensure adequate supervision was provided to prevent falls and implement resident-centered care interventions for one (Resident 31) of four sampled residents when, Resident 31 had repeated unwitnessed falls. This failure caused Resident 31 to continued to fall and had the potential to result in injuries. Findings: During a review of Resident 31's Annual Minimum Data Set (MDS), Resident Assessment and care guide tool, dated 7/17/24, indicated Resident 31's Basic Interview of Mental status (BIMS, a scoring system used to determine the resident's cognitive status regarding attention, orientation, and ability to register and recall information. A BIMS score of thirteen to fifteen is an indication of intact cognitive status.). Resident 31's score was 03, meaning poor cognition. Resident 31's diagnoses included Non-Alzheimer's Disease (a group of diseases characterized by progressive deficits in behavior, executive function or language). Resident 31 was independent and once standing had the ability to walk at least 150 feet in corridor or similar space. Resident 31's behavior included wandering , the wandering placed Resident 31 at significant risk of getting to a potential dangerous place. During an observation on 11/20/24 at 1:19 p.m. Resident 31 wandered the hallways looking into other residents rooms. Review of Resident 31's Interdisciplinary Team (IDT- an approach to healthcare that integrates multiple disciplines through collaboration). The IDT progress notes indicated Resident 31 was at risk for falling and had the following falls: 6/28/24-Resident 31 had unwitnessed fall with no injury. 7/19/2-Resident 31 had unwitnessed fall with injury (hematoma on nose and face). Resident 31 was up ambulating went into the dining room and had an unwitnessed fall. Resident 31 laid face down head to the side assisted to the floor in the hallway when he tried to stand up and lost his balance. Resident 31's nose was swollen and discolored with small amount of blood from nose Resident 31 was transferred to the hospital for further evaluation and treatment. 9/1/24-Resident 31 lost her balance and fell on her buttock at the nursing station. 9/10/24-Resident 31 had an unwitnessed fall with no injuries. During a review of Resident 31's Change of Condition Evaluations (COC), dated 9/26/24, the COC indicated Resident 31 had unwitnessed fall, observed sitting on the floor, difficult to assess or redirect due to dementia. During a concurrent interview and record review on on 11/20/24 at 9:01 a.m. with the Director of Nursing (DON), Resident 31's IDT progress notes, COCs and fall care plan were reviewed. The IDT progress notes indicated prior interventions before each fall included remind resident to ask for help and current interventions after falls included redirection and reorientation. Resident 31's care plan indicated provide verbal reminders to ask for assistance as needed. DON stated Resident 31 wandered around the facility and had some falls in room and sometimes in the hallways. During an interview on 11/20/24 at 1:14 p.m. Certified Nursing Assistant (CNA2), CNA2 stated Resident 31 wandered around the facility, goes to every other residents' room and closet. CNA2 stated Resident 31 was very confused difficult to redirect. During an interview on 11/20/24 at 2:39 p.m. with DON, DON stated despite the interventions Resident 31 continued to wanders into other residents rooms despite redirection and reorientation. DON stated the interventions before and after falls are the same.

Based on interview and record review, the facility failed to complete the Level I Preadmission Screening and Resident Review (PASARR, a federal requirement to ensure that residents are not inappropriately placed in nursing homes for long term care) assessment for one of one sampled resident (Resident 31). This failure had the potential for residents to not received appropriate care and services. Findings: During a review of Resident 31's Admission Record, dated November 20 2024, the record indicated Resident 31 was originally admitted to the facility on [DATE]. During a concurrent interview and record review on 11/19/24 at 4:01 p.m. with Director of Nursing(DON), DON stated the facility was expected to complete a PASARR screening prior to residents' admission to the facility. DON could not provide Resident 31's Level 1 PASARR. DON stated Resident 31's Level 1 PASARR was not done. DON stated when Resident 31 was admitted to the facility she was a newly hired DON and did not know why Resident 31 did not have level 1 screening for PASARR completed. DON stated residents on psychotropic medication need to be screened for Level 1 PASARR. During an interview on 11/21/24 at 11:50 a.m. with Admission Coordinator(AC), AC stated she was responsible to coordinate with hospital case managers prior to residents admissions to the facility. AC stated she did not know about Resident 31 level 1 PASARR because she was hired after Resident 31's admission to the facility.

Based on interview and record review, the facility failed to provide necessary medications for one of four sampled residents (Resident 1). Resident 1's Milk of Magnesia (medication used to treat constipation) was not administered after Resident 1 did not have a bowel movement for eight days. Resident 1 developed fecal impaction (inability to evacuate large, hard stool), urinary tract infection and sepsis (sepsis: a life-threatening complication of an infection) and was subsequently admitted to the hospital. Findings: Review of the document Admission Record, showed the facility admitted Resident 1, who was [AGE] year-old on 6/30/2021. Resident 1's diagnoses included constipation and retention of urine (urine retention: when the bladder fails to empty completely). Record review at 2:59 p.m. on 10/18/2021 of the document Progress notes, dated 5/7/2021, showed Resident 1 Was complaining of stomach pain .resident ate poorly. Review of the document, SBAR Communication form and progress notes, dated 5/8/21, showed Resident 1 was found unresponsive and diaphoretic (sweaty) at 6:45 a.m. on 5/8/2021. Review of the document Physician's Order Sheet, dated 5/8/2021 at 7:40 a.m. showed staff were to call 911 and transfer Resident 1 to the hospital. Review of the document ED to Hosp-Admission (discharged ) in 3NA, dated 5/8/21, showed Resident 1's active hospital problem includes Sepsis, urinary tract infection (UTI, an infection in any part of your urinary system) and constipation. Under Hospital Course and Significant Findings it indicated Sepsis was due to UTI which was likely caused by urinary retention secondary to severe constipation. Further review showed the result of the computed tomography scan (CT scan, a medical imaging technique used in radiology to obtain detailed internal images of the body noninvasively for diagnostic purposes) of the abdomen and pelvis indicated large volume of stool in the rectum suggesting fecal impaction . scan performed notable for large volume of stool in the rectum thus enema ordered . Further review indicated Resident 1 was admitted on [DATE] and was discharged on [DATE] (six days). Review of the document Look Back Report, showed Resident 1 had a bowel movement on 4/22/21. Further review indicated Resident 1 did not have bowel movements from 4/23/2021 through 4/30/2021. Review of the Order Summary Report for all active physicians order as of 4/1/2021, indicated an order to administer 30 milliliters (ml, unit of measurement) of Milk of Magnesia Suspension every 24 hours for constipation. Review of the Medication Administration Record (MAR) showed Resident 1 did not receive Milk of Magnesia between 4/23/2021 and 4/30/2021. During an interview at 12:53 p.m., Certified Nursing Assistant 1 (CNA 1) stated she could not recall what was done regarding Resident 1's constipation. She stated if a resident does not have a bowel movement every day, she reports this information to the charge nurse. During an interview on 12/15/2021 at 12:46 a.m., Licensed Vocational Nurse 1 (LVN 1) stated she could not recall why Milk of Magnesia had not been administered to Resident 1 to relieve her constipation. LVN 1 stated if a resident has not had a bowel movement for three days, staff typically give standing order medications such as Milk of Magnesia or suppositories. In a concurrent interview and record review on 10/11/2021 at 11:41 a.m., the DON stated Resident 1 had not received the Milk of Magnesia between 4/23/21 and 4/30/21. In an interview on 9/30/2021 at 10:40 a.m., the Director of Nursing (DON) stated Resident 1 had developed a bowel impaction because staff at that time were not monitoring her bowel movements. In an interview on 10/12/2021 at 1:30 p.m., Medical Doctor 1 (MD 1) stated severe fecal impaction puts pressure on the bladder which causes Urinary retention and ultimately a Urinary Tract Infection. MD 1 stated Resident 1 had a Severe impaction, and her hospitalization could have been avoided if she had been having regular bowel movements. MD 1 stated Resident 1 developed sepsis due to the infection and facility staff should have called the doctor when she was not having a bowel movement after 2-3 days.

Based on interview, and record review, for one of three sampled residents (Resident 1), the facility failed to ensure safety when Resident 1 was turned and repositioned in bed without bed rails as assistive device and staff assistance. This failure resulted in Resident 1 falling off the bed resulting in head injury leading to a hospital stay between 2/8/15 to 2/11/15. Findings: Review of the admission record showed that Resident 1 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. The narrative notes dated 2/8/15 showed that Resident 1 fell off her bed when Certified Nursing Assistant (CNA) 1 repositioned her to provide incontinent care (care for people who lack control of their bladder or bowel). Resident 1 was transferred to the hospital with a [DIAGNOSES REDACTED]. Review of Resident 1's Minimum Data Set Assessment (MDS, an assessment tool used to direct resident care) dated 2/3/15 showed Resident 1 needed staff assistance with turning and repositioning when in bed and was totally dependent on staff assistance for toileting (how one uses toilet room, commode, cleanses self after elimination, changes pad, or adjusts clothes). In an interview on 2/17/15 at 2:18 p.m., Certified Nursing Assistant (CNA) 1 stated on 2/8/15 at 8:45 p.m., he provided incontinent care for Resident 1 and he changed the bed linen because it was wet. CNA 1 said he stood at the left side of Resident 1's bed when he changed the linen on the left side of the bed. CNA 1 stated that when it was time to change the linen on the right side of the bed, he turned Resident 1 to face the other direction, away from him. CNA 1 said he rolled Resident 1 to a right side-lying position. CNA 1 explained there were no bed rails attached to any part of the bed that Resident 1 could hold on to or to prevent her from falling off the bed. CNA 1 stated that he held Resident 1 on her left shoulder with one hand but when he needed to tuck the sheet under Resident 1, CNA 1 said he had to release his hold of Resident 1's left shoulder so he could roll the linen with both hands. CNA 1 said that Resident 1 was not positioned at the center of the mattress, rather "was closer to the right edge of the bed". Resident 1 rolled over and fell off the bed. CNA 1 explained that at the time, Resident 1 was "irritated and moving a lot" and that he would have asked help from other CNAs but at that particular time, there was nobody to help him. Review of the narrative notes dated 2/8/15 showed that Resident 1 sustained laceration and swelling on the back of her head and an open wound on her right middle finger and that Resident 1 complained of pain following the fall. Resident 1 had to be transferred to the hospital. Review of the ED Provider Notes dated 2/8/15 showed a Computerized Tomography scan (CT scan, a procedure that combines a series of x-ray images from different angles and uses computer processing to create images of bones, blood vessels and soft tissues inside the body) result performed on 2/8/15 at 11:59 p.m. that showed possible small subacute subdural hematoma because of the head injury that Resident 1 sustained from the fall. In an interview on 2/17/15 at 1 p.m., Director of Staff Development (DSD) stated that she talked to CNA 1 after the incident. DSD said CNA 1 told her that he may have positioned Resident 1 too close to the edge of the bed rather than at the center. DSD explained that when a staff turns a resident while in bed, staff had to turn the resident towards them and not away from where the staff is positioned. DSD said that one should ask for help if they feel that they could not do the task by themselves. DSD confirmed that facility did not have bed rails for purposes of repositioning. In an interview on 2/17/15 at 3:05 p.m., CNA 2 said that she always provided incontinent care to Resident 1 with help from another CNA 2 because Resident 1 could not help with turning to her sides. In an interview on 2/17/15 at 2:50 p.m., Administrator (Adm) said the facility did not have a policy and procedure for provision of incontinent care to totally dependent residents. According to American Healthcare Association: -When moving a resident to the side of the bed (when the resident is unable to help), "stand on the side to which you plan to move the resident, slide both your hands under the resident's head, neck, and shoulders and glide them toward you on your arms, slide your arms under the resident's hips and glide them toward you." -"When turning a resident from supine to side-lying for personal care, help the resident bend their knees up at one at a time and place their feet flat on the bed, place one hand on the resident's shoulder farther away from you and the other hand on the hip farther from you, on the count of 3, help the resident roll toward you and continue personal care." (Reference:http://www.ahcancal.org/quality_improvement/howtobe/Documents/Chapter15.pdf).

Based on observation, interview, and record review, the facility failed to provide one (Resident 12) of two randomly sampled residents a therapeutic diet based on a nutritional assessment including his food allergy. Resident 12 was served slices of oranges that he was allergic to on 8/19/14. Resident 12 had a history of [REDACTED]. This failure had the immediate potential to result in serious harm to Resident 12, who was allergic to oranges, producing vomiting in the past, and had a swallowing disorder which could result in choking on vomitus. Findings: Review of the clinical record showed that Resident 12 was admitted with [DIAGNOSES REDACTED]. Physician Admitting Orders, dated 9/21/11, showed that Resident 12 was allergic to oranges. During tray line observation on 8/19/14 at 12:15 p.m., Dietary Aide (DA) 1 placed desserts and beverages on lunch trays while Cook 1 checked the food temperatures. All lunch trays were loaded in a cart and each had a copy of the tray card that was pre-printed. A copy of the tray card was noted on Resident 12's tray showing he was allergic to oranges. DA 1 placed a small bowl of sliced oranges on Resident 12's and others' trays, then proceeded to push the cart towards the tray line for Cook 1 to place the main entree. Cook 1 read Resident 12's tray card and placed the main entree on Resident 12's tray. DA 1 then brought the cart with Resident 12's lunch tray out of the kitchen and loaded the cart onto the dumbwaiter. During dining observation on 8/19/14 at 12:27 p.m., lunch trays were taken out of the cart to be distributed by the Certified Nursing Assistants (CNAs) to respective residents. Resident 12's tray was taken out of the cart by CNA 1 and was checked by Registered Nurse (RN) 1, who did not notice that a bowl of sliced oranges was on the tray, before CNA 1 brought the tray to Resident 12. CNA 1 served the tray to Resident 12 and proceeded to set it up by taking off the plastic cover from the bowl that had the orange slices and placed it next to Resident 12's plate. Resident 12 did not refuse the oranges even after he saw the oranges that were served and proceeded to eat his lunch. CNA 1 started to walk away and stated that Resident 12 was able to feed himself and just needed set up help. Review of Resident 12's Minimum Data Set (MDS, an assessment tool used to direct resident care), dated 7/4/14, Resident 12 had some memory impairment and was independent with meals after the staff set up the tray. In an observation and concurrent interview on 8/19/14 at 12:30 p.m., CNA 1 stated when passing trays, she checked meal trays making sure that it was for the right resident and it had correct diet consistency. CNA 1 also said she had to take note of the likes and preferences of the residents. CNA 1 acknowledged that she did not check whether or not Resident 12 had an allergy. The orange slices remained on Resident 12's tray until CNA 1 was prompted, then looked at the tray card and took away the orange slices. In another interview on 8/19/14 at 12:32 p.m., RN 1 confirmed that she checked the meal tray against the tray card and made sure that Resident 12 had the right tray, but said that she did not see the allergy because it was written at the bottom part of the tray card. RN 1 also stated her role during meal times was to help feed residents, to check that food served was "within their order," and to make sure that help was there should there be a choking accident. During an interview and concurrent record review on 8/19/14 at 12:40 p.m., the Dietary Service Supervisor (DSS) stated kitchen staff should always check the meal tickets carefully during tray line. She also confirmed that Resident 12 was allergic to oranges and that Resident 12's wife had been very particular about Resident 12's allergy to oranges, because of an "allergic reaction in the past," wanting to always be on the safe side. The Dietary Manager Nutritional Screening and Observation Form, dated 9/16/13, showed under food allergies [REDACTED]." In an interview on 8/19/14 at 12:50 p.m., DA 1 confirmed that Resident 12's tray card showed he was allergic to oranges. Review of Resident 12's Nutrition care plan, dated 3/25/14, showed that Resident 12 had an allergy to oranges. One of the interventions was to remove all orange products. A condition of Immediate Jeopardy was identified by the survey team for the facility's failure to ensure that Resident 12 was not served food that he was allergic to. Given his past reaction to oranges which was vomiting and his [DIAGNOSES REDACTED]. On 8/19/14 at 1:25 p.m., in the presence of the Administrator and facility owners, an Immediate Jeopardy situation was announced. Interview on 8/19/14 at 1:50 p.m., the Director of Nursing (DON) stated when passing meal trays, charge nurses were to check the trays to make sure the residents were given the right consistency and were not given foods they were allergic to. During an interview on 8/20/14 at 11:23 a.m., the Director of Staff Development (DSD) stated that she expected the charge nurses and the CNAs to make sure that residents were getting the right consistency of food and that they did not get food that they were allergic to. In a phone interview on 8/19/14 at 12:55 p.m., Resident 12's spouse confirmed that Resident 12 had an allergy to oranges. Resident 12's spouse stated that Resident 12's allergic reaction to oranges included the white of his eyes turning orange and that he would vomit a lot. Resident 12's spouse stated the facility knew he had an allergy to oranges and she had to remind the facility in the past of his allergy to oranges. In an interview on 8/21/14 at 1:53 p.m., the Director of Staff Development (DSD) stated that she had not orientated licensed nurses on "tray pass" since she to work there three months ago. The DSD also stated that she had never thought of any in-service before on orientation for licensed nurses to check the tray cards for food allergies [REDACTED]. In a phone interview on 8/21/14 at 2:10 p.m. the Medical Director (MD) stated that Resident 12, "Chokes a lot" and needed to be fed slowly. MD also stated that Resident 12's "esophagus (tube that carries food from mouth to stomach) does not coordinate very well." Record Review of the "Monthly Visit Note", dated 8/18/14, showed Resident 12 choked easily while eating, had difficulty swallowing, choked, occasionally severely, with swallowing difficulty and was to have a mechanical soft diet.