Every finding on record at Belmont Healthcare Center

Based on observation, interview and record review the facility failed to ensure food were stored and prepared in a sanitary manner when these were observed during kitchen tour:There was a dirty window screen next to an interior air conditioning (A/C) unit.There was a water collection tray under an interior A/C unit.There was a dirty filter screen on an interior A/C unit.Floors were not cleaned when: A. Two packets of creamers and four packets of sugar were found on the floor under a storage shelve; B. a small container of sherbet (frozen desert) and a used paper towel were found on the floor under a freezer.These failures had the likelihood for food items to be stored and prepared in an unsanitary environment.Findings: During a concurrent observation and interview with the Dietary Manager (DM) on 6/16/2026 at 9:53 AM, there were observed during initial kitchen tour:There was a dirty window screen next to an interior air conditioning (A/C) unit.There was a water collection tray under an interior A/C unit.There was a dirty filter screen on an interior A/C unit.Floors were not cleaned when: A. Two packets of creamers and four packets of sugar were found on the floor under a storage shelve; B. a 4 fluid ounce partially melted container of lime flavor sherbet and a used paper towel were found on the floor under a freezer.During the concurrent interview, the DM was asked how often staff were supposed to empty the water collection tray under the A/C unit. The DM was unable to provide documented evidence staff were emptying the water tray. Issues regarding stagnant water providing a reservoir for mold, algae, and a water source for pests were discussed with the DM. The DM was asked how often staff were supposed to clean the floor. The DM stated at least once a day. Review of the facility's policy titled GENERAL CLEANING OF FOOD & NUTRITION SERVICES DEPARTMENTS, dated 2023, indicated .Floors, floor mats, and walls must be scheduled for routine cleaning and maintained in good condition. I. Floors must be mopped at least once per day. 2. Sweep the floor, pushing all debris forward. Use a dust pan to remove and dispose of debris as it accumulates. Review of the facility's policy titled Departmental (Maintenance) - Plumbing, HVAC, and Related Systems, dated February 2026, indicated .Inspect air-conditioning unit drains and filters weekly. Change filters at least monthly during use. Discard soiled filters. Review of the facility's policy titled Routine Cleaning and Disinfection Policy, not dated, indicated .It is the policy of this facility to ensure the provision of routine cleaning and disinfection in order to provide a safe, sanitary environment and to prevent the development and transmission of infections to theextent possible.

Based on interview and record review, the facility failed to ensure that the resident representative (RR) for one of three sampled residents (Resident 1) were notified of a significant change in condition when Resident 1 experienced an unwitnessed fall with head injury. The RR was not notified until approximately more than seven hours after the incident, despite Resident 1 having impaired cognition and sustaining a documented head injury. This failure resulted in delayed awareness of Resident 1's condition by the RR, which hindered RR's timely involvement in care decisions.During a review of Brief Interview for Mental Status (BIMS) dated 01/26/2026 at 9:04 AM, the Brief Interview for Mental Status (BIMS) indicates Resident 1 has a BIMS score of 3, which means Resident 1 has severely impaired cognitive function. The BIMS score stands for Brief Interview for Mental Status, which is a short test used in nursing homes to see how well a resident's memory and thinking skills are working. A BIMS score of 3 means a resident has serious difficulty with memory or thinking. During a review of Change of Condition Fall dated 02/20/2026 at 12:52 AM, the Change of Condition Fall indicated Resident 1 had an unwitnessed fall on 02/20/2026 at 12:45 AM.During a review of Nurses Progress Note dated 02/20/2026 at 2:18 AM, the Nurses Progress Note indicated Resident 1 was found lying on their right side on the floor near the toilet and that Resident 1 had hit the right side of the head on the wall before falling to the floor and landing on the right side of the body. The Nurses Progress Note also indicated Resident 1 had a swelling on the right side of the head measuring 3 centimeters (cm). The Nurses Progress Note indicated the fall was reported to the on-call Nurse Practitioner (NP), but did not indicate that Resident 1's representative had been notified of Resident 1's fall that occurred on 02/20/2026 at 12:45 AM. On call NP means the NP is not actively working at that moment, but must be available to work if someone needs the NP.During a review of Post Fall assessment dated [DATE] at 3:25 AM, the Post Fall Assessment indicated Resident 1 had been ambulating and responding to bowel or bladder needs during the fall and the location of the fall took place in Resident 1's bathroom. The Post Fall Assessment also indicated Resident 1 had a history of falls, had impaired safety awareness, and a level of consciousness (LOC) that was alert with some forgetfulness. Resident 1 verbalized hitting the wall with the right side of their head to Registered Nurse 1 (RN 1), who had completed the assessment. The Post Fall Assessment indicated Resident Representative 1 (RR 1) was notified about Resident 1's fall on 02/20/2026 at 8:00 AM. During a review of NP note dated 02/20/2026 at 6:19 AM, the NP note indicated Resident 1 had a video call with the NP to evaluate Resident 1 for a fall with injury and that Resident 1 had hit the right side of their head resulting in a 3 cm swelling. The NP note indicated Resident 1 would stay in the facility for monitoring after the fall. During a review of Social Services Progress Note dated 02/20/2026 at 9:45 AM, the Social Services Progress Note indicated that Resident 1 was scheduled to be discharged [DATE] and Resident 1's resident representative agreed to transport Resident 1 to the emergency room (ER) according to a NP order. During a review of Nurses Progress Note dated 02/23/2026 at 10:29 PM, the Nurses Progress Note indicated it was a late entry note with effective date 02/20/2026 at 11:02 AM. The Nurses Progress Note indicated Resident 1's family member informed Registered Nurse 2 (RN 2) that Resident 1 had reported to the family member one episode of vomiting after the fall at approximately 9:30 AM on 02/20/2026. RN 2 notified the NP, who ordered immediate transfer of Resident 1 to the ER for further evaluation. During a review of Progress Note dated 02/20/2026 at 11:57 AM, the Progress Note indicated Resident 1 had been sent to the hospital ER at 10:10 AM as ordered by the NP for the unwitnessed fall. During a review of the Care Plan for Resident 1 dated from Resident 1's admission date of 01/23/2026 to that last revision date of 02/28/2026, the Care Plan indicated focus area, The resident has impaired cognitive function/impaired though processes related to neurological symptoms as evidenced by BIMS SCORE: 03. The focus area is associated with the intervention, Communicate with the resident/family/caregivers regarding residents capabilities and needs. The Care Plan also indicated the intervention related to falls as, Medical Doctor (MD) and Responsible Party (RP) notified was initiated on 02/25/2026, after Resident 1 was discharged from the facility on 02/20/2026.During an interview on 04/03/2026 at 10:12 AM with Resident Representative 2 (RR 2), RR 2 stated, Resident 1's RR 1 was informed about Resident 1's fall on 02/20/2026 at approximately 7:00 AM. RR 2 stated that the facility should have called 911 after Resident 1 fell and had Resident 1 sent to the hospital ER right away. RR 2 states the facility was unable to explain why the family was not notified about Resident 1's fall immediately after the fall. During an interview on 04/03/2026 at 12:03 PM with the Director of Nursing (DON), the DON confirms RN 1 did not document that the facility had notified Resident 1's family immediately after Resident 1 had an unwitnessed fall on 02/20/2026 at 12:45 PM. During an interview on 04/03/2026 at 1:46 PM with Resident Representative 1 (RR 1), RR 1 stated the facility called RR 1 at 8:20 AM on 02/20/2026, based on RR 1's personal phone record, to notify RR 1 of Resident 1's fall. Based on the documented timeline, RR 1 was notified more than seven hours after the fall occurred. RR 1 stated RR 1 had initially thought Resident 1's fall had just happened at the time of the call at 8:20 AM on 02/20/2026, but during the call RR 1 found out Resident 1's fall had happened on 02/20/2026 at 12:45 AM. RR 1 wanted the facility to have called 911 and notified RR 1 immediately after Resident 1 had a fall. RR 1 stated that the family have the right to know about Resident 1's condition and would have gone to the facility immediately if the facility would have notified the family. RR 1 stated RR 1 arrived at the facility on 02/20/2026 at around 9:00 AM after learning about Resident 1's fall. RR 1 stated that Resident 1 reported to RR 1 that Resident 1 had vomited the morning of 02/20/2026 and as a result was sent to the hospital ER by paramedics and was later admitted to the hospital.During a review of the hospital After Visit Summary dated 02/25/2026, the hospital After Visit Summary indicated Resident 1 was admitted to the hospital from [DATE] to 02/25/2026. During an interview on 04/03/2026 at 2:30 PM with the Director of Nursing (DON), the DON stated the appropriate time frame for notifying the physician and family after a fall depends on what time it is, maybe within eight hours or so. During a review of the facility's policy and procedure titled, Assessing Falls and Their Causes, dated March 2018, indicated, notify the resident's attending physician and family in an appropriate time frame and, notify the following individuals when a resident falls: the resident's family, the attending physician, the director of nursing services, and the nursing supervisor on duty.

Based on observation, interview and record review the facility failed to ensure the accuracy of the Minimum Data Set (MDS, an assessment tool) for two (2) of six (6) sampled residents (Residents 1 and 2) when: 1. For Resident 1, the number of Pressure Injury (PI, a localized injury to the skin and/or underlying tissue, usually over a bony prominence, as a result of intense and/or prolonged pressure, or pressure in combination with shear), Stage 1 (intact skin with non-blanchable redness of a localized area usually over a bony prominence), was inaccurately coded as two (2) instead of one (1) on the MDS, section M. 2. For Resident 2, the number of PI, Stage 3 (full thickness tissue loss. Subcutaneous fat maybe visible but bone, tender or muscle is not exposed. Slough maybe present but does not obscure the depth of tissue loss) was inaccurately coded as four (4) instead of three (3) on MDS, section M. These deficient practices had the potential to negatively affect the care and services rendered to the residents. Findings: 1.Record review of the Face Sheet dated 6/10/25 indicated, Resident 1 was admitted to the facility on [DATE]. In an interview on 6/10/25, at 10:14 AM, with the Wound Care Nurse (WCN 1), WCN 1 stated, Resident 1 has PI in the coccyx (tailbone), it's resolving. Record review of the History and Physical (H&P) dated 4/29/25 indicated, the diagnoses that included subdural hematoma (a buildup of blood on the surface of the brain), vascular dementia (changes to memory, thinking, and behavior caused by reduced blood flow to the brain), Parkinson's disease (movement disorder). In a concurrent record review and interview on 6/10/25, at 11:20 AM, with the MDS Coordinator (MDS-C1), the admission MDS dated [DATE], was reviewed. The MDS section M0300, Current number of Unhealed Pressure Ulcers/injuries at Each stage, A. Stage 1, was reviewed. The MDS section M0300 section A. Stage 1 indicated, 1. Number of Stage 1 PI was marked 2 (two) in the box next to it. The MDS-C1 stated, the resident has one (1) Stage 1 pressure injury in the coccyx, but it was documented two (2). The MDS-C1 stated, he has to do the search to determine the number of PI since the MDS assessment was done by another MDS Coordinator, not him. After searching the Treatment Administration Record (TAR) and the Nurse's Progress Notes, (NPN), the MDS-C1 verified there was only one PI, Stage 1, not two, I don't see the other location (body areas) for Stage 1. 2. Record review of the Face Sheet indicated Resident 2 was admitted to the facility on [DATE]. In an interview on 6/10/25, at 10:20 AM, with the WCN 1, WCN 1 stated, Resident 2 has three (3) PIs: on the left shin, left heel, and left lateral malleolus (bony knob on the side of the ankle), it's now healing. Record review of the H&P dated 5/15/25 indicated, the diagnoses that included acute blood loss, upper gastrointestinal hemorrhage (bleeding occurs in the upper parts of the digestive tract), and chronic ulcer of left lower leg. In a concurrent record review and interview, on 6/10/25, at 11:30 AM, with the MDS-C1, the admission MDS dated [DATE], was reviewed. The MDS, section M0300, Current number of Unhealed Pressure Ulcers/injuries at Each Stage, section C. Stage 3 indicated, the Number of Stage 3 PI was marked four (4) in the box next to it. The MDS-C1 stated he has to search the TAR and the NPN to determine the number of the PI since another MDS coordinator has done the assessment and after searching the TAR and the NPN, the MDS-C1 verified, the resident has three (3) PI, Stage 3, not four (4) as documented. In an interview on 6/10/25 at 2:20 pm with the Facility Administrator -in Training (FA-iT), FA-iT stated, the facility followed the Resident Assessment Instrument (RAI,) Manual (a comprehensive process used to evaluate a resident's functional status, strengths, and needs). Record review of the CMS (Centers for Medicare & Medicaid Services) for Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, dated 10/24 indicated, Steps for Assessment: 1. Perform head-to-toe assessment. Conduct a full body skin . (sacrum, buttocks, heels, ankles, etc. 2. For the purposes of coding, determine that the lesion being assessed is primarily related to pressure and that other conditions have been ruled out.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure staff implemented enhanced barrier precautions (EBP) and wore the appropriate personal protective equipment (PPE) while providing care for 1 (Resident #25) of 2 residents reviewed for tube feedings. Findings included: A facility policy titled, Enhanced Barrier Precautions, revised 11/14/2024, revealed, It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms. 'Enhanced barrier precautions' (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and gloves use during high contact resident care activities. The policy indicated, 2. Initiation of Enhanced Barrier Precautions: included b. An order for enhanced barrier precautions will be obtained for residents with any of the following: i. Wounds (e.g. [exempli gratia, for example] chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and chronic venous stasis ulcers) and/or indwelling medical devices (e.g., central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes, hemodialysis catheters, PICC [peripherally inserted central catheter] lines, midline catheters) even if the resident is not known to be infected or colonized with a MDRO [multi-drug resistant organism]. The policy revealed, 3. Implementation of Enhanced Barrier Precautions: included b. PPE for enhanced barrier precautions is only necessary when performing high-contact care activities and may not need to be donned prior to entering the resident's room. According to the policy, 4. High-contact care activities include: g. Device care or use: central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes, hemodialysis catheters, PICC lines, midline catheters. An Admission Record indicated the facility readmitted Resident #25 on 11/09/2020. According to the Admission Record, the resident had a medical history that included diagnoses of dysphagia (difficulty swallowing) following cerebral infarction (stroke) and gastrostomy status (feeding tube). A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/23/2024, revealed Resident #25 had severe impairment in cognitive skills for daily decision-making and had a short-term and long-term memory problems per a Staff Assessment of Mental Status (SAMS). The MDS indicated the resident had a feeding tube and received 51% of their total calories and 501 cubic centimeters (cc) of fluid a day through the feeding tube. Resident #25's care plan included a focus area revised 08/03/2024, that indicated the resident required EBP due to having a gastrostomy tube. Interventions directed staff to clean their hands before and when leaving the room; to wear gloves and a gown for device care and when using feeding tubes; and to instruct certified nurse assistants (CNAs) and licensed nurses regarding proper use of personal protective equipment. Resident #25's Order Summary Report for active orders as of 12/05/2024 revealed an order dated 08/01/2024 for enhanced barrier precautions related to the presence of a gastrostomy tube. During an observation on 12/04/2024 at 12:33 PM, Registered Nurse (RN) #1 entered Resident #25's room wearing a surgical mask and gloves, with no gown. RN #1 checked the placement of the resident's gastrostomy tube and residual. RN #1 also connected the resident's feeding to a pump and started the pump, while still not wearing a gown. During an interview on 12/05/2024 at 10:58 AM, RN #1 confirmed that he did not wear the proper PPE when setting up the tube feeding for Resident #25. He stated he was nervous and forgot. RN #1 stated he should have worn a gown while providing care to help prevent the spread of infection. During an interview on 12/05/2024 at 10:52 AM, the Infection Control Preventionist (ICP) stated EBP should be used for any resident that had an indwelling device, and the staff should wear a gown and gloves when providing care. He stated he provided training on EBP in November 2024. During an interview on 12/05/2024 at 11:56 AM, the Director of Nursing (DON) stated if a resident was on EBP, the staff should wear a gown, gloves, and a mask to help prevent the spread of infection to staff and other residents. She stated EBP was needed for residents that had feeding tubes. She stated RN #1 should have put on a gown and gloves prior to providing care to Resident #25. During an interview on 12/05/2024 at 12:16 PM, the Administrator stated EBP should be used for the safety of the residents, and he expected that the staff to use the appropriate PPE when providing care for a resident that was on EBP.

Based on interview and record review, the facility failed to implement fall care plans for two of 3 sampled residents (Resident 1 and Resident 2) when there was no evidence of frequent monitoring. This failure had the potential to delay the identification of needs, functional and health status for Resident 1 and Resident 2. Findings: 1. Review of Resident 1's clinical record indicated, Resident 1 was [AGE] year-old female, and admitted to the facility with diagnoses including hypertension (high blood pressure), diabetes (high blood sugar), hyperlipidemia (an excess of lipids or fats in your blood). Review of Resident 1's Minimum Data Set (MDS, resident assessment tool), dated 6/10/22, indicated, Resident 1 was cognitively moderately impaired. During a concurrent interview and record review on 6/13/24 at 1:39 PM with Assistant Director of Nursing (ADON), Resident 1's Resident Incident Report dated 6/25/22, and fall care plans were reviewed. The Resident Incident Report indicated, . After few minutes of taking her routine medicines. Noted resident found facing down the floor inside in her room. Noticed bruise on the right eye and episode of nose bleeding. This nurse called 911, resident is conscious (aware of and responding to one's surroundings) but still remains in the floor while waiting with paramedics and approximately at 8:25 pm resident was sent out to XXXX (hospital name) . ADON stated, it was an unwitnessed fall, and Resident 1 was at high risk for fall. ADON stated, the nurse called 911 because Resident 1 had a bruise on the right eye, and she was transferred to the hospital right after vital signs (measurements of the body's most basic functions such as blood pressure) were checked. Review of Resident 1's fall care plan, initiated 6/28/22 indicated, . frequent monitoring of the resident . ADON stated, they didn't have the evidence of frequent monitoring when asked. He stated, frequent monitoring meant checking a resident within 2 hours as standard of practice. During an interview on 6/13/24 at 3:21 PM with ADON, ADON disputed this surveyor's finding that there was no evidence of frequent monitoring per care plan of 6/28/22, but did not show any evidence when asked. 2. Review of Resident 2's clinical record indicated, Resident 2 was [AGE] year-old male, and admitted to the facility with diagnoses including dementia (memory loss), hypertension, and diabetes. Review of Resident 2's MDS dated [DATE] indicated, Resident 2 was cognitively severely impaired. During a concurrent interview and record review on 6/13/24 at 11:20 AM with ADON, Resident 2's Patient Incident Report and Follow-up dated 12/28/23, and Morse Fall Scale (a rapid and simple method of assessing a resident's likelihood of falling) dated 10/27/23 were reviewed. The incident report indicated, . Patient last seen at 1 am while doing routine rounds sleeping . Then at 2am CNA assign was about to give her Christmas present to him, but patient found lying down on the floor next to the bathroom on his room . Per patient statement He got up and tried to walk towards the bathroom and when he was closer to the bathroom loss his balance but he was able to hold on to the bathroom door frame and slowly falling the floor without hitting his head . no bruises, no skin breakdown was noted . ADON verified, Resident 2 fell on [DATE] at 2 AM. Review of Resident 2's Morse Fall Scale (MFS) dated 10/27/23 indicated, the scale was 75. The MFS also indicated, . High Risk 45 and higher ADON stated, Resident 2 was at high risk for fall even before the fall. During a concurrent interview and record review on 6/13/24 at 11:28 AM with ADON, Resident 2's fall care plan with initiated date of 7/17/23 was reviewed. The fall care plan indicated, . Check resident for safety every 2 hours . ADON stated, We don't have. I don't think I have this . There is no evidence . when asked if the facility had the evidence of monitoring safety every 2 hours. He stated, Yes when asked if the facility should have done 2 hours monitoring per the care plan. During a concurrent interview and record review on 6/13/24 at 11:35 AM with ADON, Resident 2's Q Shift charting (Nursing) dated 12/29/23 was reviewed. The nursing record indicated, . Patient was sent to #### (name of the hospital) . Patient c/o (complained of) pain from fall on left hip . Xray (an examination to show images of a resident's internal organs or bones) ordered and results show possible hip fracture (broken hip) . ADON stated, there was no injury at the time of Resident 2's fall on 12/28/23, but they found the fracture on X-ray. ADON stated, Resident was transferred to the hospital for fracture on 12/29/23, then came back to the facility on [DATE] after hip repair. Review of Resident 2's X-ray result titled, Patient Report dated 12/28/23 indicated, . Acute left intertrochanteric fracture (a type of broken hip) . Review of Resident 2's Discharge summary from the hospital dated 1/11/24 indicated, . ORIF (open reduction and internal fixation, a type of surgery used to stabilize and heal a broken bone) with IT (Intertrochanter, a part of the hip bone) nail on 12/30/23 . Review of the facility's policy and procedure (P&P) titled, Comprehensive Care Plans undated indicated, . It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment . Review of the facility's P&P titled, Fall Risk Assessment undated indicated, . It is the policy of this facility to . provide supervision . to prevent avoidable accidents . 4. The At Risk for Falls care plan will include interventions, including adequate supervision . in order to reduce the risk of an accident .

Based on interview, and record review, the facility failed to update the fall care plan for one of 3 sampled residents (Resident 3) when there was no evidence that the fall care plan was updated after her fall on [DATE]. This failure had the potential to put the resident at risk of not receiving appropriate care. Findings: Review of Resident 3's clinical record indicated, Resident 3 was [AGE] year-old female, and admitted to the facility on [DATE] with diagnoses including acute kidney failure (sudden loss of the ability of the kidneys to excrete wastes, concentrate urine, conserve electrolytes, and maintain fluid balance, with a mortality rate of between 50% and 80%), heart failure (a condition that develops when your heart does not pump enough blood for your body's needs), and diabetes (high blood sugar). Review of Resident 3's Minimum Data Set (MDS, resident assessment tool), dated [DATE] indicated, she was cognitively intact. But her MDS also indicated, Resident 3 had dementia (memory loss) and failure to thrive (a state of decline that is multifactorial and may be caused by chronic concurrent diseases and functional impairments). During an interview on [DATE] at 2:54 PM with Assistant Director of Nursing (ADON), ADON stated, Resident 3 was on DNR (a do-not-resuscitate order, written by a health care provider. It instructs providers not to do CPR which stands for cardiopulmonary resuscitation if a patient's breathing stops or if the patient's heart stops beating) and comfort focused treatment (a patient care plan that is focused on symptom control, pain relief, and quality of life. It is typically administered to patients who have already been hospitalized several times, with further medical treatment unlikely to change matters) upon admission, then became hospice (a program that gives special care to people who are near the end of life and have stopped treatment to cure or control their disease) on [DATE], then died on [DATE]. During a concurrent interview and record review on [DATE] at 2:59 PM with ADON, Resident 3's Resident Incident Report and Follow-up-Copy dated [DATE] at 00:02 AM was reviewed. The incident report indicated, . patient was found lying on her left side on the floor inside her room approximately at 9:10pm . No signs of injury . ADON verified, it was an unwitnessed fall approximately at 9:10 PM on [DATE]. During a concurrent interview and record review on [DATE] at 3:45 PM with ADON, Resident 3's fall care plan was reviewed. The fall care plan was initiated on [DATE]. But there was no evidence that the fall care plan was updated after her fall on [DATE]. ADON stated, No when asked if the fall care plan was updated. He stated, It should be updated when asked about the facility's policy and procedure of fall. Review of the facility's policy and procedure (P&P) titled, Fall Risk Assessment undated indicated, . It is the policy of this facility to . provide supervision . to prevent avoidable accidents . 4. The At Risk for Falls care plan will include interventions, including adequate supervision . in order to reduce the risk of an accident. 5. Monitor the effectiveness of the care plan interventions, and modify the interventions as necessary . Review of the facility's P&P titled, Care Plan Revisions Upon Status Change undated indicated, . The comprehensive care plan will be reviewed, and revised as necessary, when a resident experiences a status change . d. The care plan will be updated with the new or modified interventions .

Based on interview and record review, the facility failed to thoroughly investigate an allegation of abuse. A Physical Therapist (PT) reported she saw a nurse (RN 1) slapped Resident 4's hand and was yelling at him to wake him up. Failure to thoroughly investigate an allegation of abuse did not ensure residents were protected from abuse. Findings: During an interview on 06/14/2024 at 2:39 PM, the PT was asked what happened to Resident 4 on 03/20/2022. The PT stated .This happened at the end of my workday. I was walking down the hallway and I see . (Resident 4), he's sitting and there was this nurse (RN1), and she was trying to wake him up to give him his medication. She didn't gently shake his shoulder. She was slapping his hand and yelling at him to wake up. According to the .(residents) I worked with (the residents said) she (RN1) was disagreeable pushy, mean, and aggressive. When I saw this, .I called my supervisor and reported it and left a message. On 06/13/2024 at 10:00 AM during a concurrent interview and record review of the facility's abuse/neglect paperwork/folder with the Medical Record Clerk (MRC). There was no evidence the facility conducted a thorough investigation. On 6/13/24 at 3:30 PM, the Administrator was made aware that the only interview within the facility's abuse/neglect folder was with the alleged perpetrator. The Administrator was asked what her expectations were when staff conducts an abuse/neglect investigation. The Administrator stated she expected staff to interview other residents and other staff who may have knowledge of the allegation. Review of the facility's policy titled Abuse, Neglect and Exploitation, revised on 08/10/2023, indicated .Investigation of Alleged Abuse, Neglect and Exploitation .An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur . Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations .

Based on interview and record review, the facility failed to have a Registered Dietitian (RD) working full-time or part-time at the facility from January to April 2024. Failure to have a RD working at the facility did not ensure residents were assessed appropriately to maintain the residents' weight and other nutritional parameters. Findings: During an interview on 06/12/2024 at 2:34 PM, the RD stated he had been contracted to work at the facility since 2022. The RD stated his employment at the facility .was not continuous. (I stopped working in) January (and) started back up in early April. During an interview on 06/12/2024 2:58 PM, the Administrator was asked if there was another RD covering the facility between January and April 2024. The Administrator stated .I don't want to answer those questions . Review of the facility's policy titled Nutritional Management (not dated) indicated . Facility Registered Dietitian is a registered member of the Academy of Nutrition and Dietetics, (AND) and is a staff member employed full-time, part-time, or on a consultant basis, depending on the needs of the facility. The Facility Registered Dietitian provides regularly scheduled on-premises consultation and guidance to the Administrator, .(food service director) , the residents, and other facility personnel and staff, as needed.

Based on interviews and record reviews, facility staff failed to protect Residents 1, 2, 3, 4, and 5, five out of five sample residents from inappropriate touching by Resident 6 and wandering unsupervised into other resident ' s room. Review of facility documents indicated Resident 6 touched these residents inappropriately: 1. Resident 1 on 07/12/2021. 2. Resident 2 on 01/29/2022. 3. Resident 3 on 06/23/2022. Review of facility documents indicated Resident 6 was found unsupervised in these resident ' s room: 1. Resident 4 ' s room on 08/02/2022. 2. Resident 5 ' s room on 05/07/2023, and Resident 5 alleged that Resident 6 touched her .all over . Failure to manage Resident 6 ' s inappropriate behavior and/or supervising him around vulnerable/dependent residents, did not ensure vulnerable/dependent residents were protected from sexual abuse. These failures have severe consequences, as Resident 3 reported experiencing nightmares, feeling unsafe, and having to sleep with the lights on due to the traumatic experience of being touched by Resident 6. Findings: Resident 1 Review of Resident 1 ' s record titled ADMISSION RECORD, printed on 06/20/2023, indicated she was admitted with multiple diagnoses including: left thigh bone fracture, generalized muscle weakness, difficulty walking, dementia (memory loss and deterioration of thinking ability due to brain disease or brain injury), and cerebral infarct (blockage of blood supply to brain, resulting in death of brain cells). Review of Resident 1 ' s MDS (Minimum Data Set, a standardized resident assessment tool), dated 08/12/2021, indicated her BIMS (Brief Interview for Mental Status, a tool to assess thinking and memory) score was 5 out of 15. A score of 0-7 indicates severe impairment in cognition (serious decline in thinking and memory). Her MDS indicated she required extensive assistance from one staff with: bed mobility, transfers, walking in room, moving around the unit, dressing, toilet use, and personal hygiene. Review of Resident 1 ' s records titled Progress Notes, dated 07/12/2021, indicated .At .(4:30 PM), witnessed by .staff, was found with .(Resident 6 ' s) hands underneath resident's gown touching her chest & breast area.(Resident 6) was instructed immediately to step away from .(Resident 1) and return to his room.(Resident 1) was not harm and did not exhibit any signs of physical injury.At this time, .(Resident 6) was removed moved away from victim immediately & transferred to room . with staff assistance; order given from administrator via phone. Resident 2 Review of Resident 2 ' s record titled ADMISSION RECORD, printed on 06/20/2023, indicated he was admitted with multiple diagnoses including: weakness, depression, and dementia. Review of Resident 2 ' s MDS, dated [DATE], indicated his BIMS score was 4 out of 15 (serious decline in thinking and memory). His MDS indicated he required extensive assistance from two staff with: bed mobility, transfers, dressing, and toilet use. His MDS indicated he required extensive assistance of one staff for personal hygiene and limited assistance of one staff for moving around on the unit. Review of Resident 2 ' s records titled Progress Notes, dated 01/29/2022, indicated .(staff) reported entering room and observing .(Resident 6) with hand underneath bedspread of .(Resident 2).(staff) told .(Resident 6) to leave the room. The Administrator and Nurse visited the victim and asked what happened ' Resident answered he touched my penis ' .Denies injury- No injury observed Stated ' I don't want that to happen again ' . Resident 3 Review of Resident 3 ' s record titled ADMISSION RECORD, printed on 06/20/2023, indicated he was admitted with multiple diagnoses including: generalized muscle weakness, obesity (overweight due to body fat), and urine retention. Review of Resident 3 ' s MDS dated [DATE], indicated his BIMS score was 15 out of 15 (no problem with thinking and memory). His MDS indicated he required limited assistance from one staff with: bed mobility, transfers, walking in room, moving around the unit, dressing, and personal hygiene. His MDS indicated he required extensive assistance of one staff for personal hygiene and limited assistance of one staff for toilet use. Review of Resident 3 ' s record titled Progress Notes, dated 06/23/2022, indicated .Resident remains alert and verbal. At .(12:15 PM) today . (Resident 3) reported to . (staff) that he was awaken from his sleep because he felt something on his private part, when he opened his eyes he saw .(Resident 6) touching his ' penis' and asking him ' do you like it ' ? .(Resident 3) then press the call light and the .(staff) immediately answered and saw .(Resident 6) in the room, .(staff) immediately took .(Resident 6) out of the room and put him back to his room .(Resident 3) verbalizes that he does not want a room change. Will continue to monitor. During an interview on 06/20/2023 at 11:34 AM, Resident 3 stated I ' m still suffering from it. One night I woke up and he was in his wheelchair by my bedside and touching my groin. Rubbing it. I don ' t know how long he was there and rubbing me before I woke up. Now I sleep with the lights on. I thought I was in a safe place. I never thought that somebody could just come in and molest you. (crying) I have nightmares because of this. I finally got out of that place. They weren ' t monitoring him. Once in a while you would see staff trying to chase him down and redirect him. They try to restrict him to his room, but they are pretty lax in monitoring him, especially at night. There ' s less foot traffic and those nurses at night are behind the nurse ' s station, they can ' t see him. This happened again to my roommate. There was a power outage, it was at night, and it was dark, and I heard this noise, I pull open the curtain and there he was over there touching my roommate. I immediately yelled for help. That ' s when staff came and got him out of there. After the 2nd incident I thought they were going to move him. But I think it ' s just talk. I still see him later on going up and down the hallway to where some of the ladies lived. Making sexual comments to them. Resident 4 Review of Resident 4 ' s record titled ADMISSION RECORD, printed on 06/20/2023, indicated he was admitted with multiple diagnoses including: complete to partial paralysis of the left side of the body, and dementia. Review of Resident 4 ' s MDS dated [DATE], indicated he had severe problems with making decisions and severe problems with memory. His MDS indicated he was totally dependent on two staff with: bed mobility, transfers, dressing, and toilet use. His MDS indicated he was dependent on one staff for moving around the unit, and personal hygiene. Review of Resident 4 ' s record titled Progress Notes, dated 08/02/2022, indicated .(Resident 4 ' s roommate) was .(calling for staff). (The roommate) was shouting in a loud voice and immediately .(staff) went to the room . It was noted that .(Resident 6) was in the room by the foot (of Resident 4 ' s bed), and right away .(staff, brought Resident 6) out of the room. Resident 5 Review of Resident 5 ' s admission record, printed on 06/13/2023, she was admitted with multiple diagnoses including: schizoaffective disorder-bipolar type (mental illness that negatively impact your mood, thoughts, and behaviors), and diabetes (blood sugar control disease). Review of Resident 5 ' s Minimum Data Set (MDS, a standardized resident assessment tool), dated 06/21/2023, indicated she was severely impaired in her cognition (problems with reasoning, decision making and memory). Additionally, her MDS indicated she required extensive assistance from two staff with: bed mobility, dressing and personal hygiene. She was totally dependent on two staff for transfers and toilet use. Resident was assessed as having hallucinations (hearing voices and seeing things not based in reality), rejection of care, verbal, and physical inappropriate behaviors toward others (yelling, cursing, hitting, scratching) Review of Resident 5 ' s record titled Progress Notes, dated 05/07/2023, indicated .(Resident 6) was seen by . (staff) in the .(Resident 5 ' s) bedroom facing the sink, past 6 in the evening, .(staff) assisted .(Resident 6) outside the room and lead .(Resident 6) to his own room.(staff) asked .(Resident 5) how she is and .(Resident 5) said get him out of this room, and also allegedly said he touched me everywhere. Resident 6 Review of Resident 6 ' s MDS, dated [DATE], indicated he was admitted on [DATE] and had multiple diagnoses including: dementia, and depression. His BIMS score was 8 out of 15. A score of 8 out of 15 indicated moderate cognitive impairment. Moderate cognitive impairment is characterized by early stage of memory loss or other cognitive ability loss (such as trouble finding the right words or reasoning). His MDS indicated he required: supervision of one staff for 1. walking in the corridor 2. moving around the unit limited assistance from one staff for 1. transfers 2. walking in his room. extensive assistance of one staff for 1. bed mobility 2. dressing 3. personal hygiene 4. toilet use Review of Resident 6 ' s record titled Behavior Care Plan, initiated on 07/12/2021, indicated . Goal . The resident will not have any new incidences of actual or suspected inappropriate touching .Interventions .one on one caregiver visual monitoring .Observe resident where abouts and always remind not to go inside other residents' room . Resident will be accompanied by .staff . if wanted to ambulate for safety . The resident will be the only one to use the .(shared) bathroom, making sure that he cannot pass thru to the other door of the .(shared) bathroom which opens to the next room . Review of facility documents faxed to this Department (California Department of Public Health, CDPH, San Francisco) indicated the facility was aware of Resident 6 ' s pattern of inappropriate sexual behavior and unsupervised wandering into other resident ' s room. Furthermore, these documents recorded a pattern of failed attempts to monitor Resident 6, failed attempts at discharging Resident 6, and failed attempts to prevent Resident 6 from abusing other residents. On 02/04/2022, the facility sent a fax to this Department .Both . (Resident 2) and .(Resident 6) were interviewed by . (Social Service Director) following incident of abuse on 1/29/22. (Resident 6) has been separated from .(Resident 2) and closely monitored by staff to make sure he has not had any incidents of wandering into other's rooms. On 06/28/2022 the facility sent a fax to this Department . Since the incident on Thursday 6/23/22 involving .(Resident 6)and .(Resident 3) . Social Services has been actively in touch with [NAME] .(police department) and Ombudsman Services with the goal of finding placement elsewhere for .(Resident 6) as this has not been his first incident of sexual impropriety and he poses danger to other residents in the building. Facility is actively looking for options to find a facility or place that would be safer for him to go to. In the meantime, staff are logging a visual monitoring for him every shift and work to keep him at a safe distance from other residents. On 08/02/2022 the facility sent a fax to this Department .(Resident 6) has engaged In Inappropriate behavior in the past and . was observed loitering in .(other residents ' room) . In the meantime, he will be confined to his room and closely supervised at all times by facility personnel. During an interview on 6/16/2023 at 12:50 PM, the Medical Director of the facility stated .I heard reports that .(Resident 6) had been molesting another .(residents). When we heard about it we tried to get him out of the area. I think the facility move residents away (to other rooms). They tried to isolate him in his own room. They were keeping an eye on him. But he was ambulatory, and he would move around. They had him in a private room had people watching out for him to redirect him. They did have a Velcro barrier sign . (across his door) that says stop. But anybody can take that off. They did try to put surveillance on him. Earlier this year, I heard that he molested somebody .I deemed that surveillance was not effective. Because he was seen in a patient ' s room by a .(staff).I talked to the administrator and told them that they need eyes on him 24/7 (24 hours and seven days a week). They did not have the staffing initially, but they did find staffing later. They finally put that in place, and they finally moved him out of the facility. They were able to discharge him. The Medical Director was asked if Resident 6 was appropriate for a skilled nursing facility setting? The Medical Director stated No he would have been better off at a geriatric psych facility with more intense monitoring. He would have been better off at a different place.Looking back on, hindsight we should have had a 1-1 on him (one staff to monitor him on a continuous basis). During an interview with the Administrator (ADM) and the Director of Nursing (DON) on 06/15/2023 at 11:15 AM, the ADM agreed that sexual abuses should never happen in a nursing home. The DON identified visual monitoring every 30 minutes, two psychiatric consults with medication recommendations, relocating residents to another room and attempts at discharging Resident 6 as interventions in managing Resident 6 ' s inappropriate sexual behavior. The ADM stated these inteventions were not 100% effective and the latest incident was Resident 6 was found in a vulnerable/dependent resident ' s room on 05/07/2023. During the interview, the ADM and DON were asked to provide a policy on residents who are sexually abusive. The facility stated via an email to this Department on 6/20/2023 that they do not have a policy regarding residents who are sexually abusive. Review of facility policy titled Abuse Prevention & Reporting, not dated, indicated .ensure that residents are free from abuse, neglect, and misappropriation of property. The facility has a ZERO TOLERANCE for any/all types of abuse directed toward any resident, patient or dependent adult within its care. B. To provide guidelines to all staff regarding their roles and responsibilities in the prevention and reporting of resident abuse, neglect, and misappropriation of property. Sexual abuse: includes, but is not limited to, sexual harassment, sexual coercion, sexual assault, . (dependent adult): any person over the age of 18 who has physical or mental limitation which restricts his or her ability to carry out normal activities or to protect his or her own rights, including but not limited to, persons who have physical or developmental disabilities or whose physical or mental abilities have diminished because of age.

Based on interview and record review, the facility failed to ensure a resident (Resident A) with a known history of inappropriate sexual behaviors was consistently supervised and monitored by staff according to his care plan. This failure resulted in Resident A to be found unsupervised inside the room of another resident (Resident B) on 5/7/23. This failure did not ensure Resident B and other residents at the facility were protected from a potential and/or actual sexual abuse by Resident A. This failure resulted in a potential violation of Resident B's rights to privacy and dignity. Findings: During a review of Resident A's Admission Record (AR), the record indicated, Resident A's diagnoses included Dementia (loss of mental functions) and Depression (mood disorder). During a review of the Minimum Data Set (MDS, an assessment tool), dated 3/24/23, Resident A's assessment for Functional Status (Section G), indicated, supervision and one-person physical assist when walking in corridor on unit and moving between locations in his room and adjacent corridor on same floor. The MDS also indicated Resident A used a walker for mobility. During a review of Resident A's History & Physical (H&P), dated 12/8/22, the H&P indicated, He [Resident A] had inappropriate sexual behavior towards staff and patients and was evaluated by psychiatry. The H&P also indicated, He [Resident A] was placed in a private room and was discouraged from leaving his room unattended. During an interview on 5/10/23, at 9:52 AM, with the Director of Nursing (DON), DON confirmed a reported allegation of abuse on 5/7/23 when Resident A was found by a Certified Nursing Assistant (CNA) 1 standing inside Resident B's room facing the sink. DON confirmed the alleged abuse report provided to the state survey agency, indicated that Resident B told the CNA 1 that Resident A touched her everywhere and wants him [Resident A] out of the room. DON stated Resident B's conservator (a person appointed by a judge to act or make decisions for the person who needs help) was notified of the incident. During an interview on 5/10/23, at 10:10 AM, with the DON, DON stated staff conducted visual checks or visual monitoring of Resident A every 30 minutes. When asked how Resident A ended up in Resident B's room unsupervised on 5/7/23, DON stated Resident A was able to walk on his own with a walker. DON stated at the time the alleged abuse incident occurred, CNA 1 was in another resident's room. DON stated Resident A should not be inside Resident B's room. During a concurrent interview and record review on 5/10/23, at 4:39 PM with the DON, Resident A's Visual Monitoring (VM) records from 7/1/22 through 5/10/23 were reviewed. The DON stated she had oversight Resident A's visual monitoring to ensure that there was staff available and that records were completed. DON stated it was important that Resident A did not go out of his room without staff supervision to protect residents in the facility given Resident A's inappropriate behavior history. DON confirmed and acknowledged there was no visual monitoring by staff on Resident A and that Resident A's VM records had no information on the staff member who monitored the resident, any resident behaviors noted by the staff, and the resident's location or whereabouts for the following dates and times. July 2022 There were no visual monitoring records on file for Resident A from: 7/1/22 through 7/6/22 (6 days) 7/15/22 through 7/16/22 (2 days) 7/19/22 (1 day) August 2022 There were no visual monitoring records on file for Resident A from: 8/4/22 to 8/13/22 (10 days) 8/27/22 - no visual monitoring from 7:30 AM up to 3 PM 8/30/22 - no visual monitoring from 7:30 AM up to 3 PM September 2022 9/2/22 - no visual monitoring from 10 AM up to 3 PM 9/7/22 - no visual monitoring from 4 PM up to 11 PM October 2022 10/13/22 - no visual monitoring from 7:30 AM up to 3 PM December 2022 There were no visual monitoring records on file for Resident A from: 12/24/22 to 12/31/22 (8 days) 12/13/22 - no visual monitoring from 9:30 PM up to 11 PM March 2023 3/12/23 - no visual monitoring from 4 PM up to 11 PM 3/13/23 - no visual monitoring from 3:30 PM up to 11:30 PM 3/14/23 - no visual monitoring from 12 AM up to 7 AM April 2023 4/28/23 - no visual monitoring from 4 PM up to 11:30 PM 4/29/23 - no visual monitoring from 12 AM up to 6:30 AM 4/29/23 - no visual monitoring from 7:30 PM up to 11 PM May 2023 5/1/23 - no visual monitoring from 7:30 AM up to 3 PM 5/2/23 - no visual monitoring from 7:30 AM up to 11 PM 5/3/23 - no visual monitoring from 7:30 AM up to 11 PM 5/4/23 - no visual monitoring from 7:30 AM up to 3 PM 5/4/23 - no visual monitoring from 4 PM up to 11 PM 5/5/23 - no visual monitoring from 4 PM up to 11 PM 5/7/23 - no visual monitoring from 11 PM up to 11:30 PM 5/8/23 - no visual monitoring from 12 AM up to 7 AM 5/9/23 - no visual monitoring from 12 AM up to 6:30 AM During an interview on 5/10/23, at 1:35 PM, with the Registered Nurse (RN) 1 assigned to Resident A on 5/7/23, the date of Resident B's reported abuse allegation incident, RN 1 stated she did not know that Resident A was able to walk of his room unsupervised by staff at the time. RN 1 stated she was aware a staff had to be present when Resident A left his room based on his care plan. During an interview on 5/16/23, at 3:58 PM, with the CNA 1, who was assigned to Resident A on 5/7/23, the date of Resident B's reported abuse allegation incident, CNA 1 stated she and RN 1 were responsible to monitor and check Resident A's whereabouts to ensure the resident did not leave his room unsupervised given his history of inappropriate behavior towards other residents. CNA 1 stated she found Resident A inside Resident B's room at the time of the alleged incident on 5/7/23. When asked why Resident 1 was able to leave his room without staff supervision, CNA 1 said, At the time, we are busy and we are short handed and when you're busy you cannot watch a patient closely. CNA 1 stated she was helping a resident in another room when the alleged incident happened. CNA 1 stated, she was unable to monitor Resident A at the time of the alleged incident because they were short-handed. During a review of Resident A's behavioral care plan (BCP), dated 3/1/23, the BCP indicated an intervention initiated on 7/1/22 that included, On visual monitoring, to know the whereabout [sic] of the resident. Further, Resident A's care plan (CP), dated 3/1/23, indicated, Resident has episodes .inappropriately touching staff and other residents on genitals or breasts. The CP included an intervention that was initiated on 9/8/22 that indicated, Staff to accompany him when he leaves the room. During a concurrent interview and record review of Resident A's care plans on 5/10/23, at 5:16 PM with the DON, DON stated Resident A's care plan interventions on visual monitoring and supervision by staff when Resident A left his room were not followed and implemented by staff. Review of the facility's Policy and Procedures (P&P), titled, Comprehensive Care Plans, undated, the P&P indicated, Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs . The comprehensive care plan will describe, at a minimum the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable, physical, mental, and psychosocial well-being .Qualified staff responsible for carrying out interventions specified in the care plan will be notified of their roles and responsibilities for carrying out the interventions, initially and when changes are made . Review of the facility's Policy and Procedures (P&P), titled, Visual Monitoring, dated 11/18/21, the P&P indicated, The facility may develop arrangements for Visual Monitoring for the staff or outside resources to provide dedicated individual to provide monitoring of the resident every 30 minutes for a specific period of time. Definition: Visual Monitoring is the term used by the Facility when assigning staff members or individual person to observe the resident's whereabouts and activities being done during the specific time. Policy Explanation: 1. Charge nurses may consult with the Director of Nursing or Administrator regarding the concern need for any resident to require Visual monitoring. 2. The director of Nursing or Administrator (or their designees) will assess the situation and confirm the need for visual monitoring. 3. Once confirmed, the charge nurse will assign CNA or non-nursing personnel to visually observe or monitor the resident every 30 minutes and it will be documented on a visual monitoring sheet with specific coding for behaviors observe and location codes at specific times. 4. The charge nurse from the resident's unit will be responsible for overseeing the process. 5. The Director of Nursing will validate that visual monitoring is being conducted, per instruction. Review of the facility's Policy and Procedures (P&P), titled, Resident Rights, dated 4/28/04, the P&P indicated, Policy - 1. The facility's governing body, administration and employees fully support the concept that each resident shall be informed of his/her rights in a language that the resident understands, and of the facility rules and regulations governing resident conduct and responsibilities . Procedure . Resident rights include: a. Federal - OBRA- Rights; b. Title 22 - Regulatory Rights; c. Statutory Rights .

Based on interview and record review, the facility failed to ensure medical records related to provision of care and services to 1 resident (Resident A) were complete and accurately documented, in accordance with accepted professional standards and practices, including the facility's policy and procedures when: 1.Resident A had two non-identical One-on-One Monitoring (is the term used by the Facility when assigning a staff member or other individual to provide close observation of a resident for a specific period of time) records completed by staff on 5/11/23. 2.Resident A's One-on-One Monitoring staff assignment record on 5/8/23 for Staff 1 (S1) did not correspond with S1's timecard report and employment status. 3.There was no record of half-hour Visual Monitoring checks (is the term used by the Facility when assigning a charge nurse to the caregiver watching One-on-One monitoring of a patient) conducted by charge nurses for Resident A on 5/16/23. These failures resulted in inconsistent and unreliable documentation of Resident A's records. These failures had the potential to not ensure Resident A was monitored consistently by staff. Findings: 1.During a concurrent interview and record review with the Medical Records Staff (MRS) on 5/17/23 at 9:35 PM, Resident A's Visual Monitoring binder was reviewed. MRS explained staff assigned to do One-on-One monitoring on Resident A were instructed and trained to fill out and complete the Visual Monitoring sheets for designated times. The Visual Monitoring sheets indicated the time, staff initials, and behavior and location codes noted on Resident A. The Visual Monitoring sheets from 5/10/23 through 5/17/23 were reviewed with MRS present. MRS confirmed there were two Visual Monitoring sheets noted in the Visual Monitoring binder, and completed by staff for Resident A on 5/11/23, that were not identical. When asked, MRS stated couldn't tell which one is real. MRS acknowledged she was unable to determine the accuracy and reliability of the One-on-One Visual Monitoring record for Resident A on 5/11/23. Review of the facility's Policy and Procedures (P&P), titled, One-on-One Monitoring, dated 5/11/23, the P&P indicated, . Policy Explanation .Once confirmed, a staff member or other trained individual will be assigned to perform the one-on-one monitoring for a specific amount of time .The Director of Nursing will validate that one-on-one monitoring is conducted, per instruction . The facility will retain written documentation of one-on-one monitoring for an appropriate length of time. Review of the facility's Policy and Procedures (P&P), titled, Documentation in Medical Record, undated, the P&P indicated, . Policy: Each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation . Policy Explanation and Compliance Guidelines . Principles of documentation include, but are not limited to . Documentation shall be accurate, relevant and complete . 2.During review of Resident A's One-on-One Monitoring staff assignment record for 5/8/23, the record indicated Staff 1 (S1) was assigned to the resident from 11:30 PM to 5:30 AM the following day, 5/9/23. During a review of facility's the Employee Time Card Report, for 5/8/23, the report indicated the following: a record of S1's name, time In 11:30p [pm], and time Out 5:30a+1 [am] the next day, 5/9/23. During an interview with S1 on 5/25/23 at 12:18 PM, S1 stated she was promoted to a supervisor position for over a year now. S1 stated her new role as supervisor was a salaried position. S1 stated since she held the salaried position, she stopped clocking in and out from the facility's timecard system. S1 stated she had not clocked in and out for timecard purposes for more than a year since they put me to salaried. When asked, S1 stated she provided One-on-One Monitoring on Resident A on 5/8/23 from 11:30 PM up to 5:30 AM on 5/9/23. Review of the facility's Policy and Procedures (P&P), titled, Documentation in Medical Record, undated, the P&P indicated, . Policy: Each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation . Policy Explanation and Compliance Guidelines . Principles of documentation include, but are not limited to . Documentation shall be accurate, relevant and complete . 3.During a concurrent interview and record review with Charge Nurse (CN) 1, on 5/17/23 at 8:51 PM, Resident A's half-hour Visual Monitoring binder used by charge nurses was reviewed. With CN 1 present, the half-hour Visual Monitoring sheets from 5/11/23 through 5/17/23 were reviewed. CN 1 confirmed the finding and said, I don't see a paper for monitoring by charge nurses for 5/16/23. CN 1 stated there should have been documentation on Resident A's visual monitoring by charge nurses for 5/16/23. CN 1 acknowledged no documentation meant the monitoring was not done by the nurses. CN 1 stated he was not working that day and said, I don't know what happened that day. CN 1 stated they were short-handed on 5/16/23 and had registry nurses on the schedule. Review of the facility's Policy and Procedures (P&P), titled, Documentation in Medical Record, undated, the P&P indicated, . Policy: Each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation . Policy Explanation and Compliance Guidelines . Principles of documentation include, but are not limited to . Documentation shall be accurate, relevant and complete .

Based on interview and record review, the facility failed to ensure an allegation of abuse incident that occurred on 5/7/23 was reported within required timeframes to the State Survey Agency when: 1.There was no documented evidence the abuse allegation incident that involved Resident A and Resident B on 5/7/23 was reported within 2 hours after the allegation was made. 2.There was no documented evidence the results of the abuse allegation investigation that involved Resident A and Resident B on 5/7/23 was reported within 5 working days of the incident. These failures could result in avoidable delays that help provide protections for the health, welfare, and rights of residents in the facility. Findings: 1.During an interview with the Director of Nursing (DON), on 5/30/23 at 2:15 PM, DON stated the nurse who reported the initial abuse incident that occurred on 5/7/23, between Resident A and Resident B, to the State Survey Agency cannot give me [DON] the date and time. DON was unable to provide documented evidence of the date and time the State Survey Agency was notified of the abuse allegation incident on 5/7/23. DON stated the fax machine that the nurse used to send the initial abuse report to the State Survey Agency had a date and time issue that was not fixed. 2.During an interview with the Director of Social Services (DSS), on 5/31/23 at 4:30 PM, DSS stated she was responsible to report the results of the abuse allegation investigation to the State Survey Agency on 5/12/23. DSS stated she faxed the follow up investigation report to CDPH (California Department of Public Health, State Survey Agency) on 5/17/23. DSS stated she faxed the follow up investigation report late. DSS was unable to provide documented evidence of the date and time the State Survey Agency was provided with the report on results of abuse allegation investigation. Review of the facility's Policy and Procedures (P&P), titled, Abuse Prevention & Reporting, revision dated 1/13, the P&P indicated, . Policy . C. All staff will be oriented at time of hire and in-serviced at least annually regarding the topic of Abuse Prevention and Reporting. This training will include a review and discussion of . What, when, and to whom to report suspected, reported, or observed abuse . Employees will receive a copy of the facility's Mandated Reporter template . F. The facility Administrator will be responsible for: Ensuring that a thorough investigation of all suspected, reported, or observed abuse is completed in a timely manner and documented appropriately . Timely and accurate reporting to the appropriate agencies of any/all abuse incidents according to state and federal regulations .

Based on interview and record review, the facility failed to ensure the facility's abuse policy was developed and implemented when: 1.There were no abuse care plans developed for two residents (Resident A and Resident B) involved in a reported abuse allegation incident on 5/7/23. 2.The facility did not provide the state survey agency with sufficient information on the initial abuse allegation report that involved Resident A and Resident B on 5/7/23. 3.The facility did not provide the state survey agency with sufficient information on the results of investigation regarding an abuse allegation incident that involved Resident A and Resident B on 5/7/23. 4.The facility's abuse policy was not reviewed and updated annually and/or as necessary. 5.There was no written procedures for investigating allegations of abuse, neglect, exploitation, and misappropriation of resident property. These failures had the potential to not provide protections for the health, welfare, and rights of each resident in the facility. Findings: 1.During an interview on 5/10/23, at 1:28 PM, with the Registered Nurse (RN) 1, RN 1 stated the Certified Nursing Assistant (CNA) 1 informed on 5/7/23, at approximately after 6 PM, of an abuse allegation incident by Resident A towards Resident B. Refer to F689. During a concurrent interview and record review of Resident A and Resident B's care plans on 5/10/23, at 5:26 PM with the Director of Nursing (DON), DON stated there were no written care plans and interventions developed for both residents regarding the reported abuse allegation incident on 5/7/23. DON stated the nurses were responsible for initiating care plans for Resident A and Resident B, on the alleged abuse incident, to ensure there was a plan to keep both residents including other residents safe. DON further stated that Resident A's care plan was not updated and revised to include the physician's order on 5/8/23 at 3:45 PM, to have the resident monitored 24 hours by a dedicated person. Review of the facility's Policy and Procedures (P&P), titled, Abuse Prevention & Reporting, revision dated 1/13, the P&P indicated, I. Purpose . To provide guidelines to all staff regarding their roles and responsibilities in the prevention and reporting of resident abuse . II. Policy . F. The facility Administrator will be responsible for . d. Ensuring that the Interdisciplinary Team meets to review and revise the plan of care with appropriate interventions for residents who are victims or perpetrators of abuse to prevent further occurrences . Review of the facility's Policy and Procedures (P&P), titled, Comprehensive Care Plans, undated, the P&P indicated, Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs . The comprehensive care plan will describe, at a minimum the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable, physical, mental, and psychosocial well-being .Qualified staff responsible for carrying out interventions specified in the care plan will be notified of their roles and responsibilities for carrying out the interventions, initially and when changes are made . 2.During a review of the facility's initial abuse allegation report titled, Report of Suspected Dependent Adult/Elder Abuse, dated 5/7/23, provided to the state survey agency, the report did not include the following: reporting party's name, signature, occupation, agency/name of business, relation to victim/how abuse is known, address and telephone; incident date and time of incident; reported type of abuse; reporter's observation of any known time frame; other person believed to have knowledge of abuse such as family, significant others, neighbors, medical providers, agencies involved, etc. and dates of written report mailed or faxed to agencies such as Ombudsman and State Licensing Agency. During a concurrent interview and record review with Registered Nurse (RN) 1, on 5/10/23 at 2 PM, the initial abuse allegation report titled, Report of Suspected Dependent Adult/Elder Abuse, dated 5/7/23 was reviewed. RN 1 confirmed she filled out the initial report. RN 1 acknowledged the findings and stated she did not completely fill out the report. RN 1 said, I probably missed some of the important details. RN 1 stated she was supposed to write the date and time of the alleged abuse incident on the report. RN 1 said, I need to fill out the form as accurate and complete as possible. RN 1 stated she was trained by the facility's Director of Staff Development (DSD) on abuse policy and procedures. Review of the facility's Policy and Procedures (P&P), titled, Abuse Prevention & Reporting, revision dated 1/13, the P&P indicated, . Policy . C. All staff will be oriented at time of hire and in-serviced at least annually regarding the topic of Abuse Prevention and Reporting. This training will include a review and discussion of . What, when, and to whom to report suspected, reported, or observed abuse . Employees will receive a copy of the facility's Mandated Reporter template . F. The facility Administrator will be responsible for: Ensuring that a thorough investigation of all suspected, reported, or observed abuse is completed in a timely manner and documented appropriately . Timely and accurate reporting to the appropriate agencies of any/all abuse incidents according to state and federal regulations . 3.During a concurrent interview and record review with the Director of Social Services (DSS), on 5/31/23 at 5:20 PM, the report titled, Exhibit 359 Follow-Up Investigation Report, related to the abuse allegation incident that involved Resident A and Resident B on 5/7/23 was reviewed. DSS confirmed she wrote the follow up investigation report. The report indicated, Within five (5) business days of the incident, the facility must provide in its report sufficient information to describe the results of the investigation, and indicate any corrective actions taken if the allegation was verified. It is important that the facility provide as much information as possible, to the best of its knowledge at the time of submission of the report. The facility should include any updates to information provided in the initial report and the following additional information, which should include, but are not limited to the following: 1. Additional/Updated Information Related to the Reported Incident, 2. Steps taken to investigate the allegation, 3. Conclusion, 4. Corrective Action(s) Taken 5. Facility Investigator and 6. Submitted by. Further review of the report titled, Exhibit 359 Follow up Investigation Report, written by the DSS, the report did not indicate a detailed summary of all steps taken to investigate the allegation such as the summary of interviews with the alleged victim and any visual cues from the resident of psychosocial distress and harm, summary of interviews with witnesses and what the individual observed or knowledge of the alleged incident or injury, summary information from the investigation related to the incident from the resident's clinical record such as relevant portions of the RAI, the resident's care plan, nurses' notes, social services note, physician or other practitioner reports or reports from other disciplines that are related to the incident, summary information of other documents obtained, such as hospital/medical progress notes/orders and law enforcement reports as applicable, detailed summary of all corrective actions taken, the name of the facility individual/s who had the primary responsibility for conducting the investigation, name of the administrator or designee who submitted the report, and time the report was submitted to the state survey agency. DSS acknowledged the report did not include sufficient information as indicated in the follow up investigation form or report she used. DSS said, I will be more clear. I was not nearly thorough and descriptive enough. DSS stated the assistant to the previous Director of Social Services taught her how to use the follow up investigation form or report submitted to the state survey agency. Review of the facility's Policy and Procedures (P&P), titled, Abuse Prevention & Reporting, revision dated 1/13, the P&P indicated, . Policy . C. All staff will be oriented at time of hire and in-serviced at least annually regarding the topic of Abuse Prevention and Reporting. This training will include a review and discussion of . What, when, and to whom to report suspected, reported, or observed abuse . F. The facility Administrator will be responsible for: Ensuring that a thorough investigation of all suspected, reported, or observed abuse is completed in a timely manner and documented appropriately . Timely and accurate reporting to the appropriate agencies of any/all abuse incidents according to state and federal regulations . 4.During a concurrent interview and record review with the ADM on 6/1/23 at 11:24 AM, the facility's policy and procedure (P&P), titled, Abuse Prevention & Reporting, revision dated 1/13 was reviewed. ADM confirmed the facility's current Abuse P&P was last revised on 1/2013. ADM stated there was no revision made on the policy after 1/2013. ADM stated the facility's abuse policy did not indicate it was reviewed by the Quality Assurance Staff and the Director of Nursing in 2022. When asked how often the facility review and updates the abuse policy, ADM said, we don't have a scripted review date. Review of the facility's Policy and Procedures (P&P), titled, Abuse Prevention & Reporting, revision dated 1/13, the P&P indicated, . Policy . E. The facility's Quality Assurance Committee will review . Abuse Prevention and Reporting policies and procedures will be reviewed at least annually and updated as warranted to better safeguard residents . 5.During a concurrent interview and record review with the Administrator (ADM) on 6/1/23 at 11:38 AM, the facility's policy and procedure, titled, Abuse Prevention & Reporting, revision dated 1/13 was reviewed. When asked to describe the facility's procedure for investigating patient abuse allegation incidents, ADM explained that concerned parties involved in the incident were interviewed to determine if there was any injury, including the need to relocate or guard people. ADM stated responsible parties had to be identified and notified of the incident and staff members involved or might have knowledge of the incident had to be interviewed. ADM also stated phone call notifications and submission of written and follow up incident reports to appropriate agencies within the required timeframes had to be made. When asked who was responsible for the investigation of abuse allegation incidents at the facility, ADM said, it depends on which department is involved and what kind of abuse occurred. ADM stated if the incident involved residents, the DON [Director of Nursing] is heavily involved, sometimes we involve our social worker. ADM further stated, we do a 5-day follow up [report of the investigation] and send that to CDPH (California Department of Public Health, state survey agency). When asked if the facility had a written policy and procedure for investigating abuse allegations, ADM said, I don't see it written, I don't see it in this policy [referring to facility's current policy and procedure on abuse]. ADM stated she thought the facility's current abuse policy and procedure had to be revised and said, it's time to do a major tweak. Review of the facility's Policy and Procedures (P&P), titled, Abuse Prevention & Reporting, revision dated 1/13, the P&P indicated, . Policy . E. The facility's Quality Assurance Committee will review . Abuse Prevention and Reporting policies and procedures will be reviewed at least annually and updated as warranted to better safeguard residents .

Based on interview and record review, the facility failed to ensure staff were effectively trained on abuse reporting and investigation when: 1.The initial abuse allegation report did not have sufficient information on the alleged abuse incident that involved Resident A and Resident B on 5/7/23. 2.The follow up investigation report did not have sufficient information on the results of the alleged abuse incident that involved Resident A and Resident B on 5/7/23. Lack of sufficient information and/or knowledge on abuse allegation reporting and investigations by staff could result in inconsistent implementation of the facility's abuse policies and procedures. These failures could result in avoidable delays that help provide protections for the health, welfare, and rights of residents in the facility. Findings: 1.During a review of the facility's initial abuse allegation report titled, Report of Suspected Dependent Adult/Elder Abuse, dated 5/7/23, provided to the state survey agency, the report did not include the following: reporting party's name, signature, occupation, agency/name of business, relation to victim/how abuse is known, address and telephone; incident date and time of incident; reported type of abuse; reporter's observation of any known time frame; other person believed to have knowledge of abuse such as family, significant others, neighbors, medical providers, agencies involved, etc. and dates of written report mailed or faxed to agencies such as Ombudsman and State Licensing Agency. During a concurrent interview and record review with Registered Nurse (RN) 1, on 5/10/23 at 2 PM, the initial abuse allegation report titled, Report of Suspected Dependent Adult/Elder Abuse, dated 5/7/23 was reviewed. RN 1 confirmed she filled out the initial report. RN 1 acknowledged the findings and stated she did not completely fill out the report. RN 1 said, I probably missed some of the important details. RN 1 stated she was supposed to write the date and time of the alleged abuse incident on the report. RN 1 said, I need to fill out the form as accurate and complete as possible. RN 1 stated she was trained by the facility's Director of Staff Development (DSD) on abuse policy and procedures. During a concurrent interview and record review with the Director of Staff Development (DSD) on 5/25/23 at 4:30 PM, the initial abuse allegation report used by the facility titled, Report of Suspected Dependent Adult/Elder Abuse, was reviewed. DSD stated she conducted abuse training and in-services to staff at the facility quarterly. DSD stated she provided training to staff on how to fill out the initial abuse report. DSD stated staff were taught to be objective and complete the form. DSD stated staff were expected to fill out all sections of the report and to indicate not applicable if appropriate. DSD stated it was not acceptable for the staff to not provide sufficient information on the initial report. DSD stated staff were taught and expected to fill out the report completely and accurately. When asked how she evaluated the staff's knowledge and competency on abuse policies and procedures, DSD stated staff were provided opportunities to ask questions during abuse training and in-services. DSD stated she had not done reviews of the initial abuse reports completed by the staff. DSD stated it was important to review the initial abuse reports to assess knowledge and competency of staff and ensure they were equipped with the right information when reporting abuse. 2.During a concurrent interview and record review with the Director of Social Services (DSS), on 5/31/23 at 5:20 PM, the report titled, Exhibit 359 Follow-Up Investigation Report, related to the abuse allegation incident that involved Resident A and Resident B on 5/7/23 was reviewed. DSS confirmed she wrote the follow up investigation report. The report indicated, Within five (5) business days of the incident, the facility must provide in its report sufficient information to describe the results of the investigation, and indicate any corrective actions taken if the allegation was verified. It is important that the facility provide as much information as possible, to the best of its knowledge at the time of submission of the report. The facility should include any updates to information provided in the initial report and the following additional information, which should include, but are not limited to the following: 1. Additional/Updated Information Related to the Reported Incident, 2. Steps taken to investigate the allegation, 3. Conclusion, 4. Corrective Action(s) Taken 5. Facility Investigator and 6. Submitted by. Further review of the report titled, Exhibit 359 Follow up Investigation Report, written by the DSS, the report did not indicate a detailed summary of all steps taken to investigate the allegation such as the summary of interviews with the alleged victim and any visual cues from the resident of psychosocial distress and harm, summary of interviews with witnesses and what the individual observed or knowledge of the alleged incident or injury, summary information from the investigation related to the incident from the resident's clinical record such as relevant portions of the RAI, the resident's care plan, nurses' notes, social services note, physician or other practitioner reports or reports from other disciplines that are related to the incident, summary information of other documents obtained, such as hospital/medical progress notes/orders and law enforcement reports as applicable, detailed summary of all corrective actions taken, the name of the facility individual/s who had the primary responsibility for conducting the investigation, name of the administrator or designee who submitted the report, and time the report was submitted to the state survey agency. DSS acknowledged the report did not include sufficient information as indicated in the follow up investigation form or report she used. DSS said, I will be more clear. I was not nearly thorough and descriptive enough. DSS stated the assistant to the previous Director of Social Services taught her how to use the follow up investigation form or report submitted to the state survey agency. During an interview with the Director of Staff Development (DSD) on 6/1/23 at 2:01 PM, DSD stated she was not responsible for providing training of staff in completing and submission of the 5-day follow up investigation report on abuse allegation incidents. DSD stated she was not aware if there was a training provided to staff on how to investigate and submit a follow up report on abuse allegation incidents to appropriate agencies to meet the regulations. DSD said, I just know that the Administrator, DON [Director of Nursing] and Social Services would always be the key people to do the investigation. Review of the facility's Policy and Procedures (P&P), titled, Abuse Prevention & Reporting, revision dated 1/13, the P&P indicated, . Policy . C. All staff will be oriented at time of hire and in-serviced at least annually regarding the topic of Abuse Prevention and Reporting. This training will include a review and discussion of . What, when, and to whom to report suspected, reported, or observed abuse . Employees will receive a copy of the facility's Mandated Reporter template . F. The facility Administrator will be responsible for: Ensuring that a thorough investigation of all suspected, reported, or observed abuse is completed in a timely manner and documented appropriately . Timely and accurate reporting to the appropriate agencies of any/all abuse incidents according to state and federal regulations .

Based on observation, interview, and record review, the facility failed to ensure call lights for six residents were maintained to ensure call lights were functioning as intended. Five call lights did not light up inside the resident's room when activated (Residents 21, 27, 38, 46, and 60). Resident 35's call light was not functioning when checked. Failure to maintain indicator lights had the potential to increase a resident's anxiety when there was no visual indication to let a resident know if their call light was functioning. Failure to ensure Resident 35's call light was functioning had the potential to delay staff's response to Resident 35's request for assistance. Findings: During a concurrent observation and interview on [DATE], at 10:00 AM, the Maintenance Director was asked to check call lights for Residents 21, 27, 38, 46, and 60. The Maintenance Director stated, there was an indicator light next to where the call light plugs into the wall. The Maintenance Director confirmed these indicator lights were not working for Residents 21, 27, 38, 46, and 60. The Maintenance Director checked Resident 35's call light and stated, the call light was not functioning and he would change the call light cord. The Maintenance Director said the facility had known about these call light indicators not working for one to two years. The Maintenance Director said this was an old system and replacement bulbs are not available. The Maintenance Director said the call light system needs to be replaced because he was unable to find companies with the knowledge to repair the facility's call light system. The Maintenance Director did not offer any alternative solution for the indicator lights. During a review of the facility's policy and procedure titled Call lights: Accessibility and Timely Response (not dated) indicated, .Staff will report problems with a call light or the call system immediately to the supervisor and/or maintenance director and will provide immediate or alternative solutions until the problem can be remedied .

Based on observation, interview and record review, the facility failed to ensure competency of one dietary aide (DA) when: 1. Standardized recipes for pureed foods were not followed for three lunch menu items on 11/16/21. 2. Scoop sizes for pureed foods were not followed during lunch tray line service on 11/16/21. Failure to ensure staff competency in kitchen related duties could negatively impact provision of prescribed diets and preferences for 13 residents who received pureed food from the kitchen. Findings: 1. During a review of the facility document titled, GOOD FOR YOUR HEALTH MENUS . November 15-21, 2021 - Week 3, the lunch menu indicated, .TUESDAY November 16 . Fish Fillet with Garlic Butter, Rice Pilaf, Ginger Carrots, Wheat Roll, Peanut Butter Cake . During an observation of food production activities in the kitchen on 11/16/21, that began at 10:30 AM, with the Assistant Dietary Supervisor (ADS) present, Dietary Aide (DA) 1 was observed to prepare pureed ginger carrots recipe. After proper hand hygiene and clean gloves worn, DA 1 used a slotted spoon to scoop and drain boiled crinkle-cut carrots from a pot into a plate then placed the boiled carrots in the blender, added a total of 4.5 cups of water that was used to boil the carrots and pureed the mixture for 5 minutes. During a concurrent interview with DA 1, the surveyor asked how the boiled carrots in the pot were prepared. DA 1 stated, he used 2 pounds of frozen crinkle cut medium carrots and boiled them with water. DA 1 then emptied contents of blender container and transferred the pureed carrot mixture into a rectangular, steam table container pan and set it aside on the counter. During an observation on 11/16/21, at 10:40 AM, with ADS present, DA 1 was observed to prepare pureed rice pilaf. DA 1 transferred cooked rice pilaf from a container vessel in the blender, added 2 cups of hot water and pureed the mixture for 5 minutes. During a concurrent interview with DA 1, the surveyor asked how much cooked rice pilaf was used for the pureed mixture. DA 1 stated, he used 2 pounds. DA 1 then transferred the pureed rice mixture from the blender into a rectangular steam table container pan, covered it with a transparent plastic wrap, and wrote puree rice 11/16/21 as label. During a concurrent observation and interview on 11/16/21, at 11 AM, the surveyor asked DA 1 how he prepared the pureed fish fillet on a rectangular steam table container pan that was set aside on the kitchen counter next to the stove. DA 1 stated, he used 7 pieces of cooked fish fillets, added 8 ounces of the fish juice from the container pan used to cook the fish, added 1 cup of water and pureed the mixture for 5 minutes. During a concurrent interview and record review of the recipe binder on 11/16/21, at 11:10 AM with DA 1 and ASD present, the surveyor asked DA 1 to show the recipes for pureed ginger carrots, pureed rice pilaf and pureed fish fillets. DA 1 was not able to identify the recipes in the binder. ASD assisted DA 1 and DA 1 was later able to point out recipes for pureed food items on the lunch menu that day. The recipe binder for GINGER CARROTS, indicated, . Portion size: ½ cup . Ingredients . Serves 8 . Frozen sliced carrots 1 lb (pound) 10 oz (ounces), Margarine 2 Tbsp (tablespoon) (1 oz), Ginger, ground* 1 tsp (teaspoon), Salt ¼ tsp, Parsley flakes as desired . *Cook: Taste carrots and more ginger if desired. DIRECTIONS: 1. Steam or boil carrots in a small amount of water until tender. Drain. Place in steam table pan. 2. Combine melted margarine with ginger and salt. 3. Pour margarine mixture over carrots and mix to blend. Garnish with parsley flakes as desired . SPECIAL DIETS . PUREEDS: Puree and serve #12 [scoop measure #12]. The recipe binder for RICE PILAF, indicated, .Portion size: 1/3 cup (#12) [scoop measure #12] . Ingredients . Serves 8 . Brown rice, uncooked . 1 cup (6 oz), Margarine, melted 2 ½ Tbsp, Boiling water 2 cups, Salt ½ tsp, Green bell pepper, chopped ½ (inch) or less 1 oz, Onions, chopped ½ or less 1 oz, Fresh red bell pepper, chopped ½ or less 1 oz, Parsley, flakes As desired . DIRECTIONS: 1. Rinse vegetables well under cool running water. 2. Bring water and margarine to a boil in a pan and pour over rice in steam table pan. Combine all other ingredients, except parsley flakes with rice and stir to mix. 3. Cover with foil and bake for 45 minutes to 1 hour .Garnish with parsley flakes as desired .Fluff with fork, cover with towel and let sit for 5 minutes. Re-fluff . SPECIAL DIETS . PUREEDS/DYSPHAGIA: Puree and serve #12 [scoop measure #12]. (Small #16, [scoop measure # 16], large #8 [scoop measure #8]). See Binder # 1, misc. section for Puree Starch recipe . The recipe binder for FISH FILLET WITH GARLIC BUTTER, indicated, .Portion size: 3 oz fish + 1 tsp sauce (= 3 oz protein) . Ingredients . Serves 8 . Fish fillet of choice . thawed (About 4 servings/lb) 2 lbs, Lemon juice 1 TBSP + 1 tsp, Water ¼ cup, Dill, dried (optional) ½ tsp. Sauce: Margarine, melted 2 oz (2 Tbsp), White cooking wine or chicken broth, 1 Tbsp + 1 tsp, Garlic powder ¼ tsp, Onion powder ¼ tsp, Tartar Sauce ½ cup, Parsley: Sprinkle for color . DIRECTIONS: 1. Place pieces of fish close together in single layer on greased sheet pan. Combine lemon juice, water and dill, if using. Pour over fish. 2. Bake at 375 °F (Fahrenheit) approx. 10 minutes per inch of thickness . 3. Sauce: Combine sauce ingredients and simmer 3-5 minutes to blend flavors. Pour sauce over fish in steamtable pans. Sprinkle with parsley flakes for color. 4. Serve with 1 Tbsp. Tartar sauce per serving . SPECIAL DIETS . PUREEDS: Puree and serve hot #8 scoop. Use parsley flakes for color. Puree tartar sauce . Upon further interview and review of the recipes for pureed ginger carrots, pureed rice pilaf and pureed fish fillet with ASD, ASD confirmed and acknowledged DA 1 did not follow recipe directions. ASD stated DA 1 was a relatively new staff and began to work in the kitchen about 4 months ago. ASD stated a kitchen supervisor who no longer worked at the facility provided DA 1 with the required job training. During a review of the resident dietary tray tickets provided by the Dietary Supervisor (DS) on 11/16/21, there were 13 total residents who received pureed meals from the kitchen. 2. During a tray line service observation on 11/16/21, at around 12:08 PM, a large rectangular steam table pan moderately filled with water sat on top of lit stove. The large pan held three steam table pans that contained the prepared pureed fish fillets, pureed rice pilaf and pureed ginger carrots. Green-colored scoops were noted on all three pans. During a review of the facility document titled, Scoop Measurement Color Guide, undated, indicated, Number 12 - Color Green - Measure 1/3 cup . During an observation on 11/16/21, at 12:10 PM, with the ASD present, the dietary tray ticket for Resident 28 was called for a regular diet, puree consistency and large portion. DA 1 used green-colored scoops of pureed rice pilaf and pureed ginger carrots from the steam table pans into Resident 28's plate. During a concurrent interview with DA 1, DA 1 confirmed green-colored scoops were used instead of the gray-colored scoops. During a review of the recipe for RICE PILAF, indicated, .SPECIAL DIETS . PUREEDS . Puree and serve . large #8 [scoop measure #8]) . Review of the menu for Pureed Rice Pilaf, indicated, .Large #8 . During a review of the menu for Pureed Ginger Carrots, indicated, .Large ½ c (cup) . During a review of the facility document titled, Scoop Measurement Color Guide, undated, indicated, . Number 8 - Color Gray - Measure ½ cup . During a concurrent observation and interview on 11/16/21, at 12:13 PM with ASD, ASD acknowledged incorrect scoops were used by DA 1 for Resident 28. ASD placed a gray-colored scoop on steam table pans for the pureed rice pilaf and pureed ginger carrots. ASD replaced Resident 28's plate with corrected portions of pureed food items. During an observation on 11/16/21, at 12:18 PM, with the ASD present, the dietary tray ticket for Resident 43 was called for a pureed diet, small portion. DA 1 used green-colored scoop of pureed rice pilaf from the steam table pans into Resident 43's plate. During a concurrent interview with DA 1, DA 1 acknowledged incorrect scoop was used. During a review of the recipe for RICE PILAF, indicated, .SPECIAL DIETS . PUREEDS . Puree and serve . (Small #16, .) . Review of the menu for Pureed Rice Pilaf, indicated, .Small #16 . During a review of the facility document titled, Scoop Measurement Color Guide, undated, indicated, . Number 16 - Color Blue - Measure ¼ cup . During a concurrent observation and interview on 11/16/21 at 12:22 PM with ASD, ASD confirmed the wrong scoop was used by DA 1 for Resident 43. ASD got a blue-colored scoop for the pureed rice pilaf pan and replaced Resident 43's plate with the corrected portion size. During a concurrent interview on 11/17/21, at 10:03 AM, with the Dietary Supervisor (DS) and Registered Dietitian (RD), DS stated, she had oversight of the kitchen operations. RD stated, he provided consultant services to the facility since September 2021. RD stated, he worked 8 hours, one day a week at the facility. When asked about an approximate percentage of time spent on kitchen-related responsibilities, RD said, can't say with certainty. RD stated, when in the facility, his time was spent mostly on clinical work. The surveyor discussed observed food and nutrition service practices in the facility that included pureed food preparation and tray line service noted on 11/16/21. During a concurrent record review of pureed diet menu and recipes for fish fillet, rice pilaf and ginger carrots with DS, DS stated, staff were expected to follow directions as indicated on the approved menus and recipes. RD stated, it was important that staff followed pureed recipe directions because it would affect the consistency and palatability of foods. RD stated, he had not yet done tray line service observations in the kitchen. During a review of the facility's policy and procedure (P&P) titled, FOOD PREPARATION, dated 2018, the P&P indicated, POLICY: Food shall be prepared by methods that conserve nutritive value, flavor and appearance. PROCEDURE: 1. The facility will use approved recipes, standardized to meet the resident census . 2. Recipes are specific as to portion yield, method of preparation, amounts of ingredients, and time and temperature guide . During a review of the facility's policy and procedure (P&P) titled, FOOD PREPARATION, dated 2018, the P&P indicated, PORTION CONTROL - POLICY: To provide specific portion control information. PROCEDURE: To be sure portions served equal portion sizes listed on the menu, portion control equipment must be used. A variety of portion control equipment should be available and utilized by employees portioning food. 1. Scoops are sized by number . Scoop numbers and amounts are listed in the RDs for Healthcare recipe book . During a review of the facility document titled, .DEPARTMENT OF FOOD AND NUTRITION SERVICES CONSULTANT (CONSULTANT DIETITIAN) JOB DESCRIPTION, dated 2018, indicated, POLICY . The Registered Dietitian provides consultation to the facility for the purpose of providing nutrition care and oversight of the operations of the Department of Food and Nutrition Services, which will result in optimal health of the resident/patient . RESPONSIBILITIES . Evaluates and monitors the food service department to assure that the department is providing adequate, acceptable quality food. Evaluates and monitors the meal delivery system. Monitors and recommends food service standards for sanitation, safety, and infection control. Advises and counsels Director of Food and Nutrition Services in all areas of food service and nutritional care . During a review of the facility document titled, JOB DESCRIPTION, dated 2018, indicated, POSITION: FNS (Food and Nutrition Service) Director . DUTIES AND RESPONSIBILITIES . Is responsible for the preparation and service of all food and ensures that approved menus and accompanying recipes are followed . Check trays to ensure diets are served as ordered . Review, update and follow policies & procedures . During a review of the facility document titled, JOB DESCRIPTION, dated 2018, indicated, POSITION: Cook A . QUALIFICATIONS . Ability to accurately measure food ingredients and portions . Knowledge of basic principles of quantity food cooking and equipment use . DUTIES AND RESPONSIBILITIES . Responsible for the preparation of food for breakfast and noon meals . During a review of the facility document titled, JOB DESCRIPTION, dated 2018, indicated, POSITION: Dietary Aide . DUTIES AND RESPONSIBILITIES .Assist with tray line . All other duties as assigned by the FNS (Food and Nutrition Service) Director . LIMITATIONS . Does not cook .

Based on observation, interview and record review, the facility failed to store, prepare, and distribute food in a safe and sanitary manner when: 1.Food items stored in kitchen refrigerators were expired, not labeled and dated, had labels beyond dates of use, produce discolored and fruits had mold-like substance 2. Food item brought in by family member for a resident was stored in the kitchen refrigerator 3. Food items stored in dry storage room were not dated and stored properly 4. Equipment and food service trays were not cleaned and maintained properly, and dietary staff did not perform proper hand hygiene 5. Temperature in freezer was out of range This deficient practice had the potential to put residents at risk for foodborne illnesses. Findings: 1.During an initial kitchen tour observation and concurrent interview on [DATE] that began at 10:08 AM, in the kitchen, with Assistant Dietary Supervisor (ADS) present, ADS confirmed the findings below and stated these food items had to be discarded. ADS stated food items had to be labeled and dated. 1.1) In refrigerator 1, an opened jar of clam base paste labeled with use by date [DATE] 1.2) In refrigerator 1, a container of cut, orange-colored lettuce leaves with use by date [DATE] 1.3) In refrigerator 1, a container of sliced tomatoes and green bell pepper with use by date [DATE] 1.4) In refrigerator 1, an undated cup of sliced strawberries 1.5) In refrigerator 1, 2 unopened yogurts with expiration date [DATE] 1.6) In refrigerator 2, an undated glass of milk 1.7) In refrigerator 2, 2 unopened yogurts with expiration date of [DATE] 1.8) In refrigerator 2, 4 packages of strawberries dated [DATE] that had mold-like substances During a review of the facility's policy and procedure (P&P) titled, LABELING AND DATING OF FOODS, dated 2018, the P&P indicated, POLICY: All food items in the storeroom, refrigerator, and freezer need to be labeled and dated. PROCEDURE: Food delivered to facility needs to be marked with a received date. Note that the delivery sticker is dated, and it can serve as the delivery date of the product . Newly opened food items will need to be closed and labeled with an open date and used by date . All prepared foods need to be covered, labeled and dated . During a review of the facility's policy and procedure (P&P) titled, PROCEDURE FOR REFRIGERATED STORAGE, dated 2018, the P&P indicated, . Produce will be delivered frequently and rotated in the order it is delivered to assure that a fresh product is used, free of any wilting or spoilage . During a review of the facility's policy and procedure (P&P) titled, GENERAL RECEIVING OF DELIVERY OF FOOD AND SUPPLIES, dated 2018, the P&P indicated, . POLICY: Food deliveries will be inspected to assure high quality food and supplies. They are to be received in proper condition. PROCEDURE . Carefully inspect deliveries for proper labeling, temperature and appearance .Produce is to be fresh and free of any wilting or spoilage . Label all items with delivery date or a use-by date . 2. During a kitchen tour observation and concurrent interview on [DATE], at 10:25 AM, with ADS present, a plastic container of soup with lid labeled [DATE] soup, use by [DATE] was found in refrigerator 1. The label indicated Resident 10's last name. ADS stated, the soup was store-bought and brought in by Resident 10's family member. ADS stated, kitchen staff would heat and serve the soup for Resident 10 during meals. During a review of the facility document, titled, Bringing in Food for A Resident, dated ,d+[DATE], the document indicated, .If you plan to bring food into the Facility for a resident, please be sure to follow these food safety guidelines . Resident should plan to consume prepared food within ,d+[DATE] hours of it being received into Facility. If food is to be eaten later, it should be taken immediately to the Activity Room where staff will label the food with the resident's name, date and time - and refrigerate it for up to 24 hours . Please consult facility staff regarding re-heating foods that have been refrigerated . 3. During an observation of the dry storage room located next to the kitchen, and concurrent interview on [DATE] that began at 11:08 AM, with ADS present, ADS acknowledged the findings below: 3.1) An opened, undated package of gelatin mix 3.2) An opened, undated package of polenta 3.3) 1 unused, undated package of cherry gelatin mix 3.4) An opened, package of pasta with use by date [DATE] was not tightly closed 3.5) 10 pieces of partly rotten bananas were found in plastic bin that was not kept clean and had had several brown-colored stains During a review of the facility's policy and procedure (P&P) titled, STORAGE OF FOOD AND SUPPLIES, dated 2017, the P&P indicated, POLICY: Food and supplies will be stored properly and in a safe manner. PROCEDURES FOR DRY STORAGE . The storeroom should be well-lighted, .dry and clean at all times . All food will be dated - month, day, year . Dry food items which have been opened . will be tightly closed, labeled and dated . During a review of the facility's policy and procedure (P&P) titled, GENERAL RECEIVING OF DELIVERY OF FOOD AND SUPPLIES, dated 2018, the P&P indicated, . POLICY: Food deliveries will be inspected to assure high quality food and supplies. They are to be received in proper condition. PROCEDURE . Carefully inspect deliveries for proper labeling, temperature and appearance .Produce is to be fresh and free of any wilting or spoilage . Label all items with delivery date or a use-by date . During a review of the facility's policy and procedure (P&P) titled, LABELING AND DATING OF FOODS, dated 2018, the P&P indicated, POLICY: All food items in the storeroom . need to be labeled and dated. PROCEDURE: Food delivered to facility needs to be marked with a received date. Note that the delivery sticker is dated, and it can serve as the delivery date of the product . Newly opened food items will need to be closed and labeled with an open date and used by date . 4.1 During a concurrent observation and interview on [DATE], at 10:31 AM, with ADS present, a gray-colored electric fan was on the counter of a three-compartment sink in the kitchen. The fan ran and blew air in the food production counter next to the stove. The fan's blade guards had significant accumulation of dust-like debris. The base of the fan was also wet. ADS confirmed the observations. ADS stated, the fan had been used in the same location for a while now. ADS acknowledged the blade guards were not clean, and location of the fan was unsafe. 4.2 During a follow-up observation and concurrent interview on [DATE], at 9:39 AM, with ADS, in the kitchen, a stack of 6 service trays used to hold clean beverage cups were inspected. The trays had sticky residues of paper tapes attached on the edges. There was also a stack of 5 resident food trays used during meal service that had several pieces of plastic tapes attached on the edges. ADS acknowledged the observations and stated, the tape and tape residues had to be removed to ensure the trays were washed and cleaned properly. During a concurrent interview on [DATE], at 10:20 AM, with the Registered Dietitian (RD), RD stated, the tapes and residues noted by the surveyor on food service trays were an infection control concern. 4.3 During an observation of food production activities in the kitchen on [DATE], that began at 10:30 AM, with the Assistant Dietary Supervisor (ADS) present, Dietary Aide (DA) 1 was observed to prepare pureed ginger carrots recipe. After proper hand hygiene and clean gloves worn, DA 1 used a slotted spoon to scoop and drain boiled crinkle-cut carrots from a pot into a plate then placed the boiled carrots in the blender, added a total of 4.5 cups of water that was used to boil the carrots and pureed the mixture for 5 minutes. DA 1 then emptied contents of blender container and transferred the pureed carrot mixture into a rectangular, steam table container pan and set it aside on the counter. With the same gloves worn, DA 1 removed the food container and cover from the blender base, washed them with water in the sink and re-attached the blender parts back to the base. With used wet gloves still worn, DA 1 then held and touched the interior container of the prepared pureed carrot mixture on the counter. ASD noted the observations and stated the pureed carrot mixture had to be discarded. DA 1 removed his used gloves. DA 1 did not perform proper hand hygiene and was about to proceed with preparation for another pureed food item. DA 1 acknowledged he did not wash his hands after glove removal. ASD acknowledged the blender parts were not properly washed. DA 1 and ASD confirmed dirty gloves had to be removed after use, and appropriate hand hygiene must be performed after glove removal. During a review of the facility's policy and procedure (P&P) titled, SANITATION, dated 2018, the P&P indicated, POLICY: The Food & Nutrition Services (FNS) Department shall have equipment of the type . for proper preparation, serving and storing of food . All equipment shall be maintained as necessary and kept in working order . PROCEDURE . The FNS Director is responsible for instructing Food and Nutrition Services personnel in the use of equipment. Each employee shall know how to operate and clean all equipment in his specific area . All utensils, counters, shelves and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seam, cracks and chipped areas . Plastic ware, china and glassware that becomes unsightly, unsanitary or hazardous because of chips, cracks or loss of glaze shall be discarded .All Food & Nutrition service staff shall know the proper hand washing technique. The FNS Director is responsible for the proper training of this . The FNS Director is responsible for instructing employees in the fundamentals of sanitation in food service and for training employees to use appropriate techniques . During a review of the facility's policy and procedure (P&P) titled, HAND WASHING PROCEDURE, dated 2018, the P&P indicated, Hand washing is important to prevent the spread of infection . PROCEDURE: 1. Use warm running water . and soap, preferably from a dispenser. 2. Wet hands . Add soap and rub hands together . 3. Rinse thoroughly and dry hands . WHEN HANDS NEED TO BE WASHED: 1. Before starting work in kitchen 2. After handling soiled dishes and utensils . 4. Before and after handling foods with hands (cutting, peeling, mixing, etc.) . 5. During a concurrent observation and interview on [DATE], at 9:28 AM, with ADS present, the kitchen freezer #2 temperature was checked. There were ice cream cups and breads stored inside. The thermometer inside the freezer #2 indicated, 7° Fahrenheit (F). ADS stated the temperature was supposed to be zero or below. During a follow-up observation and concurrent interview on [DATE] at 11:29 AM, with ADS present, the kitchen freezer #2 temperature was checked. The thermometer inside the freezer #2 indicated, 10° Fahrenheit (F). During a follow-up observation and concurrent interview on [DATE] at 12:48 PM, with ADS present, the kitchen freezer #2 temperature was checked. The thermometer inside the freezer #2 indicated, 5° Fahrenheit (F). ADS stated she will notify the maintenance department. During a review of the facility's policy and procedure (P&P) titled, COLD STORAGE TEMPERATURE LOGGING, dated 2018, the P&P indicated, Food and Nutrition Services staff shall review and record temperatures of all refrigerators and freezers to ensure they are at the correct temperature for food storage and handling. PROCEDURE: 1. Food and Nutrition services staff will check the inside temperature of refrigerators and freezers . If temperatures are not withing standards, Food & Nutrition services staff will notify the FNS Director . Freezer temperature standards are 0° F (Fahrenheit) or below .

Based on observation, interview, and record review, the facility failed to store medications and biologicals (biologicals are made from variety of natural sources- human, animal or microorganisms, may include a wide range of products such as vaccine, blood and blood components) in a safe condition when the temperature of two of two sampled medication refrigerators were out of range in accordance with Federal, State, and CDC vaccine storage and handling guidelines. This failure had the potential to compromise the integrity and effectiveness of medications and biologicals and could potentially cause harm to the residents. Findings: During an observation of the Medication Refrigerator 1 (MR 1) in the Medication Storage Room Area 1 (MSRA 1), on 11/16/21, at 1:45 PM, with the Registered Nurse (RN) 4, the temperature reading of MR 1 indicated, 32 degrees Fahrenheit (F). Inside MR I, a [MEDICATION(S)] N [MEDICATION(S)] (a single-dose packet of medication to which a needle has been fixed by manufacturer) of NPH insulin (a hormone that lowers the level of blood sugar) for Resident # 59, the manufacturer ' s instruction written on the medication label, . Keep in a cold place. Store at 36 degrees to 46 degrees F, do not freeze. In a concurrent record review, the Refrigerator and Freezer Temperature Log 1 (RFTL 1) indicated, the temperature of MR 1 was .2 on 11/11/21 at 6 AM and 6 PM, no scale of temperature (Fahrenheit scale or Celsius scale. Celsius is a temperature scale based on the freezing point of water), recorded. The RFTL 1 indicated that MR 1 ' s temperature on 11/13/21, at 6 AM and 6 PM was both .0 (zero) ., with no temperature scale recorded. In a concurrent interview, RN 4 acknowledged the observation and stated, . Will refer this to maintenance . When asked about which temperature scale staff was using on the temperature log, RN 4 was unable to provide an answer. During an observation in the Medication Refrigerator 2 (MR2) in the Medication Storage Room Area 2 (MSRA 2) on 11/16/21, at 2:30 PM, with RN 2, the temperature reading of MR 2 indicated, 32 degrees Fahrenheit (F). Inside MR 2, an Influenza Vaccine, single dose, pre-filled syringe for resident use. The manufacturer ' s instruction on the label, . Store between 36 degrees - 46 degrees F. Do not freeze. Discard if the vaccine has been frozen . In a concurrent record review, the Refrigerator and Freezer Temperature Log 2 (RFTL 2) indicated, the temperature of MR 2 was .0 (zero) with no scale of temperature (Fahrenheit scale or Celsius scale. Celsius is a temperature scale based on the freezing point of water), recorded on 11/01- 11/16/21 at 6 AM and 6 PM. In a concurrent interview, RN 2 acknowledged the observation and stated, . will discard this vaccine now . During an interview on 11/16/21, at 2:15 PM, with the Director of Maintenance (DOM), DOM stated, . Every morning I checked the maintenance logbook, but there is no request to check refrigerator. I did not come to fix it . During an interview on 11/16/21, at 4:00 PM, with RN 1, RN stated, . staff to report to maintenance if the temperature is out of range . During an interview on 11/18/21, at 11:00 AM, with the Director of Nursing (DON), DON stated, . checked the thermometer, but did not check the log . During a review of the facility pharmacy Policy and Procedure (P&P) titled, Medication Storage, Storage of Medication dated 09/10, the P & P indicated, . 11. Medication requiring refrigeration or temperature between 36 to 46 degrees F are kept in a refrigerator with a thermometer to allow temperature monitoring.A daily recorded temperature should be documented and signed off . temperature should be recorded twice daily.A facility policy should be developed which describes the steps that will be followed if temperature falls out of the range .

Based on observation, interview, and record review, the facility failed to ensure 1. Dresser surfaces covered with Formica (a thin plastic laminate glued onto furniture to provide a durable surface) in rooms 102 and 105 were free of chipped damage. 2. The chipped and cracked surface of an enameled sink (metal sink coated with a shiny hard ceramic layer) in room 102 was repaired and/or replaced. These failures had the potential for surfaces not to be cleaned in a sanitary manner and may negatively impact residents' psychosocial health when they have to live in an unmaintained room that is not homelike. Findings: During observation and concurrent interview on 11/16/21, at 9:11 AM, the Maintenance Director stated, the Formica covering the bottom of the dresser in room 102 was chipped and the damaged area was approximately 2 inches by 4 inches. The Maintenance Director stated, the sink in room 102 had a ¼ inch by ¼ chip on the enamel surface with spider web like cracks next to the chip. In room 105, the Maintenance Director stated, there was a 1 inch by 6 inch damage on the Formica covering the dresser. The Maintenance Director stated, they were aware of the Formica/dresser problem and started replacing some dressers in 2016 (approximately five years ago). The Maintenance Director stated, the facility ran out of funds to replace other dressers. During a review of the facility's policy titled Preventative Maintenance Program (not dated), the policy indicated .2. The Maintenance Director shall assess all aspects of the physical plant to determine if Preventative Maintenance (PM) is required. Required PM may be determined from manufacturer's recommendations, maintenance requests, grand rounds, life safety requirements, or experience. 3. If preventative maintenance is required, the Maintenance Director shall decide what tasks need to be completed and how often to complete them.

Based on observation, interview and record review, the facility failed to ensure residents are protected from abuse when a verbal abuse allegation incident that involved Resident 42 and Resident 44 was not identified and reported to appropriate agencies within two hours after knowledge of the allegation. This failure put residents at risk from from further abuse. Findings: Resident 44 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 42 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a concurrent observation and interview on 11/15/21, at 12:20 PM, with Resident 42, in her bed, Resident 42 was awake and alert. Resident 42 stated, she was upset and reported that her roommate [Resident 44] curses, yells . the language she [Resident 44] uses, it's filthy . During an observation on 11/15/21, at 12:38 PM, Resident 44 was in bed with eyes closed. During a record review of Resident 42's social services progress notes, the progress notes dated 10/15/21 indicated, Resident . alert and oriented x 4 [person, place, time, and situation]. She still has mental capacity to make decisions for herself . About two weeks ago, resident [Resident 42] had a new roommate . New roommate has a dementia with behavioral disturbance during ADLs (activities of daily living). Resident 42 [name redacted] is very upset about the new roommate's behavior and yet she does not want to be moved to a different room which was also offered to her . During an interview on 11/18/21, at 11:03 AM, with Certified Nursing Assistant (CNA) 1, CNA 1 stated, she was familiar with Resident 42. CNA 1 stated, Resident 42 did not want a roommate. CNA 1 stated, Resident 42 thought her roommates had a mental problem. CNA 1 stated, every day her [Resident 42] mood [was] different . up and down behavior . when angry, she starts yelling . During a record review of Resident 42's social services progress notes, the progress notes dated 10/27/21 at 3:11 PM indicated, Social Services met with resident [Resident 42] after CNA reported her [Resident 42] making foul verbal comments to her roommate [Resident 44] during ADLs this afternoon. Resident [Resident42] made comments such as you belong in a mental hospital and when roommate [Resident 44] asked where she was going to CNA, resident [Resident 44] said to a waste basket. SSD [Social Services Director] talked with resident [Resident 42] about inappropriate language and even if her roommate cannot hear her and is not aware of what is being said, it does not make it okay . During a concurrent interview and record review of Resident 42's social worker's progress notes on 11/19/21, at 9:22 AM, with the Social Services Director (SSD), SSD stated, her understanding of verbal abuse was use of harmful language, profanity . SSD stated, verbal abuse meant there was an intent to harm, intentional, malicious . causing emotional, psychological distress resulting in feeling unsafe and uncomfortable . SSD stated, verbal abuse allegation had to be reported to CDPH [state agency], Ombudsman and police within 2 hours of knowledge of the incident. When asked about Resident 42's social progress notes dated 10/27/21 regarding foul verbal comments made by Resident 42 towards her roommate, Resident 44, SSD stated, yes, it's considered verbal abuse. SSD stated, the incident happened around 11AM on 10/27/21 and was reported to her by CNA 3. SSD stated, she discussed the incident with the administrator at the time and they determined that the incident was not a reportable allegation of verbal abuse. SSD stated, moving forward, this [verbal abuse incident] would be a reportable incident. During a review of the facility's policy and procedure (P&P) titled, Abuse Prevention & Reporting, last revision dated 1/13, the P&P indicated, I. PURPOSE - A. To ensure that residents are free from abuse . The facility has a ZERO TOLERANCE for any/all types of abuse directed toward any resident, patient or dependent adult within its care. B. To provide guidelines to all staff regarding their roles and responsibilities in the prevention and reporting of resident abuse . II. POLICY - A. DEFINITIONS 1. ABUSE: the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish . Types of Abuse: a. Verbal abuse: any use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families or are made within their hearing distance, regardless of their age, ability to comprehend, or disability . F. The facility Administrator will be responsible for: Ensuring that a thorough investigation of all suspected, reported, or observed abuse is completed in a timely manner and documented appropriately . Involving the Interdisciplinary Team to ensure that interventions, review and follow up are initiated in a timely manner. Ensuring that the resident is protected from further episodes of abuse during the investigation of an alleged abuse . Timely and accurate reporting to the appropriate agencies of any/all abuse incidents according to state and federal regulations .

Based on observation, interview and record review, the facility failed to provide the necessary care and services for one of 16 sampled residents (Resident 53) when the facility did not remove the surgical site staples per the physician's orders; the facility did not assess the surgical site per the plan of care and the facility policy and procedure; or revise the comprehensive care plan to address a change in skin integrity and infection at the surgical site. This deficient practice resulted in an infected surgical site for Resident 53. Findings: During a review of the clinical record of Resident 53, it indicated he was admitted on [DATE] for rehabilitation following a joint replacement surgery. Resident 53's medical [DIAGNOSES REDACTED]. Resident 53 is his own responsible party. A review of the Minimum Data Set (MDS - a resident assessment tool) for Resident 53, dated 3/24/19, indicated the Skin Condition section of the MDS reflected the resident had a surgical wound upon admission. Resident 53 had a Brief Interview for Mental Status (BIMS - an aide in detecting cognitive impairment) score of 15 (meaning no cognitive impairment). During an observation and a concurrent interview with Resident 53, on 6/3/19, at 9:14 AM, in the room of Resident 53, Resident 53 sat in a chair and stated he was admitted to the facility for a broken leg, which made it difficult to move, stand up, and use the bathroom. During a concurrent record review and interview with Staff 24, on 6/4/19, at 10:20 AM, Staff 24 reviewed the binder of treatment records and stated, There's no wound care treatment performed to his surgical site today. The Treatment Administration Record (TAR) for Resident 53, between 6/1/19 and 6/30/19, indicated an order effective 5/31/19 through 6/4/19 to cleanse the area and pat dry the surgical site on the right distal femur, and apply a nickel sized amount of Santyl ointment (an ointment that removes dead tissue) to the right distal femur surgical site's wound bed avoiding contact with surrounding skin, apply wet gauze (dressings are used to help maintain a moist wound healing environment) to the wound or Hydrogel gauze (a dressings used for packing deep wounds and maintaining a moist wound), and cover the area with a dressing, every other day. During a concurrent record review and interview with Staff 24, on 6/4/19, at 10:20 AM, Staff 24 reviewed the skin assessment records in the Treatment binder for Resident 53, such as the Non Pressure Sore Skin Report(s) from admission until present (6/4/19), the TAR, dated 6/1/19 and 6/30/19, and the initial skin assessment, dated 3/17 /19. Staff 24 stated, The last time a skin assessment sheet was completed was on 5/23/19, but the skin assessments records in the binder don't address the surgical site on the right lower femur. When asked if all skin assessments for surgical sites should be documented in the ''.Treatment binder, Staff 24 stated, They (the records in the Treatment binder) should (address the surgical wound) . The skin assessment sheets (reports) should be done every week . During a concurrent observation and interview with Resident 53, on 6/4/19, at 10:43 AM, in the room of Resident 53, a clean and dry dressing covered his right femur. Resident 53 declined an observation of his wound care for the surgical incision on the next day. A review of the Skin Assessment Record for Resident 53, dated 3/17/19, indicated 22 staples on the surgical site. There was no other documentation on the characteristics (such as redness and measurements) of the right femur surgical site or the signs or symptoms of infection present. A review of the Progress Notes for Resident 53, between 3/17/19 and 3/24/19, indicated a dressing covered the surgical incision site upon admission. No documentation of a physician or orthopedist (a medical specialty which focused on the skeletal system) notification on the staple removal from the surgical site 3/17/19 through 3/24/19. The notes indicated no documentation of an assessment or treatment performed to the surgical site between 3/18/19 and 3/24/19. A review of a Nursing Weekly Assessment for Resident 53, dated 3/24/19, indicated a description of surgical wound with 22 staples in the Skin Assessment section. A review of the Comprehensive Care Plan of Resident 53 included care plans to address the skin integrity of the surgical site and potential for infection related to the surgical site. The care plan for Resident 53 titled: .Altered Skin Integrity r/t (related to) Surgical Wound . with 22 staples . revised 3/24/19, indicated goal and interventions, such as assessing the site for signs and symptoms of infection (redness, swelling, pain, and drainage, the liquid produced by the body in response to tissue damage), to identify and prevent wound complications, such as infection. Another care plan for Resident 53 titled: .Potential for infection . surgical wound site, revised 3/17/19, indicated measures to address the risk for infection. A review of a Physician's Order for Resident 53, dated 3/25/19, indicated the physician ordered laboratory testing in one week (4/1/19). A review of the Progress Notes for Resident 53, dated 3/25/19, indicated the physician ordered a complete blood count (laboratory testing to evaluate the composition of the blood) for 4/1/19 without a documented reasoning for ordering the test. There was no documentation of a notification or communication to the physician or the orthopedic surgeon regarding the surgical staple removal. A review of the Progress Notes for Resident 53, dated 3/26/19, indicated, . at 10:30 (am) 22 staples were removed from his right thigh, applied skin closure strips and island dressing (a dressing used to absorb fluid from wounds, such as surgical sites) . A review of the Progress Notes for Resident 53, dated 3/27/19, indicated the nurse called the physician regarding surgical site drainage and redness noted at 16:01 PM. A note at 22:09 PM indicated no frequency of the New order to cleanse surgical incision on right thigh with . apply triple atb (antibiotic medication used against bacterial infections) ointment and cover with island dressing. A review of the TAR for Resident 53, between 3/1/19 and 3/31/19, indicated three orders unrelated to any treatments, e.g. the order for the removal of the surgical staples, or assessments or monitoring of the site. A review of the Laboratory Result Report for Resident 53, received 4/1/19, indicated a WBC (white blood cell - cells in the immune system involved in fighting infection) level of 9.3, higher than the Reference Range of 4.2 9.1 K/uL (cubic milliliter). According to Medline Plus, 2019, infection is a cause of a high white blood cell count. (https://medlineplus.gov/ency/article/ 7.htm). A review of a Progress Note for Resident 53, dated 4/2/19, indicated the nurse notified the physician of serosanginous/yellow (a combination of both blood and serous fluid) drainage noted on old dressing . The note also indicated, Resident denied pain, but (reported) tenderness. Warm to touch, right leg brace kept on. Received (a physician's) order to start Keflex (a medication used against bacterial infections) . Order carried out. A review of the Medication Administration Record [REDACTED]. A review of the TAR for Resident 53, between 4/1/19 and 4/30/19, indicated three orders, none of which addressed an assessment or wound care orders for the surgical site. A review of the Physician's Progress Note for Resident 53, dated 4/3/19, indicated the right femur fracture had redness and slough (yellow or white colored dead skin tissue) on the incision site and an order to .add Santyl to the area of slough on 4/3/19. A review of the Nursing Weekly Assessment for Resident 53, dated 4/ 4/19, indicated one surgical site listed on the right trochanter (upper portion of the leg) had a description of a Surgical Wound with 22 staples. There was no documentation of a surgical site on the right distal femur included. A review of the Physician's Progress Note for Resident 53, dated 4/8/19, indicated the Santyl (was) not working well; will refer to orthopedic surgeon for debridement (a procedure that removes dead tissues). Continue on Keflex . A review of the Physician's Order for Resident 53, dated 4/8/19, indicated an order to Refer back to orthopedic surgeon to debride wound at incision. During a concurrent record review and interview with Staff 3, on 6/5/19, at 10:09 AM, Staff 3 was asked to detail the skin assessments process and documentation. Staff 3 stated the nurses were trained to conduct skin assessments of a surgical site on admission and document a skin assessment in the Treatment binder once a week. When asked to describe the documentation for a skin assessment, Staff 3 answered, Nurses must document the wound's size, drainage, wound bed appearance, odor . Staff 3 reviewed the clinical record of Resident 53 and stated Resident 53 had a surgical site on the right distal femur. Staff 3 further reviewed the resident's records in the Treatment binder, the TARs, the Physician's Orders, the Non Pressure Sore Skin Report(s) recorded from admission until present (6/4/19), the Progress Notes, between 3/17/19 and 6/4/19, and acknowledged wound infection and orders for Keflex, wound care, and wound debridement began in the facility and were not present on admission. In addition, Staff 3 acknowledged there was no documentation of a skin assessment between 3/18/19 and 3/25/19. When asked if the Nursing Weekly Assessments incorporate a skin assessment of the surgical site, she stated, No due to the lack of information, such as the wound's measurements and drainage, in all the records (including 3/24/19 and 4/4/19). Staff 3 further stated, .The first assessment isn't even right, the surgical site is on the right lower leg, not the trochanter . Staff 3 also acknowledged the Progress Notes did not contain documentation of an assessment or treatment of [REDACTED]. Staff 3 reviewed the comprehensive care plan and stated the care plan on the skin integrity of the surgical site (on the right femur) and the potential for infection needs to be revised as no update occurred since (MONTH) 24th (2019) (prior to the surgical staple removal and the surgical site infection). During a concurrent record review and interview with Staff 20, on 6/5/19, at 3:11 PM, Staff 20 stated Resident 53 was admitted to the facility with a surgical wound. Staff 20 reviewed the Inter Facility Transfer Report (the general acute care hospital (GACH) discharge summary) for Resident 53, dated 3/17/19, and the clinical record of Resident 53. Staff 20 stated Resident 53 received discharged orders from the GACH's physician to remove the surgical staples on the right femur on 3/24/19. Staff 20 stated the progress notes did not document a skin assessment or treatment performed to the surgical site on the right femur between 3/18/19 and 3/25/19, and a Progress Note for Resident 53, on 3/26/19, was the first documentation covering the removal of the right femur's surgical staples. Staff 20 reviewed the Progress Notes, between 3/17 /19 and 3/25/19, and was unable to find documentation of a notification to the physician or orthopedist regarding the removal of the right femur's surgical site staples, or any documentation to remove the surgical site staples on different date than 3/24/19, ordered by the GACH physician. Staff 20 stated the surgical staples were removed late, and the resident's surgical site became infected, which required antibiotics, wound care treatments, and wound care debridement. Staff 20 acknowledged the Progress Notes for Resident 53, between 3/17/19 and 3/25/19, indicated no documentation of an assessment or treatment performed to the surgical site on the right femur between 3/18/19 and 3/25/19 or a notification to a physician or orthopedist (a medical specialty which focused on the skeletal system) regarding the removal of the surgical staples on the right femur's surgical site between 3/17 /19 through 3/25/19. Staff 20 reviewed the Initial Assessment, dated 3/17/19, and the Weekly Nursing Assessment, dated 3/24/19 and 4/4/19, and stated the records lacked the assessment information, such as the characteristics of the surgical site. When Staff 20 was asked to provide additional skin assessment of the surgical site on the right femur, Staff 20 was unable to provide additional documentation. Staff 20 acknowledged revision dates for the care plans on the potential for infection and the surgical wound's skin condition, were outdated and required revision. During a concurrent record review and interview with Staff 12, on 6/6/19, at 3:14 PM, Staff 12 was asked about performing and documenting skin assessments. Staff 12 replied, Skin assessments for surgical wounds are documented once a week in the Treatment binder . An assessment for a surgical wound includes noting the redness, appearance of the dressing . a wound infection assessment consists of documenting the amount and appearance of the drainage, the smell of the wound, the drainage, the temperature of the resident . Staff 12 was asked when care plans on wounds and infection were revised. Staff 12 answered, .The care plans are revised when there is a change in the wound or when there is a new infection present . Staff 12 reviewed the skin assessment records for Resident 53 in the Treatment binder and was unable to provide documentation of a surgical wound assessment. After reviewing the clinical record of Resident 53, Staff 12 acknowledged the surgical staples removal was late and the skin assessments records on the surgical wound's condition didn't have enough entries or details. In addition, upon further review of the care plan, Staff 12 stated the care plan addressing the skin integrity of the surgical site, revised 3/24/19, indicated the care plan still shows when the resident has surgical staples, and the care plan on the potential for infection is overdue for a revision. Staff 12 added both care plans had interventions and goals created no more than two weeks after he came here (was admitted to the facility). Staff 12 added the comprehensive care plan needs to be revised as the resident was no longer at risk for infection, but had a [DIAGNOSES REDACTED]. Staff 12 acknowledged without the necessary care (the lack of skin assessments, late surgical staple removal and care plan revisions) the surgical site became infected, which required Keflex, wound care treatment, and debridement. During a record review and interview with Staff 2, on 6/7/19, at 12:12 PM, Staff 2 was asked about the skin assessment process. Staff 2 answered nurses assess surgical wounds once a week and document the findings in the Treatment binder. Staff 2 continued, To assess a wound, a nurse looks at the drainage, the redness, the location, the measurements of the wound . signs and symptoms of infection include odor, drainage . Staff 2 was asked when care plans for the skin integrity of surgical wounds and an infection were revised. Staff 2 stated care plan revisions should be completed when a wound, or infection, occurs or worsens. Staff 2 reviewed the clinical record of Resident 53. Staff 2 stated Resident 53 was admitted with orders from the GACH (General Acute Care Hospital) to remove the surgical staples following surgery on the right femur. Staff 2 was unable to provide documentation the staples were removed per the orders, and Staff 2 was unable to provide documentation supporting the staff notified the physician or orthopedic surgeon regarding the surgical staples prior to removal. When asked to provide additional documentation of a skin assessment for the surgical site, Staff 2 was unable to do so. Staff 2 reviewed the Weekly Nursing Assessments and was asked if the Weekly Nursing Assessments contained documentation which included a surgical site skin assessment. Staff 2 stated, No. Staff 2 acknowledged the (potential for) infection and skin integrity of the surgical site care plans required revisions to reflect the changes in the resident's condition. Staff 2 stated there was no policy and procedure on assessing and documenting a surgical wound, or removing surgical staples. Review of the facility policy and procedure titled: Wound Care Management, dated (YEAR), indicated the wound documentation assessments must contain characteristics of the wound and treatment performed to the wound. Review of the facility policy and procedure titled: Comprehensive Care Plan dated 8/24/18, indicated, .The plan of care shall be individualized, based on diagnosis, resident assessment and personal goals of the resident and his/her family .The needs of the resident, goals, time frames, required services and the service settings are critical considerations in determining the plan of care.

Based on observation, interview and record review, the facility failed to implement its policy and procedure to maintain an effective infection control program, when: 1. Single patient use glucometers were used on more than one resident in need of fingerstick procedures. An Immediate Jeopardy (IJ) was identified on 7/18/18 at 5 PM for 11 residents (Residents 13, 18, 25, 28, 30, 35, 38, 41, 45, 53, 63) in the presence of the Administrator (Admin), Director of Nursing (DON) and Director of Staff Development (DSD). The IJ was lifted on 7/20/18 at 4 PM. IJ is a situation wherein the provider's non-compliance has caused, or is likely to cause serious injury, harm, impairment or death to a resident. The use of Single Patient Use glucometers for multi resident use had the potential to jeopardize the health and safety of the residents by causing the transmission of blood borne pathogens that can result in the development of communicable and infectious diseases. 2. A hand sanitizer without alcohol in 56 dispensers was in use by all staff. These failures had the potential to jeopardize the health and safety of residents by causing the transmission of blood borne pathogens that can result in the development of communicable and infectious diseases. Findings: 1. During observation inside Medication room [ROOM NUMBER] on 7/18/18 at 2:50 PM, a box of True Metrix Self Monitoring Glucose System Meter Kit had instructions, Single Patient Use, on the front of it's box. True Metrix Self Monitoring Glucose System - a device that measures the blood glucose in fresh human capillary whole blood taken from the fingertip or forearm. It is intended to be used on a single person. The system included test strips where blood is applied and inserted into the meter and lancets to prick the skin to obtain the blood sample. During the Medication Cart 1 inspection with Registered Nurse (RN) 1 on 7/18/18 at 3:13 PM, A True Metrix Self Monitoring Glucose meter was found inside the cart. During concurrent interview, RN 1 stated, We use this glucometer for all residents on finger stick checks. We use the hand sanitizer or the alcohol swabs to disinfect it (glucose meter) after use. During an interview on 7/18/18 at 3:15 PM, Licensed Vocational Nurse (LVN) 1 stated, We use this (hand sanitizer) or alcohol swabs to clean the glucose meter. During an interview on 7/18/18 at 3:20 PM, Charge Nurse (CN) acknowledged that nurses were using True Metrix Glucose Self Monitoring Meter specified for single patient use on multiple residents. During an interview on 7/18/18 at 3:30 PM, LVN 3, who was assigned to Medication Cart 3, stated, It (True Metrix Glucose Meter) is used on multiple residents. Each nursing station has only one, and we use that for all. In a concurrent interview, LVN 4, who was assigned to Medication Cart 2, acknowledged the glucose meter was used on multiple residents. Review of the manufacturer's product insert for the True Metrix Self Monitoring Blood Glucose System Meter Kit indicated under cleaning and disinfection, .the True Metrix Self Monitoring Blood Glucose System, are for one person use only. Do not share your meter with anyone .all parts of the system (such as the meter) can potentially transmit infectious diseases from bloodborne pathogens even after cleaning and disinfecting . During an interview on 7/20/18 at 2:16 PM, Director of Staff Development (DSD) stated, I do not have records of inservice training regarding the glucose meters. I only show them (nurses) how to use it (glucose meter) when they (nurses) first start working here. During an interview on 7/19/18 at 2 PM, LVN 6 stated, We have been using that meter for a long time. I don't remember being given a training regarding the proper use and I have been working here for nine years. During an interview on 7/23/18 at 2 PM, RN 2 stated, I have been working here for [AGE] years. There was no inservice done for the glucose meters that I know of. Review of the undated facility Policy and Procedure titled, Cleaning and Disinfecting The True Metrix Glucometers indicated, To Clean .with only PDI Super Sani Cloth Wipes .rub the entire outside of the meter using three circular motions . To disinfect . using fresh wipes make sure that all outside surfaces of the meter remain wet for 2 minutes . According to Centers for Disease Control (CDC), In self monitoring of blood glucose, individuals perform the steps of monitoring for themselves .blood glucose meters should not be shared. Infectious agents, such as HBV, can be transmitted through indirect contact transmission, even in the absence of visible blood. Indirect contact transmission is defined as the transfer of an infectious agent from one patient to another through a contaminated intermediate object (such as blood glucose meter). If blood is transferred from patient to the meter, and the meter is not cleaned and disinfected after use, subsequent patients can be exposed to this blood when the meter is used on them .an excerpt from FDA (Food and Drug Administration) reads, the disinfection solvent you choose should be effective [MEDICAL CONDITION].[MEDICAL CONDITION] AND [MEDICAL CONDITION] virus. Outbreak episodes have been largely due to transmission of [MEDICAL CONDITION] and [MEDICAL CONDITION]. Please note that 70% [MEDICATION NAME] solutions are not effective against [MEDICAL CONDITION] bloodborne pathogens .Blood glucose meters dedicated for single patient use should, ideally, be stored in the patient's room in a manner that will protect against inadvertent use for additional patients and cross contamination from the surface of one meter to another does not occur . 2. During an observation in the initial screening on 7/17/18 at 2:10 PM, a glob of the solution dispensed from a hand sanitizer pump on the wall by room [ROOM NUMBER] felt as if it did not contain alcohol. During an interview on 7/17/18 at 2:24 PM, the housekeeping staff (Hskp) 1, stated, Yes, housekeeping staff replenishes all pumps on a regular basis yes, the solution contains alcohol for hand cleaning . Hskp 1 was asked to open the container on the wall, which exposed a one liter container with a label in red letters that read, Non-Alcohol Foaming Hand Sanitizer. The label listed as the main ingredient, a non-alcohol substance, [MEDICATION NAME] chloride 0.13%. During an interview on 7/17/18 at 3:11 PM, the Housekeeping Supervisor (HskpS) stated, Yes, we use these alcohol hand sanitizer pumps throughout the facility and housekeeping refills them as needed . HskpS was asked to open a wall dispensing unit by room [ROOM NUMBER], and after exposing the same Non-Alcohol . label, she stated Oh .I thought this contained alcohol .I don't know what happened . She opened two other dispensers in the vicinity and found the same solution contents inside. During an interview on 7/17/18 at 4:10 PM, the Infection Control Coordinator (ICC) stated, I was sure the solution we are using had alcohol .Our policy says we use alcohol-based hand sanitizer .I don't know what happened .we need to change all of these . During an interview on 7/17/18 at 4:30 PM, the Director of Nursing (DON) stated, Yes, we are expected to use alcohol hand sanitizer as part of staff hand hygiene . Upon showing the inside of a wall hand sanitizer unit dispenser, the DON added, Oh my gosh .that solution is not killing anything, I was not aware we are using a non-alcohol solution .I need to follow up on this . Review of a two-page facility policy located in the facility's Infection Control Manual, last reviewed on 6/1/17, and titled, Procedure for Handwashing, indicated, Procedure for Using Alcohol Sanitizer .2. Apply enough hand sanitizer to cover entire surface of the hands .4.The alcohol hand sanitizer may be used routinely for hand hygiene .Advantages of Alcohol Hand Sanitizer: Active against all bacteria .Rapid kill organisms, Spreads quickly across the skin, Evaporates quickly .