Every finding on record at Almaden Health and Rehabilitation Center

Based on observation, interview and record review, the facility failed to implement a person-centered care plan for fall prevention for one of three sampled residents (Resident 1) when one intervention to place a non-slip strips in the shared resident's restroom's floor was not done. This failure could potentially put Resident 1 at risk of falling and could result to injuries. Review of Resident 1's face sheet indicated admission to the facility on 6/9/14, with diagnoses including unspecified dementia (is an umbrella term for a decline in mental abilities-like memory, thinking, and reasoning-that is severe enough to interfere with daily life ) with other behavioral disturbance and muscle weakness (limits your mobility). Resident 1 was sent out to acute hospital on 7/3/26 after a fall with fracture (define)During a review of Resident 1 's long-term care plan for CAA (Care Area Assessment) 11 Falls, dated 6/16/23, the care plan was updated on 6/22/26 that included interventions to provide non-slip strips in the bathroom. During an observation on 7/7/26 at 9:15 a.m., in Resident 1's shared restroom (bathroom), there was no non-slip strips found on the floor of the Resident 1's shared restroom. During a follow up interview on 7/7/26, at 11:30 a.m., with the maintenance supervisor (MS), the MS stated he already asked his assistant (MA, maintenance assistant) today to start putting the non-slip strips to Resident 1's shared restroom for fall prevention. During an interview on 7/7/26, at around 11:40 a.m., with the director of nursing (DON), the DON confirmed the non-slip strips were not installed yet, and she stated that the Maintenance staff should have installed the non-slip strips in Resident 1's shared restroom to implement the fall care plan. During a telephone interview on 7/8/26, at between 9:20 a.m. to 9:30 a.m., with licensed vocational nurse A (LVN A), LVN A stated Resident 1 had an incident of fall around 4:15 a.m. of 7/3/26 when she was attempted to use toilet she slipped and fell by lying on the floor in front of the shared restroom. LVN A further stated Resident 1 had been using the toilet with her walker without needing assistance; however, once in a while she would need reminder to use walker when she forgets to use walker. Review of the facility's undated policy and procedure (P&P) titled, Comprehensive Plan of Care, the P&P indicated ,Ensure that interventions.are provided. Ensure that the care plan specifies the interdisciplinary team member responsible for providing care or services.

Based on interview and record review, the facility failed to ensure one of three sample residents (Resident 1) received medication as ordered, whentwo medications were not available at scheduled time, andOne medication was not administered after it was delivered to the facility. Those failure had the potential to compromise Resident 1's health and well-being.A review of Resident 1's medical record indicated he was admitted to the facility on [DATE] at 11:45 p.m. with diagnoses including unspecified intracranial injury (damage to the brain resulting from external physical force, such as falls, accidents, or assaults ), nontraumatic subarachnoid hemorrhage epilepsy (seizures), and cerebral edema(dangerous, often life-threatening brain swelling caused by fluid buildup from injury, tumors, infection, or stroke ).Review of Resident 1's Order Summary Report indicated he had a physician order, dated11/29/2025,for levetiracetam (medication used to manage epilepsy by treating various types of seizures, including partial-onset, myoclonic, and generalized tonic-clonic seizures) 1000mg (does measurement) one tablet by mouth twice a day (09:00 a.m. and 08:00 p.m.) for seizure. For phenytoin (medication used to control and prevent seizure disorders, particularly tonic-clonic seizures and status epilepticus), 50mg chewable tablet, 2 tablets by mouth three times a day. For trazodone (medication used to treat insomnia and, less frequently, anxiety or depression) 75mg, 0.5 tablet, by mouth at bedtime (9:00 p.m.) for insomnia related to depression.A review of Resident 1's Medication Administration Record (MAR), dated 11/29/2025, indicated that the resident did not receive levetiracetam 1000 mg at 8:00 p.m., phenytoin 50 mg at 8:00 p.m., and trazodone 75 mg at 9:00 p.m. There was no documentation indicating the reason these medications were not administered.A review of the pharmacy's electronic medication shipping manifest indicated that levetiracetam 1000 mg and trazodone 75 mg were delivered to the facility on [DATE] at 1:04 a.m., and the phenytoin 50 mg chewable tablets were delivered on 11/29/2025 at 5:48 p.m. The phenytoin was received by LVN A.1.During a concurrent interview and record review with the Director of Nursing (DON) on 3/20/2026 at 1:59 p.m., the DON confirmed that LVN A did not administer the above three night medications at their scheduled times on 11/29/2025, and there was no documentation indicating the reason they were not administered.During a phone interview with Licensed Vocational Nurse (LVN) A on 3/23/2026 at 4:40 p.m., LVN A stated that Resident 1 was admitted on [DATE] and had not received her medications by bedtime. As a result, three medications: phenytoin, trazodone, and levetiracetam were not administered. LVN A further stated that due to an update in the facility's medication administration system, she did not know how to enter notes in the system, and she acknowledged that she should have documented the information.During a phone interview with the Pharmacy Manager (PM) on 3/25/2026 at 2:09 p.m., the PM stated that there are three standard medication delivery times: 5:00 a.m., 1:00 p.m., and 9:00 p.m. Resident 1's medication orders were received on 11/29/2025 at 12:48 p.m., which was too late to meet the 1:00 p.m. delivery. Therefore, the medications were scheduled for the 9:00 p.m., and delivered to the facility on [DATE] at 1:04 a.m. The STAT (immediate) order for phenytoin was delivered to the facility on [DATE] at 5:48 p.m. The PM further stated that the facility could request all medications as STAT orders; however, only one medication was ordered as STAT. During a phone interview with the Nursing Supervisor (NS) on 3/26/2026 at 12:47 p.m., the NS confirmed that he admitted Resident 1 on 11/29/2025 and sent the resident's medication orders to the pharmacy. He stated that he was aware of the pharmacy's 1:00 p.m. delivery time and assumed the medications would be delivered by bedtime; therefore, he ordered only phenytoin as a STAT order.2. During a phone interview with the Director of Nursing (DON) on 3/26/2026 at 3:14 p.m., the DON reviewed the pharmacy's electronic medication shipping manifest and confirmed that LVN A received the phenytoin on 11/29/2025 at 5:48 p.m. The DON further stated that LVN A should have administered the medication at the scheduled time 8:00 p.m. after receiving it.A review of the facility's undated policy titled Oral Medication Administration indicated, .administer oral medication in an accurate, safe, timely, and sanitary manner.

Based on observation, interview, and record review, the facility failed to ensure safe food storage practices and sanitary conditions in the kitchen when: 1. Kitchen staff did not wear hair restraints while in the kitchen, 2. Five of seven green peppers were wrinkled and soft, one of 3 cucumbers soft, 3. Three opened spice containers and one vanilla extract bottle with expired dates, 4. Three of eight cutting boards had deep cut marks on their surface, and 5. Two of 18 cans of sliced peaches, one of 12 cans of sliced pears, one of 6 cans of fruit cocktail were dented, and one of three cans of nacho cheese sauce with expired date of [DATE], in the emergency food supplies. These failures had the potential to cause food contamination and spread food-borne illness to residents who received their food from the kitchen. Findings: 1. During a concurrent observation and interview on [DATE] at 11:50 a.m., with the Dietary Manager (DM), the DM was wearing a head covering brown in color and not covering whole hair while in the kitchen going in and out of the walk-in freezer. The DM stated she does not need to cover whole hair because she was not doing meal prep or in the tray line. During an interview on [DATE] at 1:41 p.m., with the Infection Preventionist (IP) G, the IP G stated anyone who enter the kitchen, hairnet must be worn under the hat or own covering. During a concurrent observation and interview on [DATE] at 7:12 a.m., with the DM, the DM confirmed that one of the cooks (CK E) was not wearing a hairnet under the visor cap. Review of the facility's policy and procedures (P&P) titled Food Handling Practices, undated, indicated Practice good personal hygiene: restrain hair appropriately. Review of the Food and Drug Administration's (FDA) Food Code 2022 Chapter ,d+[DATE], indicated food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food, clean equipment, utensils, lines, and unwrapped single service and single-use articles. 2. During a concurrent observation and interview on [DATE] at 12:03 p.m., with the DM, the DM confirmed the green peppers and cucumber were wrinkled and soft. The DM stated the produce are still good because it will be cooked and not served raw or added in salads. The DM also stated the wrinkles will go away once it was cooked or placed in water. During a review of the facility's P&P, titled Food Storage Principles, undated, indicated proper food storage is essential for preserving food quality. 3. During a concurrent observation and interview with Administrator (ADM) B, on [DATE] at 8:47 a.m., ADM B confirmed three spice containers, and one vanilla extract bottle were expired as follows: a. Ground Thyme with best by date [DATE]. b. Tarragon Leaves with best by date [DATE]. c. Ground Allspice with best by date [DATE]. d. Vanilla Extract with best by date [DATE]. ADM B stated the spices, and vanilla extract should be thrown away when expired or past best by date. During a review of the facility's P&P, titled Food Storage Principles, undated, indicated Discard foods that have exceeded their expiration date. 4. During a concurrent observation and interview with ADM B on [DATE] at 8:50 a.m., ADM B confirmed the three cutting boards had deep cut marks on their surfaces. The ADM B stated they should have been thrown away when they got new cutting boards. Review of the The Federal Food and Drug Administration (FDA) Food Code 2022 Chapter ,d+[DATE].12, indicated surfaces such as cutting blocks and boards that are subject to scratching and scoring shall be resurfaced if they can no longer be effectively cleaned and sanitized. 5. During a concurrent observation and interview on [DATE] at 2:14 p.m., with the DM in the emergency food supply storage room, the DM confirmed the above observation and stated it will not be used and will be thrown out. During a review of the facility's P&P, titled Food Storage Principles, undated, indicated Discard foods that have exceeded their expiration date. Review of the The Federal Food and Drug Administration (FDA) Food Code 2022 Chapter ,d+[DATE].11, indicated rusted and pitted or dented cans may also present a serious potential hazard.

Based on observation, interview and record review, the facility failed to provide proper oxygen (a colorless, odorless gas) care and treatment services for four of 18 sampled residents (Residents 168, 60, 268, and 29) when: 1. Resident 168 had an oxygen concentrator (a portable device that provides oxygen) at the bedside, but there was no oxygen signage posted on the door. 2. Resident 60 had an oxygen concentrator at the bedside, but there was no oxygen signage posted on the door. 3. Resident 268 had an oxygen concentrator at bedside, but the nasal cannula had no label, and no oxygen signage posted on the door. 4. Resident 29 had an oxygen concentrator at the bedside, but there was no oxygen signage posted on the door. This deficient practice had the potential to for accidents and hazards that could pose harm to residents in the facility. Findings: 1. During an observation on 1/21/25, at 10:20 a.m., Resident 168 was lying in bed, asleep, with a nasal cannula (NC, device placed in the nostril used to deliver oxygen) delivering oxygen attached from a running oxygen concentrator. There was no oxygen signage posted on Resident 168's door. 2. During an observation on 1/22/25, at 10:40 a.m., Resident 60 was lying in bed, with a NC delivering oxygen attached from a running oxygen concentrator. There was no oxygen signage on Resident 60's door. During a concurrent interview, Licensed Vocational Nurse (LVN) N stated that an Oxygen in Use sign should be posted on the doors of Resident 168 and 60. 48590 3. During an observation on 1/21/25 at 1:58 p.m., Resident 268 was lying in bed asleep, with a nasal cannula delivering oxygen attached from a running oxygen concentrator. The nasal cannula had no label. There was no oxygen signage posted on Resident 268's door. During an interview on 1/21/25 at 2:07 p.m., with LVN M, she confirmed the above observation and stated the nasal cannula should be labeled with date and time, and there should be a signage posted at the door. During an interview on 1/27/25 at 11:12 a.m., with the DON, the DON stated there should be labeling on the oxygen tubing and signage by the door for residents receiving oxygen. 50135 4. Review of Resident 29's medical record indicated Resident 29 was admitted on [DATE] with diagnoses including anemia (low number of red blood cells), spondylosis (wear and tear of the bones of the spine[backbone]), atrial fibrillation (an irregular heart rhythm which can lead to blood clots and stroke), and peripheral vascular disease (a blood vessel disorder that affects blood circulation). Review of Resident 29's Physician Order Report dated 11/21/24 indicated an order for oxygen support via nasal cannula (a device used to deliver supplemental oxygen or airflow) at 2 liters as needed. During an observation on 1/21/25 at 10:11a.m., Resident 29 was in her room sitting up in bed receiving oxygen via nasal cannula. There was no No Smoking sign posted at the entrance of or anywhere inside Resident 29's room. During an observation and interview on 1/27/25 at 11:18 a.m. with the Director of Nursing (DON) outside of Resident 29's room the DON verified no oxygen signage posting outside the room or anywhere inside the room of Resident 29. The DON stated there should be an Oxygen in Use and/or a No Smoking sign posted on the door of every resident receiving oxygen therapy. Review of the facility's policy titled Oxygen Administration, undated indicated, Post an oxygen precaution (No Smoking) sign on the resident's door.

Based on observation, interview, and record review, the facility failed to ensure infection control practices were implemented when: 1. One Licensed Vocational Nurse (LVN) A failed to use the proper disinfectant (chemical liquid that destroys bacteria) to disinfect a shared (used for multiple residents) glucometer (blood glucose meter to measure and display the amount of sugar [glucose] in the blood) according to manufacturer's instructions and accepted professional standards for one resident; 2. One housekeeping staff failed to handle and transport dirty laundry properly; and 3. The facility staff failed to ensure proper storage of Resident 64's breathing treatment (nebulizer treatment, which involves inhaling a mist of medication through a device) mask. These failures could result in cross-contamination and the spread of infection throughout the facility. Findings: 1. During a medication pass observation on 1/22/25 at 12:13 p.m., LVN A was observed removing the glucometer (device used to measure level of glucose [sugar]) in the blood) from the drawer of the medication cart and wiped the glucometer with alcohol pads before obtaining the blood sugar reading for Resident 169. When finished LVN A wiped the glucometer with alcohol pads then placed the glucometer back in the drawer of the medication cart. During an interview on 1/22/25 at 12:18 p.m. with LVN A, LVN A stated, I always use alcohol wipes to clean the glucometer for convenience. LVN A stated an in-service was conducted recently and was instructed to sanitize the glucometer with Clorox (a disinfectant) wipes or Sani-cloths (a germicidal disinfectant). During an interview with the Director of Nursing (DON), the DON stated she conducted an in-service in December of 2024 for all nursing staff members and a review was conducted on 1/21/25. The DON stated she instructed the staff to use the purple top canister of Super Sani cloths and Clorox wipes to clean all equipment used between residents. The DON stated the dwell time for both wipes is three minutes. The DON also stated she never instructed staff to use alcohol pads for cleaning of equipment because, It does not kill the bacteria. A review of the manufacturer's instructions titled, Medline-Evencare G2, Blood Glucose Monitoring System, indicated, .4. To disinfect your meter, clean the meter with one of the validated disinfecting wipes listed below: .Clorox Healthcare Bleach and Disinfectant Wipes. 42819 2. During an observation 1/22/25 at 9:00 a.m., housekeeper (HK) P was observed carrying a soiled curtain in the hallway without placing it in a plastic bag or a closed bin. HK P then entered the laundry room and stated that the curtain was dirty and should have been placed in a plastic bag before bringing to the laundry room. The curtain had visible yellow stains. During an interview on 1/27/25 at 2:27 p.m., the Infection Preventionist (IP) G stated that facility policy requires staff to transport soiled linens, curtains, and towels in a closed bin or a plastic bag. The IP G further stated that heavily soiled items should be placed in a red hazard bag. Review of an undated facility's policy, titled, Soiled linen Collection & Transfer, indicated, .Laundry chutes may be used for transporting soiled linens . 3. During a concurrent observation and interview on 1/22/25 at 9:10 a.m., a breathing treatment mask was observed on top of Resident 64's bedside drawer, not stored in a plastic bag. The Licensed Vocational Nurse (LVN) N confirmed that the breathing treatment mask should be stored in a plastic bag to prevent contamination/ infection. During an interview on 1/27/25 at 2:40 p.m., IP G stated that breathing treatment masks should be changed every 72 hours, replaced if visibly dirty, and stored in a plastic bag when not in use. Review of an undated facility's policy,titled, Aerosol (Nebulizer) Therapy indicated, .Clean nebulizer once treatment is completed .place in plastic storage bag .

Based on observation, interview, and record review, the facility failed to maintain an effective pest control program to keep the facility free of cockroaches and spiders when: 1. Roach and spider carcasses were observed in the kitchen, 2. No monitor log for deep cleaning of resident rooms reported to have sighting of roaches, and 3. Facility did not follow their facility's plan of correction regarding pest control. These failures had the potential to cause health hazards and food borne illness to residents. Findings: 1. During a kitchen tour on 1/22/25 at 8:47 a.m., accompanied by Administrator (ADM) D, three traps with roach carcasses were observed on the side and under the ice machine, dated 11/17. One roach carcass was observed behind the plastic containers on one side of the kitchen wall. During a tour of the dry storage room on 1/22/25 at 9:23 a.m., with ADM D, one trap was observed with six carcasses of spiders, dated 9/17. In a concurrent interview with ADM D, ADM D confirmed the above observations and stated pest control company comes in weekly to place new traps. During an interview on 1/22/25 at 10:45 a.m., with Dietary Aide (DA) I, DA I stated she saw small roaches in the kitchen in August. DA I stated she reported the sighting to the supervisor. During an interview on 1/22/25 at 10:55 a.m., with the Dietary Manager (DM), the DM stated the pest control company instructed them not to remove the traps. The DM stated she will remove the trap with roaches and not remove if not roaches. During an interview on 1/22/25 at 10:48 a.m., with [NAME] (CK) J, she stated she saw alive and dead roaches three weeks ago. During an interview on 1/22/25 at 10:52 a.m., with CK K, the CK K stated she saw two dead roaches one month ago. During an interview on 1/23/25 at 2:41 p.m., with Pest Control Company (PCM), the PCM stated it is the judgement of the pest control staff if they will change or keep or replace the monitors. The PCM also stated if its still good, as in the glue still works, then they will not replace. During a review of the facility's Pest Control/Sightings Log, dated January 2025, indicated presence of roaches in the kitchen. During an interview on 1/23/25 at 1:07 p.m., with the DM, the DM verified the entries in the log. Review of the Food and Drug Administration's (FDA) Food Code 2022 Chapter 6-501.111 indicated The premises shall be maintained free of insects, rodents, and other pests. Review of the Food and Drug Administration's (FDA) Food Code 2022 Chapter 6-501.112 indicated Dead or trapped birds, insects, rodents, and other pests shall be removed from control devices and the premises at a frequency that prevents their accumulation, decomposition, or the attraction of pests. 2. During a concurrent observation and interview on 1/21/25 at 1:45 p.m., with Resident 32, in her room, Resident 32 stated she saw a live roach on 1/10/25 and 1/19/25. Resident 32 stated she reported the sightings to the staff. During a record review of the facility's Pest Control/Sightings Log for the month of January 2025, indicated the 1/19/25 report was not documented. During an interview on 1/22/25 at 4:17 p.m., with Maintenance Director (MD) F, MD F stated he did not get any report regarding pests in the resident room. During an interview on 1/28/25 at 10:25 a.m., with ADM C, he stated they don't keep logs or written report for the rooms that were deep cleaned. ADM C stated that deep cleaning was a remedial action for pest control. During an interview on 1/28/25 at 2:19 p.m., with MD F, MD F stated no written logs of deep cleaning done in the resident rooms. During a review of the facility's policy and procedure (P&P), titled Pest Control, undated, indicated Maintain a written report of pest sightings and remedial actions. 3. During an interview on 1/27/25 at 3:38 p.m., with Infection Preventionist (IP) H, IP H stated during pest control deep cleaning, all belongings are taken out of the resident room. The IP H stated for any sightings in resident rooms, patient is moved out of the room and deep cleaning done. IP H stated maintenance will deep clean the room and housekeeping will mop the floor. During an interview on 1/28/25 at 12:19 p.m., with ADM C, ADM C just nodded his head and did not say anything when told that State Surveyors have not seen any rooms being deep cleaned for the past six days. During an interview on 1/28/25 at 10:25 a.m., with ADM C, ADM C stated rooms that were reported to have sightings will be deep cleaned. ADM C stated all belongings, curtain, bed and resident will be moved out of the room to be deep cleaned. During an interview on 1/28/25 at 1:56 p.m., with Housekeeper (HK) L, HK L stated she does not empty the room during deep cleaning. HK L stated she would move stuff around the room. During a review of the Form CMS 2567 Plan of Correction, date survey completed 9/11/24, indicated Any rooms identified for pest will be deep cleaned by housekeeping and maintenance staff immediately.

Based on observation, interview, and record reviews, the facility failed to maintain a safe and functional environment when: 1. The toilet in Resident 9's room was clogged; 2. Resident 9's bathroom call light was broken; and, 3. The facility's three of four shower rooms had multiple broken tiles. These failures compromised residents' safety, well-being, and access to a properly maintained living environment. Findings: 1. During an observation and concurrent interview on 1/21/25, at 2:50 p.m., in Resident 9's room, a sign near the toilet indicated it was out of order. Resident 9 stated that the toilet had been clogged for weeks and that he had reported it to the staff. The Director of Nursing (DON), who was nearby immediately reported the issue to the Maintenance Director (MD) F. 2. During an observation and concurrent interview on 1/24/25, at 3:00 p.m., the bathroom call light in Resident 9's room was observed to be broken. Licensed Vocational Nurse (LVN) N confirmed that the call light was not working and reported it to the maintenance staff. During an interview on 1/28/25, at 9:50 a.m., the MD F stated he conducted daily rounds, but his rounds had not identified any broken call lights. The MD F state he did not document his daily maintenance checks. Review of facility's policy, titled, Call Lights-Answering Of dated 3/21/24, indicated, .Preventive Maintenance program is in place for monitoring of the call light system . 3. During an observation on 1/22/25, at 12:27 p.m., multiple broken tiles were observed in three of four shower rooms the facility. During a concurrent observation and interview on 1/28/25, at 10:02 a.m., the MD F confirmed awareness of the above issue and stated he planned to replace the tiles. The MD F also stated he was currently fixing Resident 9's toilet. Review of an undated facility's policy, titled, Physical Plant Interior Maintenance, indicated, .Interior maintenance of the physical plant is an essential function of the preventive maintenance program to assure employee and resident safety .Check all areas of ceramic/vinyl flooring for repairs and cleanliness. Repair/report all damaged areas .

Based on observation, interview, and record review, the facility failed to provide dignity and privacy to one of 18 sampled residents (Resident 52) during care when Resident 52's lower back was partially exposed to public view while seated in a shower chair in the facility's hallway. This failure compromised Resident 52's dignity. Findings: Review of Resident 52's Face Sheet (a document that contains a summary of a patient's personal and demographic information) indicated Resident 52 was admitted to the facility with diagnoses including muscle wasting and atrophy (loss of muscle mass and strength), dementia (a condition that affects memory, thinking and the ability to make decisions) and psychotic disorder (a mental health condition that can cause confusion , hallucinations, or delusions.) Review of Resident 52's Minimum Data Set (MDS, assessment tool) assessment, dated 11/14/24, indicated Resident 52's Brief Interview for Mental Status (BIMS, cognition level) score was 3 (severe impairment). During an observation on 1/28/25, at 8:30 a.m., in the hallway outside Resident 52's room, observed Resident 52 sitting in a shower chair and being wheeled by Certified Nursing Assistant (CNA) O. Although, Resident 52 was covered with blanket, the right side of Resident 52's buttocks remained exposed. The Director of Nursing (DON) , who was also in the hallway, confirmed the observation and reminded CNA O to cover Resident 52's right buttocks. During a concurrent interview with the DON, the DON stated that Resident 52's buttocks should have been covered completely and not exposed to public view. Review of an undated facility's policy titled, Resident Dignity and Personal Privacy indicated, . 3. Drape and dress residents appropriately at all times to avoid exposure and embarrassment. 4. Maintain resident privacy during toileting, bathing, and other activities of personal hygiene .

Based on observation, interview, and record review the facility failed to ensure resident's care needs were accommodated for one of six sampled residents (Resident 37) when Resident 37's call light /button (a button device used to request assistance) was not within reach to use. This failure had the potential to affect the resident's ability to request for prompt assistance and help. Findings: Review of Resident 37's Face Sheet (a document that contains a summary of a patient's personal and demographic information) indicated, Resident 37 was admitted to the facility with diagnoses including Parkinsonism (a disease that include symptoms of slowness of movements, muscle rigidity, involuntary tremors/shaking and impaired balance and posture), vascular dementia (decline in mental capacity affecting daily function), and rhabdomyolysis (a breakdown of muscle tissue). Review of Resident 37's Admission's Minimum Data Set (MDS, assessment tool) assessment, dated 12/5/2024, indicated Resident 37's brief interview for mental status (BIMS, cognition level) score was 9 (moderate cognitive impairment). During a review of Resident 37's Care Plan dated 08/08/2023, updated on 01/19/2025, indicated The resident is at risk for falls related to history of falls and balance problem, and with intervention reflected, Keep environment free of hazards, clutter free, call light within reach. During an observation and interview on 1/21/25 at 11:22 a.m., in the room of Resident 37. Resident 37 was awake and sitting in his wheelchair next to his bed. Resident 37 was observed repeatedly verbalizing, I can't find my call light. Can somebody help me find my call light? During an observation and concurrent interview on 1/21/25 at 11:30 a.m. with Certified Nursing Assistant (CNA) B, CNA B was observed searching the bed of Resident 37 and the surrounding area, then was observed removing Resident 37's call light from the surface of the bed of Resident 37' s roommate and attaching the call light onto Resident 37' s bed. CNA B stated, The call light should not be over there. It should be on Resident 37's bed. During an interview on 1/27/25 at 3:30 p.m. with the Director of Nursing (DON) the DON stated, Resident's call lights should be within their reach not on floors or on another resident's bed. A review of the facility's policy and procedure titled, Call Lights-Answering Of dated 3/21/2024, indicated, .7. When leaving the room, ensure that the call light is placed within the resident ' s reach. Maintain Resident ' s Safety.

Based on observation, interview, and record review, the facility failed to maintain and meet current standards of nursing practice when, the medication was not administered according to the physician's order for one of 10 residents (Resident 65). This failure could potentially result in complications of the residents' medical conditions. Findings: During medication administration observation on 1/22/25 at 10:12 a.m., Licensed Vocational Nurse (LVN) A prepared seven medications for Resident 65. The medications included one tablet of aspirin (blood thinner that lowers risk of blood clots) 81 mg (mg, unit of measure), one tablet of docusate sodium (stool softener) 100 mg, one tablet of clopidogrel (an antiplatelet blood-thinning medication) 75 mg, one tablet of loratadine (medication that relieves upper respiratory allergies) 10 mg, 1 tablet of losartan (medication used to lower blood pressure) 75 mg, one tablet of Tradjenta (medication used to control blood sugar levels in the blood) 5 mg and metformin (medication used to control blood sugar levels) 1000 mg. During an observation of medication administration on 1/22/25, at 10:12 a.m., LVN A administered seven medications to Resident 65. Resident 65 swallowed one to two of the tablets at a time with sips of water provided by LVN A. Review of Resident 65's Physician Order Report dated 1/3/2025 indicated to administer metformin tablet 1000 mg; 1 tab; Special Instructions: For diabetes, administer with meals twice a day; 8:00 a.m, 6:00 p.m. A review of Resident 65's medication administration record (MAR) showed LVN A documented for the 8:00 a.m. metformin 1000 mg administration on: 1/22/25 given late at 10:12 a.m. During an interview and record review for Resident 65 on 1/28/25 at 9:05 a.m. with LVN A, LVN A stated metformin should be given with meals or at least thirty minutes after eating food. LVN A also stated Resident 65 was served breakfast between 7:00 a.m. to 7:30 a.m. on the morning of 1/22/25 and verified there were no snacks offered to Resident 65 before administering the metformin. During an interview on 1/28/25 at 9:15 a.m. with the Director of Nurses (DON), the DON stated it is her expectation that all nurses give medications according to physician orders and facility policy. Review of the facility's policy titled, Oral Medication Administration undated, indicated, .9. Administer medications with food according to the Physician's Order or manufacturer's specification.

Based on observation, interview and record review, the facility failed to ensure a sanitary environment was provided when: 1. The dumpster's lid for garbage was not fully closed and 2. Leftover foods and some trashes were found on the ground of facility's garbage storage area. These failures had the potential to attract rodents and pests and may put residents' health and safety at risk. Findings: During a facility tour with the Director of Maintenance (DM) on 8/28/24 at 9:21 a.m., one dumpster for garbage was observed with broken lid and not fully closed. Leftover foods (cooked rice and food scraps), two empty food boxes, one green plastic bottle, several cardboards and papers were found on the ground of the facility's garbage storage area. The DM confirmed the above observations. The DM acknowledged the garbage lid should be fully closed and all wastes on ground should have been put inside the garbage bin to prevent attracting rodents and pest coming to the garbage storage area. During an interview with the Administrator (ADM) on 8/28/24 at 2:43 p.m., the ADM acknowledged dumpster garbage lid should be fully closed and wastes should be placed inside the garbage bin to prevent attracting pest and rodents. Review of the facility's undated policy and procedures titled Pest Control indicated, Keep facility grounds free of trash and brush. Keep the dumpster area clean and the lid closed.

Based on observation, interview and record review, the facility failed to ensure safe environment when the screen that covers the window leading to the kitchen sink was broken. This failure had the potential for the rodents and pests to enter the kitchen and had the potential to put residents' health and safety at risk. Findings: During an observation with the Director of Maintenance (DM) on 8/28/24 at 10:02 a.m., the screen mesh that covering the window leading to kitchen sink was observed broken on the bottom part creating a small gap. The DM confirmed the observation and acknowledged the window screen should have been maintained in good repair to prevent possible entrance of pests and rodents in the kitchen and facility. Review of the facility's undated policy and procedures titled Pest Control indicated, Maintain intact screens on windows that open.

Based on observation, interview, and policy review, the facility failed to implement infection control practices when: 1. Licensed vocational nurse B (LVN B) walked in the hallway with gloves on; 2. Housekeeper C (HKP C) wore the same gloves to wipe resident Room AA and Room BB; and 3. Certified nursing assistant D (CNA D) brought the lunch tray to Resident 2's room which was an isolation room for Coronavirus disease (COVID-19, an infectious disease caused by the SARS-CoV-2 virus which can spread from an infected person's mouth or nose in small liquid particles when they cough, sneeze, speak, sing or breathe) and fed her in the room wearing a surgical mask. These failures had the potential to spread infection in the facility. Findings: 1. During an observation and interview on 8/14/24 at 11:55 a.m., LVN B was walking in the hallway wearing gloves on her hands. LVN B stated she came to help a resident in her room. LVN B acknowledged that she should not wear gloves in the hallway. During an interview with the director of nursing (DON,) on 8/14/24 at 12:15 p.m., she stated staff should not wear gloves in the hallway. 2. During an observation on 8//14/24 at 12:10 p.m., HKP C finished wiping resident Room AA, threw the trash of Room AA into the trash bin on her cleansing cart, pushed the cleansing cart in the hallway to Room BB, and wiped Room BB with the same gloves on her hands. During a concurrent interview with HKP C and Spanish interpreter E (ITP E), HKP C acknowledged that she should change gloves after cleansing Room AA and before cleansing Room BB. During an interview with the DON on 8/14/24 at 12:15 p.m., she stated housekeeper should change gloves after cleansing one room and before cleansing another room. Review of the facility's undated policy, Standard Precautions, indicated . 4. Gloves: . Remove gloves promptly after use, and wash hands immediately before touching non-contaminated items and environmental surfaces, and before going to another resident. 3. During an observation on 8/14/24 at 12:35 p.m., CNA D brought a lunch tray to Resident 2's room, a COVID-19 isolation room, wearing a gown, gloves, and a surgical mask. During an interview with CNA D, on 8/14/24 at 12:50 p.m., he stated he was feeding Resident 2 in her room. CNA D acknowledged that he should wear an N95 mask (a respiratory protective device designed to achieve a very close facial fit and very efficient filtration of airborne particles) when entering Resident 2's room. During an interview with the DON, on 8/14/24 at 1:30 p.m., she stated staff should wear N95 mask when entering COVID-19 isolation room. Review of the facility's undated policy, COVID-19 Using Personal Protective Equipment (PPE), indicated . 3. When caring for a resident with suspected or confirmed SARS-CoV-2 infection, the following infection prevention and control practices are followed: . b. Respirator: 1. An N95 respirator (or equivalent or higher-level respirator) is donned before entry into the resident room or care area .

Based on observation, interview, and facility document review, the facility failed to maintain an effective pest control to keep the facility free of cockroaches when live cockroaches were observed in Resident 4's room even though the room was inspected and treated for roaches. This failure had the potential to result in pest transferred disease to residents. Findings: During an interview with Resident 3, on 8/14/24 at 2:40 p.m., she stated about two weeks ago she saw a cockroach on her lunch tray. Review of the facility's Crossfire Pest Rodents and Termites Report indicated Resident 4's room was inspected and treated for cockroach and rodent on 5/31/24. However, on 6/10/24, the facility's Maintenance Work Request indicated pest control spray was requested for Resident 4's room because cockroaches were seen crawling on Resident 4's bed side rails and closet. It also indicated the request was completed on 6/12/24. Review of the facility's Ecolab Customer Services Report indicated Resident 4's room was treated for cockroaches again on 7/2/24. During an observation and interview with Resident 4 in his room, on 8/14/24 at 4:05 p.m., he stated there were many cockroaches in his room; they crawled under his bed and on his bed side rails. Resident 4 stated he told everyone about that; they sprayed, but there were still cockroaches. So, he bought the cockroach trap and placed it in his room. A cockroach trap was observed on the floor, beneath the curtain, and against the wall. Resident 4 stated he placed the trap there two weeks ago. The trap had five dead cockroaches on it. When Resident 4 pulled the basket on the floor toward him, there were five live cockroaches crawling out from underneath the bottom of the basket. During an observation and interview with the maintenance director (MD) in Resident 4's room, on 8/15/24 at 12 p.m., he confirmed there were five dead cockroaches on the trap and acknowledged that five live cockroaches were seen in Resident 4's room yesterday. Review of the facility's Maintenance Work Request, dated 8/13/24, indicated registered nurse F (RN F) reported cockroaches in Resident 5's room. During an interview with RN F, on 8/15/24 at 12:05 p.m., she stated on 8/13/24, a CNA in day shift reported to her that she and Resident 5 saw cockroaches in his room, so she submitted the Maintenance Work Request. During an interview with the MD, on 8/15/24 at 12:15 p.m., he reviewed the Maintenance Work Requests for Resident 4's and Resident 5's rooms, and he confirmed that the facility's pest control was not working and not effective.

Based on observation, interview, and policy review, the facility failed to treat one of three sampled residents (Resident 1) with respect and dignity when certified nursing assistant A (CNA A) did not provide privacy to Resident 1 during transporting Resident 1 from her room to the shower room. This failure had the potential to cause embarrassment for the resident. Findings: During an observation on 8/14/24 at 4 p.m., CNA A transported Resident 1 in the hallway from her room to the shower room. Resident 1 was sitting on a shower chair. The front of Resident 1 was covered with a linen sheet, but her back and her buttocks were not covered and were exposed. During a concurrent interview with CNA A, she confirmed Resident 1's back and buttocks were not covered and were exposed. CNA A stated she missed the back of Resident 1's body, and she should cover Resident 1's body before transporting her in the hallway. During an interview with the director of nursing (DON), on 8/15/24 at 1:45 p.m., she stated staff should cover the resident's body before transporting the resident in the hallway. Review of the facility's undated policy, Tub Bath and Shower, indicated . General Guidelines: . 4. When transporting the resident to and from the bath area, make sure that the resident is covered and his or her privacy is maintained.

Based on observation, interview, and record review, the facility failed to ensure a comfortable, safe temperature level was maintained in the range of 71 to 81 degrees Fahrenheit (a unit of measurement of temperature) in the facility hallway, and three resident rooms (room [ROOM NUMBER], 2, and 3). This failure had the potential for the residents to have an uncomfortable environment. Findings: Review of Resident 1's face sheet (a document that gives a resident's information at a quick glance) indicated Resident 1 admitted to facility on 7/12/2023 with diagnoses right tibia fracture (a broken right lower leg bone), left femur fracture (a broken left thigh bone), congestive heart failure (a chronic condition in which the heart does not not pump blood as well as it should), asthma (a condition in which airways narrow, swell, and may produce extra mucus, which makes it difficult to breathe), and diabetes type 2 (a chronic condition that affects the way the body processes blood sugar). Resident's minimum data set (MDS, a clinical assessment tool) dated 7/18/2023 indicated Resident 1's brief interview for mental status (BIMS) score of 15 of 15 (13-15 score means a intact cognition). During observation and interview with Resident 1 on 7/24/2023 at 10:25 a.m., Resident 1 stated she was feeling hot in room [ROOM NUMBER] and started upon admission to the facility. Resident 1 also stated room [ROOM NUMBER] was getting hotter by noon every day from last one week or so. Resident 1 further stated no cool air coming into room [ROOM NUMBER] and the facility provided a small electric fan to her but the fan was not able to keep up the cool air in the room [ROOM NUMBER]. Review of Resident 2's face sheet indicated Resident 2 admitted to facility on 2/20/2018 with diagnoses including atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), hypertension (a condition in which the force of the blood against the artery walls is too high), and dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life). Resident 2 had a resposible party 1 (RP 1- person acting on behalf of the resident for day-to-day decision making for resident) for decision making. Resident 2's MDS assessment dated [DATE] indicated Resident 2's BIMS score of 3 of 15 (0-7: severely impaired cognition). During an interview with Resident 2's RP (RP 1) on 7/24/2023 at 1:10 p.m., RP 1 stated room [ROOM NUMBER] feels hot every time when he was visiting Resident 1. RP 1 also stated he was sweating in the room [ROOM NUMBER] during his visits, and he was concerned for Resident 2 for the high temperature in the room [ROOM NUMBER]. During a concurrent observation and interview with facility's Maintenance director (MD) on 7/24/2023 at 12:40 p.m., MD checked temperature in room [ROOM NUMBER] using facility's laser thermometer (LT: non-contact thermometer designed to accurately measure temperature from a distance). MD confirmed current temperature in the room [ROOM NUMBER] was 88 degrees Fahrenheit and no cold air coming through air-condition vent (a small opening responsible to redirecting cooled air into the room) located on room [ROOM NUMBER]'s ceiling. MD stated room [ROOM NUMBER]'s temperature should have been between 71 to 81 degrees Fahrenheit. Review of Resident 3's face sheet indicated Resident 3 was admitted to facility on 6/23/2023 with diagnoses including atherosclerotic heart disease (narrow of arteries close to heart), diabetes type 2, chronic kidney disease (mild to moderate damage to kidneys), dementia, and hypertension. Resident 3 had a RP for decision making. Resident 3's MDS assessment dated [DATE] indicated his BIMS score was 3 of 15. Resident 3 had a severed impaired cognition. During an interview with Resident 3's RP 2 (RP 2) on 7/24/2023 at 1:01 p.m., RP 2 stated room [ROOM NUMBER] feels always hot when visiting Resident 3 and no cold air coming through vent located on ceiling of the room [ROOM NUMBER]. RP 2 also stated she complained about the heat in the room [ROOM NUMBER] during recent heat wave and the facility provided electric fan to Resident 3 and after few days later staff took that fan away from room [ROOM NUMBER] to use inside the facility staff office. RP 2 confirmed no actions were taken after she complained to administrator a week ago for high temperature in room [ROOM NUMBER]. During a concurrent observation and interview with MD on 7/24/2023 at 1:32 p.m., MD checked temperature in room [ROOM NUMBER] using LT and he confirmed room [ROOM NUMBER]'s temperature was 87 degrees Fahrenheit. MD stated facility's air-conditioner was not working for about a week and there was no cool air coming through the vent for room [ROOM NUMBER]. Review of Resident 4's face sheet indicated Resident 4 was admitted to facility on 1/18/2023 with diagnoses including trimalleolar fracture of left leg (broken left ankle joint), congestive heart failure, epilepsy (a disorder in which nerve cell activity in the brain disturbed, causing seizures [a sudden, uncontrolled burst of electrical activity in the brain]), diabetes type 2, and hypertension. Resident 4's MDS assessment dated [DATE] indicated Resident 3's BIMS score 15 of 15, intact cognition. During an interview with Resident 4 on 7/24/2023 at 1:15 p.m., Resident 4 stated room [ROOM NUMBER] feels hot all day. Resident 4 also stated there was no fan in room [ROOM NUMBER]. Resident 4 further stated staff were aware of heat in room [ROOM NUMBER], no one fixing. During a concurrent observation and interview with MD on 7/24/2023 at 1:35 p.m., MD checked temperature in room [ROOM NUMBER] using LT and confirmed temperature in room [ROOM NUMBER] was 88 degrees Fahrenheit. During a concurrent observation and interview with MD on 7/24/2023 at 2:10 p.m., MD checked temperature in hallway near nurse's station. MD confirmed temperature was in hallway was 90 degrees Fahrenheit. MD stated three of seven air-conditioner units were not working in the facility about a week and the date to repair was on 7/28/2023. MD also stated temperature in resident rooms, and in hallways should have maintained between 71 to 81 degrees Fahrenheit all the time. During an interview with certified nursing assistance A (CNA A) on 7/24/2023 at 2:20 p.m., CNA A stated past several days there were few residents were complaining about hot temperature, and no cool air coming from vents in their rooms. CNA A also stated facility's MD was aware about the residents concern. CNA A further stated electric fans in resident's rooms and hallways were helping to keep temperature low in the facility during this heat weather. During an interview with facility's administrator (ADMN) on 7/24/2023 at 4:00 p.m., ADMIN stated three of seven air-condition units currently not working in the facility started on 7/18/2023. ADMN scheduled a repair on 7/28/2023 regarding the air conditioning . ADMN also stated facility was using temporary cooling system with electric fans to reduce temperature in resident ' s rooms and facility hallway. ADMN further stated temperature in the facility should have been maintained between 71-81-degree Fahrenheit. During a review of the facility's policy and procedure (P&P) tilted, Air Temperature Readings, undated, the P&P indicated, Investigate air temperature complaints. The acceptable range for air temperature is 71degrees to 81 degrees F.

Based on observation, interview, and record review, the facility failed to ensure residents had an environment free from accident hazards when red sharps (objects with sharp points or edges such as needles or syringes) containers were left open, unattended, and accessible on two out of three medication carts. This failure had the potential to put residents and staff at risk for injuries from needlesticks and sharp objects. Findings: During a concurrent observation and interview on 4/24/23, at 12:33 p.m., at Medication Cart 2, with registered nurse B (RN B), a red sharps container was observed sitting on top of the medication cart. The lid was open and the container was approximately 70-80% full. RN B placed a used insulin syringe and needle into the open container on top of the cart. She stated she agreed that the sharps container can be tampered with by residents who are curious, or those with dementia who might want to put their hands in or dump the contents out. RN B stated the sharps container on the side of the medication cart did not have a lid and that's why she had to use this container on top of the medication cart. During an observation on 4/24/23, at 12:39 p.m., at medication cart 3 in the nursing station, another red sharps container was observed sitting on top of the medication cart, near a laptop, unattended, with the lid open. The container was approximately 30% full. During an interview on 4/24/23, at 12:43 p.m., with licensed vocational nurse C (LVN C), she confirmed the sharps container was opened on top of the cart, unattended, and contained lancets (used to prick the skin) and syringes. She agreed it was hazardous and stated, The sharps container on the side of the medication cart ran out of lids that's why we have to use this one. LVN C removed the sharps container from the top of the medication cart and placed it inside the drawer. During an interview on 4/24/23, at 3:15 p.m., with the LVN D, he stated, We are waiting for the [sharps] containers that fit in the medication cart and we are using those [sharps] containers in the meantime. During an interview on 4/25/23, at 8:58 a.m., with the infection preventionist (IP), regarding sharps containers left open, unattended, on top of medication carts, and accessible to anyone, she agreed that it was dangerous and stated, We ran out of rectangle bins for the carts and those containers are used as substitute. For the ones they are using, they should be locked in the [medication] cart when they leave the cart. It should not be left unattended. During a review of the facility's undated policy and procedure titled, Wastes & Cleaning Practices indicated, Contaminated sharps are discarded immediately .in containers that are closable . Ensure that sharps containers are not opened, emptied, or cleaned manually in or in any other manner which would expose employees to the risk of percutaneous (through the skin) injury [penetration of skin by a contaminated needle or sharp object] .

Based on observation, interview, and record review, the facility failed to provide care and services in accordance with professional standards of practice for four of 18 sampled residents (Residents 35, 37, 23, and 172) when: 1. For Resident 35, the facility failed to change the wound dressing as ordered and failed to label the wound dressing with the initial, date, and time; 2. For Resident 37, medication was left unattended in the room; 3. Creatinine with estimated glomerular filtration rate (creatinine with eGFR, a test that measures the level of kidney function and determines the stage of kidney disease) test was not done for Resident 23 as ordered; and 4. The wound care nurse (WCN) did not provide treatment to Resident 172's sacrum wound as ordered by the physician. These failures had the potential to negatively affect the health and safety of the residents. Findings: 1. Review of Resident 35's clinical record indicated he was admitted on [DATE] and had the diagnosis of diabetes (a disease that causes high blood sugar), chronic venous insufficiency (improper functioning of the vein valves in the leg, causing swelling and skin changes). Review of Resident 35's physician order, dated 4/23/2023, indicated a left medial heel (LMH) open blister: Cleanse with normal saline, pat dry, and apply Puracol plus collagen (a native collagen wound dressing that promotes natural healing) every other day and cover with Opti foam (Silicone Faced Foam Dressing provides gentle adhesive to create an optimum healing condition) then reassess after 21 days. Left medial shin (LMS) open area: Cleanse with normal saline, pat dry, and apply Puracol plus collagen every other day and cover with Opti foam, then reassess after 21 days. During a concurrent observation and interview with the Licensed Vocational Nurse D (LVN D) in Resident 35's room on 4/28/2023 at 11: 21 a.m., Resident 35's LMS open area was covered with a dressing dated 4/23/2023 by the wound care nurse (WCN). LMH open blister was covered by an Opti foam dressing with brownish drainage, and no initial, date and time was noted on the dressing. LVN D confirmed the above observation and stated the LMS dressing should have been changed on 4/25/23 and 4/27/23 and those two missed treatments could cause infection and delay the wound healing. The nurse should have labeled the LMH dressing with the initial, date, and time. During a phone interview with LVN K on 4/28/2023 at 3:39 p.m., she confirmed that she did not change the LMS dressing for Resident 35 on 4/25/2023 and 4/27/2023 and accidentally charted as completed on those two days. During an interview with the WCN on 4/28/2023 at 4:05 p.m., he verified that LVN K did not change the LMS dressing on 4/25 and 4/27 as ordered, and LVN K should have labeled the LMH dressing with the initial, date, and time for next shift nurse to follow up. A review of the facility's undated policy and procedure titled Wound Care and Treatment indicated, .verify that there was a physician's order for this procedure . The policy and procedure also indicated, dress wound .mark tape with initials, time and date then apply to dressing . 44733 2. During an observation and interview on 4/24/23 at 9:45 a.m., there was one medication in a medication cup on the window frame. Resident 37 stated the night shift nurse gave to her, but she didn't take the medication. Review of Resident 37's physician order dated 2/22/23 indicated: Omeprazole (acid reducer) 20 milligram (mg, a type of unit measurement) 1 capsule oral before breakfast for GI (gastrointestinal) prophylaxis once a day at 6:30 am. During a concurrent observation and interview with registered nurse B (RN B) on 4/24/23 at 9:45 a.m., she confirmed the medication was left unattended and stated the medication should have not be left unattended in the room. RN B stated the nurse should have verified Resident 37 if she took her medication. Review of the facility's undated policy Oral Medication Administration, indicated Purpose was to administer oral medications in an accurate, safe, timely, and sanitary manner. Procedure: 10. Verify that medications are actually taken. 37409 3. Review of Resident 23's physician order indicated she had an order for creatinine with estimated glomerular filtration rate (creatinine with eGFR, a test that measures the level of kidney function and determines the stage of kidney disease) on the second Monday of March and September, started on 3/25/19. But creatinine with eGFR test results were not found for 3/2020, 9/2020, and 9/2021. During an interview with the director of nursing (DON) on 4/28/23 at 4:37 p.m., she reviewed Resident 23's clinical record, verified with the laboratory staff, and confirmed the creatinine with eGFR test was not done for Resident 23 in 3/2020, 9/2020, and 9/2021. The DON stated Resident 23's creatinine with eGFR test should have been completed 4. Review of Resident 172's Admission Record indicated he was admitted to the facility on [DATE] with diagnoses including sepsis (a serious condition in which the body responds improperly to an infection) and pressure ulcer (damage to an area of the skin caused by constant pressure on the area for a long time). Review of Resident 172's physician order, dated 4/16/23, indicated he had an order to cleanse his sacrum wound with normal saline (NS, a 0.9% sterile solution of salt in water), pat dry, apply Cavilon (used to treat skin irritation) to the periwound skin, apply Eakin ring moldable barrier (helps prevent leaks and skin irritation by forming an absorptive barrier) to the inferior edge, pack the wound with Aquacel Ag (antimicrobial primary dressings), then cover with several 4 by 4 inch gauzes to make sure Aquacel Ag contact with wound bed, then cover with large Mepilex (absorbent foam dressing) every two days and as needed. During a wound treatment observation with the WCN on 4/26/23 at 10:50 a.m., the WCN cleansed Resident 172's sacrum wound with NS, patted dry, applied Cavilon to the periwound skin, applied Eakin ring moldable barrier to the inferior edge, packed the wound with Aquacel Ag, then cover with Mepilex. The WCN did not cover the wound with several 4 by 4 inch gauzes to make sure Aquacel Ag contact with the wound bed. During an interview with the WCN on 4/26/23 at 11:45 a.m., he confirmed that he did not cover the wound with several 4 by 4 inch gauzes to make sure Aquacel Ag contact with the wound bed. The WCN stated he should follow the physician's order. Review of the California Board of Registered Nursing website, California Business and Professions Code, Division 2, Chapter 6, Article 2, Section 2725(b)(2), indicated registered nurses should ensure the safety, protection of residents; administration of medications, and therapeutic agents, necessary to implement a treatment, disease prevention, ordered by and within the scope of the licensure of a physician.

Based on observation, interview, and record review, the facility failed to maintain proper infection control practices when: 1. Resident 17's suction tubing and canister were undated; 2. The wound care nurse (WCN) placed Resident 172's urine bag on his bed and let it touching the floor, opened Resident 172's night stand with contaminated gloved hand, and asked certified nursing assistant L (CNA L) to hold the clean dressing on Resident 172's left heel wound with her contaminated gloved hand; 3. Speech therapist (ST) did not practice standard precautions; 4. CNA did not use proper personal protective equipment (PPE) for contact precautions; 5. CNA wore PPE in the hallway and disposed of a unsealed trash bag from the contact isolation room on the storage room floor. 6. Registered Nurse B (RN B) failed to disinfect the rubber stopper of a medication vial before inserting the adaptor (a device) to dilute the medication; and 7. RN B did not properly dispose of personal protective equipment (PPE, gown and gloves) in the dedicated receptacle for one resident (Resident 274) with contact precautions (anyone entering the room is required to wear a gown and gloves). These failures have the potential to result in transmission of infection among residents. Findings: 1. Review of Resident 17's Admission Record indicated she was admitted to the facility on [DATE] with pneumonitis (inflammation of the lungs) diagnosis. Review of Resident 17's physician order indicated she had an order for oral suction as needed for excessive secretion, started on 2/25/23. During an observation and interview with registered nurse A (RN A) on 4/24/23 at 9:21 a.m., Resident 17's suction tubing and canister were undated. RN A stated Resident 17's suction tubing and canister should be dated. During an interview with the infection preventionist (IP) on 4/28/23 at 2:05 p.m., she stated the suction tubing and the canister should be dated. Review of the facility's undated policy, Cleaning and Disinfecting Emergency Suction Equipment, indicated Procedure: . 3. Discard suction catheter, disposable canister, and tubing into designated receptacle if the canister is 3/4 full of secretions and no longer than weekly replacements. 2. Review of Resident 172's Admission Record indicated he was admitted to the facility on [DATE] with diagnoses including sepsis (a serious condition in which the body responds improperly to an infection) and pressure ulcer (damage to an area of the skin caused by constant pressure on the area for a long time). During a wound treatment observation with the WCN and CNA L on 4/26/23 at 10:50 a.m., the WCN started the pressure ulcer treatment on Resident 172's sacrum (the large, triangle-shaped bone in the lower spine that forms part of the pelvis) and left heel by picked up Resident 172's urine bag which was hung on his bed side and put it on Resident 172's bed. While cleansing Resident 172's wound on his sacrum, the WCN noticed Resident 172 had feces at his anus area. The WCN wiped the feces with gauzes then opened Resident 172's night stand and got the wipe package with his gloved contaminated hand and asked CNA L to cleanse Resident 172's anus area. After cleansing and applying treatment and the clean dressing on Resident 172's left heel, the WCN needed to cut the abdominal pad, so he asked CNA L to hold the clean dressing on Resident 172's left heel with the same gloved hand that she turned Resident 172, held him, wiped his anus area, and put on the diaper for him. After the treatments were done, CNA L picked up the urine bag on Resident 172's bed and handed to the WCN. Instead of hanging the urine bag on the bed side, the WCN let it freely hung down from Resident 172's bed, and the urine bag was touching the floor. During an interview with the WCN on 4/26/23 at 11:45 a.m., he stated the urine bag should not be placed on the resident's bed and should not be touching the floor. The WCN stated he should remove the gloves and cleanse his hands before opening Resident 172's night stand for the wipe package, and CNA L should have remove the gloves and cleanse her hands before holding the clean dressing on Resident 172's left heel wound. During an interview with the infection preventionist (IP) on 4/28/23 at 2:02 p.m., she stated the urine bag should not be placed on the resident's bed and should not be touching the floor. The WCN should have remove the gloves and cleanse his hands before opening Resident 172's night stand, and CNA L should have remove the gloves and cleanse her hands before holding on the clean dressing on Resident 172's left heel wound. Review of the facility's undated policy, Standard Precautions, indicated Procedure: . 4. Gloves: . Remove gloves promptly after use, and wash hands immediately before touching non-contaminated items and environmental surfaces, and before going to another resident. Review of the facility's undated policy, Indwelling Catheter Care, indicated Fundamental Information: Maintenance: . Keep the drainage tube and collection bag lower than bladder at all times . Procedure: . 18. Attach collection bag, below bladder level, to bed frame. 44733 3. During an observation on 4/24/23 at 12:37 p.m., ST G came out of one resident room with a coffee cup. ST G put the cup on top of the meal tray cart and entered another room without hand hygiene. During an interview with ST G on 4/24/23 at 12:38 p.m., ST G confirmed the observation and stated she should have performed hand hygiene after touching the cup. During an interview with infection preventionist (IP) on 4/28/23 at 2:11 p.m., she stated facility staff should perform hand hygiene after contact with any subject. Review of the facility's undated policy Standard Precautions, indicated, All employees are expected to practice standard precautions to reduce both the risk of transmitting infections and the likelihood of exposure to bloodborne pathogens. Wash hands after touching or coming in contact with blood, body fluids, secretions, excretions and contaminated items. 4. During an observation on 4/24/23 at 12:43 p.m., CNA H entered one resident room on contact precaution to distribute a lunch tray without gloves and/or a gown. The signage for contact precaution was placed on the room door, and a personal protective equipment (PPE) cabinet was placed next to the room door. During an interview with licensed vocational nurse I (LVN I) on 4/24/23 at 12:43 p.m., he confirmed the observation. LVN I stated CNA H should have used proper PPE for contact precautions, like gloves and a gown, when entering the room. During an interview with CNA H on 4/24/23 at 12:45 p.m., he confirmed the observation and stated he did not know the room was on contact precaution. CNA H stated he should have used gloves and gown when entering the room. Review of the facility's undated policy Transmission Precautions: Contact, indicated, Wear clean, non-sterile gloves when entering the room. Wear a clean, non-sterile gown upon entering the resident's room. 46001 5. Review of Resident 274's clinical record indicated he was admitted on [DATE] and had the diagnoses, including bacteremia (the presence of bacteria in the bloodstream). A review of Resident 274's physician order, dated 4/17/2023, indicated resident was on contact isolation from 4/17/2023 to 5/3/2023 for MDRO (a multidrug-resistant organism resistant to many antibiotics) enterobacter urinary tract infection. During a concurrent observation and interview with the infection preventionist (IP) on 4/25/2023 at 11: 25 a.m., in the hallway. The Certified Nursing Assistant O (CNA O) was walking in the hallway with full PPE (equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses), including a gown, a head cover, and a pair of gloves and shoe covers. She held a trash bag, opened the storage room with her gloved hand, and threw the trash bag on the floor. The IP stated that CNA O should not wear any PPE in the hallway. She further stated that the shoe covers contaminated the hallway floor, and the glove contaminated the storage doorknob, potentially spreading infection in the facility. During an interview with the CNA O on 4/25/2023 at 11:33 a.m., she stated that she came into Resident 274's contact isolation room to pick up the trash and should have taken off the PPE before leaving the isolation room. She further stated that she might spread germs to the facility. During a concurrent observation and an interview with IP P on 4/25/2023 at 11:43 a.m., in front of the storage room. Observed the trash bag from 274's isolation room was on the floor and open to the air. IP P verified the above observation and stated Resident 274 was on contact isolation for MRSO, and the staff Should seal the trash bag and should not dispose of the trash bag on the floor. During an interview with the Director of Nursing (DON) on 4/28/2023 at 2:06 p.m., the DON stated that the CNA should have sealed the wastes from the contact isolation room in a plastic bag and disposed of it in a trash can with a lid to prevent spreading of infectious and contiguous disease. A review of the facility's undated policy and procedure titled Personal Protective Equipment Guidelines, indicated, remove PPE after it becomes contaminated, and before leaving the work area. A review of the facility's undated policy and procedure titled Standard Precautions, indicated, remove gloves promptly after use, and wash hands immediately before touching non-contaminated items and environmental surfaces, and before going to another resident A review of the facility's undated policy and procedure titled wastes and cleaning practices, indicated, seal waste materials from regulated waste receptacles in regulated waste collection boxes. 46393 6. During a medication pass observation for Resident 274 on 4/24/23, at 8:53 a.m., registered nurse B (RN B) was observed preparing an intravenous (IV, a way of giving a drug through a needle or tube inserted into a vein) medication, ceftriaxone (an antibiotic used to treat infections). RN B did not wipe the medication vial's rubber stopper after she removed the cap, proceeded to insert the adapter to the medication vial, and connected the saline (diluent) bag to the adapter. During an interview on 04/24/23, at 9:14 a.m., with RN B, she stated the medication vial is clean because it's covered with the cap. She stated, We clean if vial was opened like for insulin [used to treat diabetes], we clean top of vial before drawing insulin, but this one is covered with cap so I believe it's clean .not open to air. That is my understanding and that is the way we are doing it. On 4/24/23, a review of Resident 274's clinical record indicated a physician's order, dated 4/21/2023, for ceftriaxone 2 g (grams, unit of measure) intravenous (directly into a vein) twice a day, dated 4/14/23. During an interview on 4/25/23, at 8:58 a.m., with the infection preventionist (IP), she stated, nurses need to wipe the top of medication vials with alcohol and then they can poke it [with the adapter] even if there is a cap. The Association for Professionals in Infection Control and Epidemiology (APIC) is the leading professional association for infection preventionists. According to the APIC Position Paper On Safe Injection, Infusion, And Medication Vial Practices In Healthcare, dated January 2016, it indicated, Medication Vials . Disinfect the rubber septum on all vials prior to each entry, even after initially removing the cap of a new, unused vial. (https://www.apic.org/Resource_/TinyMceFileManager/Position_Statements/2016APICSIPPositionPaper.pdf) 7. During a medication pass observation for Resident 274 on 4/24/23, at 8:53 a.m., RN B was observed administering an IV medication, ceftriaxone. RN B left Resident 274's room to obtain new tubing (flexible plastic tube connected to the saline bag that delivers the IV medication into the vein), removed her gloves and gown, placed in the trash can next to resident's bedside. On 4/24/23 at 9:08 a.m., during the same medication pass observation, RN B returned to Resident 274's room with new tubing after re-gowned and new gloves. RN B programmed the IV medication pump (medical device that delivers medications into the body in controlled amounts) to deliver the IV medication, removed her gloves and gown, and placed into the trash can next to resident's beside again. During an interview on 4/24/23, at 9:14 a.m., with RN B, she stated, the PPE are supposed to be discarded in the proper receptacle. She continued, I put in the garbage bag, but I'm supposed to put in the covered trash can. A review of the signage affixed on Resident 274's room door indicated, CONTACT PRECAUTIONS EVERYONE MUST . Put on gown before room entry. Discard gown before room exit . Use dedicated or disposable equipment. During an interview with the IP on 4/25/23, at 8:58 a.m., she stated, nurses should use the black trashcan inside the room with a lid that was the designated receptacle for PPE, they cannot put [PPE] into the resident's trash can. During a review of the facility's policy and procedures titled Personal Protective Equipment (PPE) Guidelines, dated 2/7/22, it indicated, How to take off (Doff) PPE gear . Remove gown .dispose in trash receptacle.

Based on observation, interview, and facility document review, the facility failed to ensure food was stored and distributed and the kitchen floor was maintained in accordance with professional standards for food service safety when: 1. The resident food refrigerator was found out of the safe temperature range; 2. Multiple resident meal trays had crack, rough edges; 3. The floor below the dish machine had two broken tiles; and 4. The ice machines had rough whitish build up on parts. These failures had the potential to cause the growth of microorganisms or attract pests which could cause foodborne illness or cross contaminate food or ice (cross contamination occurs when unclean surfaces or utensils spread germs to food and could potentially cause foodborne illness) for the 68 residents eating at the facility. Findings: 1. During an observation on [DATE] at 8:33 a.m., the resident food refrigerator had one bag of shredded cheese inside. The two thermometers inside the refrigerator read 48 F (degrees Fahrenheit - a unit of temperature measurement) and 47 F and the cheese was 46 F. During a concurrent interview at that time, the director of nursing (DON) confirmed the observations and stated the refrigerator should have been 41 F or less and it was not safe to store foods in the refrigerator until the temperature gets down. During an observation and concurrent interview on [DATE] at 9:47 a.m., with the dietary services supervisor (DSS), the resident refrigerator was 48 F and there was no food inside and no sign on the outside saying not to use the refrigerator. DSS confirmed the observation. A review of facility document titled Temperature Log (for food) - Once Daily, undated, indicated Normal refrigerator temperature: ,d+[DATE] F (Fahrenheit) and Notify maintenance if temperature, ref (refrigerator) in nursing unit, was not within range. 2. During an observation on [DATE] at 11:12 a.m., approximately 80 pink resident meal trays were stacked by the trayline (equipment where hot foods for resident meals are served from). Approximately half of the pink meal trays had cracks on their corners, and most had chips and were rough to touch on the corners. Some cracks were large enough that the inside of the tray could be seen and white or black residue was in some cracks. During an interview at that time, the dietary services supervisor (DSS) confirmed the observation and said he is replacing the meal trays bit by bit. He pointed to approximately 20 maroon colored meal trays on the shelf below and stated he bought those to replace some of the cracked trays. During an observation on [DATE] at 11:54 a.m., during the lunch meal service in the kitchen, the pink trays from the stack described above were used for the resident lunch service. Review of facility document titled, Meal Service, dated 2023, indicated Plates and serving equipment; plates, cups, silverware, special feeding devices, that are chipped or unsightly will be discarded. According to the 2022 Food and Drug Administration (FDA) Food Code, non-food-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris and shall be free of unnecessary ledges, projections, and crevices. Non-food contact surfaces of equipment that are exposed to splash, spillage, or other food soiling or that require frequent cleaning shall be constructed of a corrosion-resistant, nonabsorbent, and smooth material and shall be cleaned at a frequency necessary to preclude accumulation of soil residues. The 2022 FDA Food Code Annex further explains that hard-to-clean areas could allow the growth of foodborne pathogenic microorganisms and the objective of cleaning is to remove soil from nonfood contact surfaces so that pathogenic microorganisms will not be allowed to accumulate. The presence of food debris or dirt on nonfood contact surfaces may provide a suitable environment for the growth of microorganisms which employees may inadvertently transfer to food. 3. During an observation on [DATE] at 8:08 a.m., two floor tiles under the dishmachine were cracked and missing pieces of tile exposing the floor beneath and sharp edges, water pooled in the gaps. During a concurrent interview at that time, the DSS stated he had reported the broken tiles to maintenance department three weeks ago and they plan to replace the tile. During an interview on [DATE] at 3:28 p.m., the DSS stated when there are issues in the kitchen they usually put them in the maintenance binder but the broken tiles were not in the binder. The DSS stated he sent an email with a list of maintenance issues in the kitchen to the Administrator (Admin) a couple of weeks ago and he would normally discuss issues like this with the Admin in the morning meeting. Review of facility document titled Dietary Problems, undated, sent as an attachment to an email sent [DATE] to Admin, indicated among other issues: Tile needs repair (cracked). During an interview on [DATE] at 9:08 a.m., the maintenance supervisor (MS) stated he was not aware of the broken tiles in the kitchen. He said usually the kitchen communicates maintenance issues to him through the maintenance binder, but broken tiles were not in the binder. He further stated sometimes the kitchen tells him issues verbally. During a concurrent observation and interview at that time in the kitchen, the MS confirmed there were two broken tiles under the dishmachine and they needed to be fixed. According to the 2022 FDA Food Code, floors shall be designed, constructed, and installed so they are smooth and easily cleanable. The 2022 FDA Food Code defines smooth as a floor, wall, or ceiling having an even or level surface with no roughness or projections that render it difficult to clean. The Food Code Annex further explains that floors that are of smooth, durable construction and that are nonabsorbent are more easily cleaned. Requirements and restrictions regarding floor coverings are intended to ensure that regular and effective cleaning was possible and that insect and rodent harborage was minimized. 4. During a concurrent observation and interview in the presence of the DSS on [DATE] at 9:51 a.m., at the ice machine in the kitchen, the MS stated he cleans the ice machine every month and the instructions for cleaning are inside the door of the machine. The MS said he empties the ice bin then cleans with warm water. He said he uses the descaler/cleaner (used to remove lime scale and mineral deposits which are a buildup of a white, chalk-like substance that forms where water collects or where water is dispensed) solution with the warm water, but does not use a sanitizer after cleaning. The MS removed the cover over the ice making part of the machine and inside the cover was a white, rough, crusty build-up that could be scraped off with a fingernail. The DSS confirmed the observation. The DSS stated the ice machine cleaning vendor just cleaned and sanitized the ice machine one to two weeks ago. The vendor cleans the machine every three to six months. The vendor was not able to remove the white build-up on the ice maker cover when they were here. During a concurrent observation and interview in the presence of the DSS on [DATE] at 10:07 a.m., at the dispenser ice machine in the nursing unit, the ice dispenser chute had a white, crusty ring around the bottom. The DSS confirmed the observation. The MS stated he cleans this machine with warm water and does not use a descaler/cleaner or sanitizer. He last cleaned it last month and he does not have the manufacturer's instructions for how to clean and sanitize the machine. The MS was not able to open up the machine so the inside could be seen. The DSS stated the ice machine cleaning vendor said this machine looked clean when they were here so they did not clean it and that they can only clean the outside. Review of facility documents Invoices from the ice machine cleaning vendor dated [DATE] and [DATE] indicated the vendor cleaned the ice machine in kitchen on these dates, but did not have any information regarding the ice machine at the nursing station. During an interview on [DATE] at 1:50 p.m., the DSS stated the maintenance department does not have logs for either ice machine for when ice machine cleaning was done by them. During an interview on [DATE] at 9:08 a.m., the MS stated he was not trained at the facility on how to clean the ice machines; he studied air conditioning in school so he already knew how to clean ice machines. Review of facility document titled 'Sanitation and Infection Control Subject: Cleaning Ice Machine', dated 2023, indicated ice machines will be cleaned and sanitized once a month, follow manufacturer recommendations to clean the internal mechanisms of the ice machine, and if another department is responsible for cleaning the ice machine, make sure the process is being followed according to policy for technique and time frame. The individual responsible must be properly trained by the manufacturer with approved competency. Review of facility documents (for the kitchen ice machine) titled 'Air/Water/Remote Condenser Ice Machines Technician's handbook' and 'Cleaning/Sanitizing Procedure' (from inside the door of kitchen ice machine), undated, indicated cleaning/sanitizing procedure removes mineral deposits from areas or surfaces that are in direct contact with water; ice machine cleaner is used to remove lime scale and mineral deposits, and depending upon the amount of mineral build-up, a larger quantity of (cleaner) solution may be required. Review of facility document (for the nursing station ice machine) titled 'Ice and Water Dispensers Operation and Service Manual', dated ,d+[DATE], indicated the recommended cleaning procedures that follow should be performed at least as frequently as recommended and more often if environmental conditions dictate - drain line - weekly, drain pan/drip pan weekly, exterior as needed, condenser monthly, dispenser and components, ice machine, transport tube, ice storage/bin - semi-annually. The manual further indicated cleaning of the condenser can usually be performed by facility personnel, and cleaning/descaling and sanitizing of the ice machine system should be performed by your facility's trained maintenance staff or a [Brand] authorized service agent. The manual further indicated a 38-step process for cleaning/descaling and sanitizing the machine semi-annually but more often if conditions dictate and indicated to use the manufacturer's ice machine cleaner/descaler and sanitizing products, a process for cleaning/ descaling and sanitizing the ice machine, and a process for cleaning/descaling and sanitizing the dispenser.