Every finding on record at Brentwood Health Care Center

Based on observation, interview and record review the facility failed to test a tab alarm (a tab placed on wheelchair with sensors connected to the resident that will alarm when a resident stands up unassisted to help prevent falls by alerting staff) for one of three sampled residents (Resident 2).This deficient practice placed Resident 2 at risk of getting up undetected and having a fall.A review of Resident 2's admission record indicated the facility originally admitted this [AGE] year old male on 12/23/2025 and most recently on 3/27/2026 with diagnosis including type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), atherosclerotic heart disease, chronic kidney disease (long term progressive loss of kidney function), dysphagia (difficulty swallowing), cognitive communication deficit, pressure ulcer of sacral region stage 3 (Full-thickness loss of skin dead and black tissue may be visible), benign prosthetic hyperplasia (BPH-enlarged prostate gland), anemia (a condition where the body does not have enough healthy red blood cells), hypothyroidism (low functioning thyroid), peripheral vascular disease (PVD - a slow progressive narrowing of the blood flow to the arms and legs) and prosthetic heart valve.A review of Resident 2's Minimum Data Set (MDS- a resident assessment) dated 3/27/26 indicated resident 2's cognition (mental ability to make decisions for daily living) was not intact. The MDS indicated Resident 2 was dependent (helper does all the effort. Resident does none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete the activity) with toileting, personal hygiene, and transfers (moving between surfaces) from bed to chair.A review of resident 2's fall risk assessment dated [DATE] indicated Resident 2 was a high risk for fall.A review of resident 2's physician order dated 3/28/26 indicated tab alarm while in bed and wheelchair to alert staff that resident is getting up from wheelchair or bed without assistance every shift.A review of Resident 2's physician order dated 3/28/26 indicated to monitor tab alarm placement and functionality every shift.On 4/7/26 the California Department of Public Health (CDPH) received an anonymous complaint alleging the facility was not placing alarms on residents with orders for alarms. During a concurrent observation and interview on 4/21/26 At 12:55pm with the licensed vocational nurse (LVN) 1, inside resident 2's room, resident 2 was sitting in a wheelchair with a tab alarm attached to the wheelchair. LVN 2 stated the tab alarm was attached to the chair but not the resident and the alarm did not have batteries. LVN 1 stated the director of staff development (DSD) rounds daily to check the alarms.During an interview with the Director of Nursing (DON) on 4/21/26 at 1:52 PM, the DON stated it is everyone's responsibility to check the alarms. The DSD does rounds in the morning and checks for placement and functionality; if any are broken or stopped working, it should be replaced. If the alarm is not functioning properly the resident could potentially get up without assistance because staff did not hear the alarm and attempt to ambulate (walk) without assistance and fall.During an interview with the DSD on 4/21/26 at 2:00pm, the DSD stated that morning Resident 2's pad alarm was checked while Resident 2 was in bed however Resident 2's tab alarm for the wheelchair was not checked at that time.A review of the facility's policy and procedures (P&P) titled, TAB ALARM I PAD ALARM POLICY & PROCEDURE, revised on 7/25, the P&P indicated, It is the policy of this facility to utilize tab alarms and/or pressure pad alarms as safety interventions to alert staff of resident movement when clinically indicated, in order to reduce risk of falls and injury while maintaining resident dignity and rights.Use of alarms shall not be considered a restraint when used solely as a monitoring device and not to restrict movement.Purpose- Provide early staff notification when a resident attempts to rise unassisted- Support fall prevention interventions- Promote safe mobility- Ensure alarms are used appropriately and effectivelyDefinitionsTab Alarm: Clip-style device attached to clothing that sounds when disengaged Pad Alarm: Pressure-sensitive device placed on bed/chairAlarm Fatigue: Reduced response due to frequent alarmsProcedure - Assessment & Initiation- Assess fall risk, cognition, mobility- Determine type of alarm- Obtain order if required- Update care planProcedure - ApplicationTab Alarm: Attach securely and testPad Alarm: Place under resident and ensure flat positioningMonitoring- Respond immediately- Assess resident safety- Reassess need each shiftMaintenance- Test each shift- Check batteries and cords- Clean per infection control policyDocumentation- Record initiation, type, response, reassessment

Based on observation, interview, and record review, the facility failed to prevent the deterioration of pressure injuries (localized damage to skin and underlying soft tissue, usually over bony prominences [heels, hips, tailbone], caused by prolonged pressure, friction, or [NAME]) and provided care and services consistent with professional standards of practice for one out of three sampled residents (Resident 1) who had multiple pressure ulcers/injuries by failing to:1. Set the low air loss (LAL - a medical bed system with air-filled cells that let out tiny amounts of air through microscopic holes to keep the user's skin cool, dry, and moisture-free. It acts like a floating surface that reduces pressure on the body, actively prevents bedsores, and helps heal existing skin ulcers. They are generally adjusted to match the patient's weight) mattress to appropriate and recommended settings.2. Create individualized Care Plans (CP, is a customized, written document detailing specific health, social, and functional needs, goals, and actions for a person in medical, residential, or school setting) for Pressure injuries.These deficient practices resulted in on worsening of the existing PU as well as the development of facility acquired PUs.Cross Reference: F726. A review of Resident 1's admission record indicated the facility initially admitted the resident on 5/13/2025 and was readmitted on [DATE], with diagnosis that included Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), encephalopathy (any disease, damage, or malfunction that affects the brain's structure or function, resulting in an altered mental state), and cognitive communication deficit (difficulty communicating because of impaired thinking skills like attention, memory, problem-solving, and organization, often following brain injury, stroke, or conditions like dementia). The same admission record indicated additional diagnoses of pressure ulcers, stage 4 (stage 1 -intact skin with a localized area of redness and/or changes in sensation, temperature, or firmness; stage 2 -partial-thickness loss of skin, presenting as a shallow open sore or wound; stage 3 - full-thickness loss of skin. Dead and black tissue may be visible; Stage 4 - full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone) of the sacral region (the triangular area at the base of the spine, overlying the sacrum, a bone formed by five fused vertebrae connecting the spine to the pelvis and lower body), left and right hips on 10/1/2025. A review of Resident 1's Minimum Data Set (MDS- a resident assessment tool) dated 10/1/2025, indicated the resident had mild cognitive impairment (noticeable memory or thinking problems that are worse than normal aging but don't significantly interfere with daily life, unlike dementia). The same MDS indicated Resident 1 was mostly dependent on staff for activities of daily living (ADLs) such as toileting hygiene, Shower/bathe, lower body dressing, and putting on/taking off footwear. The MDS indicated Resident 1 had three stage 4 Pus and was at risk of developing more (PUs).During a review of Resident's 1 physician orders dated 9/11/2025, indicated, May provide pressure relieving mattress.During a review of Resident's 1 physician orders dated 9/11/2025, indicated, turn and reposition q [every] 2hrs [hours], patient may refuse, document if patient refuses.During a review of a care plan (CP) initiated 9/12/2025 with a focus, Impaired skin integrity as manifested by resident with stage 4 pressure injury to right buttocks extending to thigh right posterior thigh, indicated interventions which included:Monitor skin daily for any changes and report to MD [Medical Doctor) if T x [treatment] ineffectiveTreatment as ordered and monitor for effectivenessDuring a review of a care plan (CP) initiated 9/12/2025 with a focus, Impaired skin integrity as manifested by resident with stage 2 pressure injury on sacrum extending to right buttocks-reclassified to stage 4 by wound MD 10/13/2025, indicated interventions which included:Labs [laboratory] as neededObserve and report signs of infectionTreatment as ordered and monitor for effectivenessTum and reposition every 2 hours and as neededDuring a review of a document titled, Skin Observation Tool, dated 9/12/2025, included the following: Left trochanter (hip) abrasion 4 [centimeters-unit of measure/cm] length and 1 [cm] width. Right buttock shearing injury 20 [cm] length and 8 [cm] width. Sacrum pressure 3 length and 2 width.The same documented indicated, skin and body check done with above findings. stage 2 pressure injury to the sacrum extending to the right buttocks, shearing injury to right buttocks extending to thigh.During a review of Resident's 1 physician orders dated 12/23/2025, indicated, pressure injury to sacrum: cleanse with NS [a sterile, 0.9% solution of salt {sodium chloride} in water, designed to match the natural salt concentration in human blood widely used to treat dehydration, clean wounds etc.], pat dry, apply Santyl [ a prescription topical medication used to debride chronic skin ulcers and severe burns by breaking down dead tissue to promote healing], pack gently with gauze and cover with foam dressing].During a review of Resident's 1 physician orders dated 12/23/2025, indicated, right buttocks pressure injury stage 4: cleanse with NS, pat dry, apply Santyl, pack gently with gauze and cover with foam dressing].During a review of a document titled, Task: Monitor - Turn and reposition, where the Certified Nursing Assistants were required to document when Resident 1 was repositioned every two hours. There was no documented evidence indicating Resident 1 was repositioned during the following times slots:1/1/20264 pm, 6 pm, 8 pm1/2/202612 am, 8 am, 10 am, 4 pm, 8 pm1/3/20268 am, 10, 12 pm, 2 pm, 10 pm1/4/20262 am, 8 am, 10 am, 12 pm, 4 pm, 8 pm, 10 pm1/5/202612 am, 2 am, 6 am, 8 am,1/6/20258 am, 10 am, 12 pm, 4 pm, 6 pm, 10 pm.1/7/202612 am, 2 am, 8 am, 10 am, 4 pm, 10 pm.1/8/20264 pm, 6 pm, 8 pm, 10 pm.1/9/20268 am, 10 am, 2 pm.1/10/202612 am, 2 am, 4 pm, 8 pm, 10 pm.1/12/202612 am, 2 am, 6 am, 8 am, 10 am, 12 pm, 4 pm, 6 pm, 10 pm.1/13/202612 am, 2 am, 8 am, 10 am, 12 pm, 2 pm, 4 pm, 6 pm, 8 pm, 10 pm.1/14/202612 am, 2 am, 4 am, 8 am, 10 am, 12 pm, 4 pm, 6 pm, 8 pm.1/16/20264 am, 8 am, 10 am, 12 pm, 2 pm.1/17/20262 am, 6 am, 8 am, 10 am, 12 pm, 2 pm, 4 pm, 6 pm, 10 pm.1/18/202612 pm, 2 pm.1/19/20262 am, 8 am, 10 am, 12 pm.1/20/20262 am, 4 am, 8 am, 10 am, 12 pm, 4 pm, 6 pm, 10 pm.1/21/20262 am, 4 pm, 6 am, 8 am, 10 am, 12 pm, 4 pm, 6 pm, 10 pm.1/22/20268 am, 10 am, 12 pm, 4 pm, 8 pm.1/23/20264pm, 8 pm.1/24/20268 am, 10 am, 12 pm, 2 pm, 4 pm, 10 pm.1/25/20266 am, 6 pm.1/26/202612 am, 2 am, 4 am, 6 am, 8 am, 10 am.1/27/20262 am, 4 am, 6 am, 4 pm, 10 pm.1/28/202612 am, 2 am, 8 am, 10 am. During a concurrent observation of Resident 1 and an interview with Certified Nurse Assistant (CNA) 1, on 1/21/2026 at 1/21/2026 at 12:30 pm, Resident 1 was noted to have an adhesive dressing to the right upper arm as well as the left leg around the shin area. CNA 1 stated that Resident 1 did not speak. CNA 1 stated that Resident 1 had PU to his buttocks, right upper arm and recently (approximately 2 weeks) to the left lower leg. CNA stated that she did her best to reposition Resident 1 but that there were instances when Resident 1 was found in the same position that he had been placed 4 hours prior. CNA 1 denied assisting with dressing change that morning and stated that the Treatment Nurse (TN) 2 completed the wound care treatments daily during Resident 1's care when she was assigned with him.During a concurrent interview and record review of Resident 1's chart with TN 1 on 1/21/2026 at 1:50 pm, TN 1 stated that Resident 1 was currently being treated for four pressure ulcers:Sacrum- stage 4 pressure injury measuring 6.2 cm (length) X 6 cm (width) X 3 cm (depth).Left posterior trochanter -Stage 4 pressure injury measuring 15.3 X 10.5 X 3Right buttocks- Stage 4 pressure injury Measurements 8.3 X 6 X 3Right shoulder- DTPI (Deep Tissue Pressure Injury - a serious form of damage to skin and underlying soft tissue caused by prolonged pressure or shear, often appearing as a persistent, non-blanchable purple or maroon area, or a blood-filled blister) measuring 4.6 cm X 5 cm. TN 1 was unable to state was under the dressing to the right upper arm or to the right shin and stated that Resident 1 had healed PUs in the areas. TN 1 stated that before/during wound care treatments, he also assessed Resident 1's skin from head to toe. On 8/23/2026 at 7:49 am, TN 1 was asked to let this writer know when he was going to complete Resident 1's wound care treatments so that this writer could observed. TN 1 verbalized understanding.During a review of Resident 1's Situation, Background, Assessment, Recommendation (SBAR, a communication tool used by healthcare workers) progress note dated 1/23/2026 at 8:07 am, indicated, Pressure injury to left shin and right shoulder. The same SBAR indicated, development of pressure injury due to pillow placement. The SBAR indicated, noted on am rounds with redness on shin concern for unstageable pressure injury. right shoulder noted with concern for dti [Deep Tissue Pressure Injury (DTPI or DTI) is a severe form of pressure ulcer occurring over bony prominences, resulting from intense, prolonged pressure that damages underlying soft tissue while the surface skin remains intact or forms a blood-filled blister ]/uti.During an interview with Family Member (FM) 1 on 1/23/2026 at 8:30 am, FM 1 stated that they only became aware of the PUs to the left shin a few days prior when Resident 1 was being repositioned during a visit. FM 1 stated that the facility had not informed FM 1 about the new PU.During a concurrent observation of Resident 1's wound care treatment and interview with TN 1 1/23/2026 at 9:22 am, the room had a pungent, foul odor. The ulcer to the right upper arm and covered in black-brownish jelly appearing eschar (a thick, black or brown scab of dead tissue that forms on the skin after a severe burn, injury, or infection) tissue and measured about 4 cm x 4 cm with no drainage. The ulcer to the left shin was elongated, almond shaped measuring approximately 7 cm x 3 cm. the wound bed was covered in hard yellow-greyish hard slough ( type of necrotic [dead] tissue found in a wound bed that has transitioned from a soft/moist state to a firm, dry, or leathery texture after prolonged poor circulation which begins in inflammation) which was lifting around the edges and surrounded by a red halo. The was no drainage.During an interview with Licensed Vocational Nurse (LVN) 2 on 1/23/2026 at 11 am, LVN 2 stated that the LAL mattress setting are based on a patient's weight and must be set to as close to their weight as possible. LVN 2 stated that if the mattress is way below the weight of a resident, it becomes too soft and could lead to more pressure injuries. If set too high, it becomes too firm preventing offloading and may lead to more or worsening of pressure ulcers.During a concurrent observation of Resident 1's LAL mattress settings with the Director of Nursing (DON) on 1/23/2026 at 11:04 am, the DON confirmed that the mattress was set to over the maximum of 400 pounds. The DON stated that the LAL mattress is comfort and weight based. The DON stated that all mattress are usually set at 400 to make sure that tubes are inflated. And should not be set lower than 152 pounds (lbs.) which was a weight that was taped to the LAL mattress setting control but was unable to state why. A review of Resident 1's weight log indicated Resident 1 weighed 139 lbs.During an interview with TN 1 on 1/23/2026 11:10 am, TN stated that it would defeat the purpose of a LAL mattress is not set based on weight and could be either too hard or too soft causing it to be untherapeutic. During a follow up interview and record review of Resident 1's CPs and SBARs with TN 1 on 1/23/2026 at 12:25 pm, TN 1 stated that a head-to-toe skin assessment which included a Braden scale and CPs are developed upon admission. TN 1 stated that all resident must have CP for issues such as wounds, treatments which must be updated when it is reclassified to a higher or lower level or when there is a new SBAR. TN 1stated that CPs must be individualized to a resident and factors such as staging must be included. TN 1 stated treatments are not specified and simply indicate, treatment as ordered. TN 1 stated that If there is a new order, then the order will only be reflected in the TAR (Treatment Administration Record) because it would be redundant to include it in the CP. TN 1 stated that an SBAR must be done immediately change happens to ensure that the physician, resident representatives, other staff are aware about the change, and that everything carried out was documented. The TN 1 admitted that the interventions for care plans dated 9/12//2026.During a follow up interview and record review of Resident 1's CPs and SBARs with TN 1 on 1/23/2026 at 12:25 pm, TN 1 stated that a head-to-toe skin assessment which included a Braden scale and CPs are developed upon admission. TN 1 stated that all resident must have CP for issues such as wounds, treatments which must be updated when it is reclassified to a higher or lower level or when there is a new SBAR. TN 1stated that CPs must be individualized to a resident and factors such as staging must be included. TN 1 stated treatments are not specified and simply indicate, treatment as ordered. TN 1 stated that If there is a new order, then the order will only be reflected in the TAR (Treatment Administration Record) because it would be redundant to include it in the CP. TN 1 stated that an SBAR must be done immediately change happens to ensure that the physician, resident representatives, other staff are aware about the change, and that everything carried out was documented. The TN 1 admitted that the interventions for care plans dated 9/12//2026 for the PU to the sacrum extending to the buttocks, TN 1 stated that it was redundant to indicate the type of treatment that was order for Resident 1 stating, it is redundant to place the actual order on the care plan. TN 1 stated that listing the treatment as ordered was enough for him. TN 1 confirmed that he indicated the same verbiage (treatment as ordered) for the residents that had various treatments ordered. TN 1 stated that the treatments for Resident 1 were for the stage 4 pressure ulcers to the left trochanter, sacrum, right buttocks, and the right shoulder DTI which was initiated on 1/14/2026. TN 1 admitted that there were no SBAR completed for the right shoulder DTI when it was discovered on 1/14/2026. TN 1 stated that the left shin DTI had just been discovered that morning at 8 am and could have developed a few hours ago due to using a regular head soft pillow. TN 1 confirmed that a head to toe assessment could have helped identify the pressure ulcer to the left shin earlier which could have prompted an completion of the SBAR, physician notification as well as Resident 1's representatives. TN 1 stated that he had not performed Resident 1's wound care on 1/21/2026 which was why he did not know about the pressure ulcer to the left shin and that it was completed by LVN 3. TN 1 confirmed that lack of treatment to the left shin could have resulted in wound deteriorate, infection, sepsis, organ failure and/or death. During an interview with LVN 3 on 1/23/2026 at 1:05 pm, LVN 3 confirmed that she had been covering as treatment nurse on 1/21/2026. LVN 3 stated that she had not completed Resident 1's treatment because she (LVN 3) was assigned to station 1 (Resident 1 was on station 2) which was covered by TN 1.During an interview with the Wound Care Specialist (WCS) on 1/23/2026 at 1:15 pm, the WCS stated that a LAL mattress helped in preventing as well as the development of PUs and that it was weight based. The WCS stated the settings must be set as close to the residents' weight as possible and that setting it to 400 lbs. for a resident who weight 139 lbs. would be like placing them on a table which could result in worsening of current wounds or the development of new PUs.During an interview with TN 1 on 1/27/26 1:34 pm, TN 1 stated that he had just remembered that he was the one who had completed the wound care treatments on 1/21/2026. TN 1 was unable to describe the PU to Resident 1's shin and repeatedly stated, it looked like a DTI, but still unable to describe what a DTI looked like.During an interview with the Medical Director of the facility, (MD) on 1/27/26 at 6:05 pm, the MD stated that the facility staff must notify a physician of a change in condition as soon as possible and urgently for new PUs. The MD stated that a care plan must include clear goals that are individualized to the resident. The MD stated that placing a resident on a hardened surface such as a table for a prolonged period could worsen and possibly cause more PUs.During a review of the facility's policy and procedure (P&P) titled, CARE PLANNING (IDT) POLICY, reviewed 2025, indicated, All residents will have a comprehensive care plan to meet their individual needs that is prepared by the Interdisciplinary Team (IDT) within 7 days after the completion of the comprehensive assessment and periodically reviewed and revised after subsequent assessments. During a review of the facility's P&P titled, Pressure Ulcers/Skin Breakdown - Clinical Protocol, reviewed 1/2026, the P&P indicated under assessment and recognition, the nurse shall describe and document/report the following:a. Full assessment of pressure sore including location, stage, length, width and depth, presence of exudate or necrotic tissue;b. Pain assessment.c. Resident's mobility status.d. Current treatments, including support surfaces; ande. All active diagnoses.

Based on interview and record review, the facility failed to ensure Licensed nurses had specific competencies and skill sets necessary to adequately, assess, describe, and report the development of a new Pressure Ulcer (PUs- localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence), for one of the three sampled residents (Resident 1) who had a new PU to the left shin to the physician. This failure resulted in Resident 1's delay in getting treatment for the left shin unstageable (deep wound where the true depth and severity cannot be seen because it is covered by dead tissue (slough) or thick, hardened, black/brown scabs known as eschar) pressure injury which could have resulted in further deterioration of the PU, infection, sepsis, organ failure, and or death. Cross reference to F686A review of Resident 1's admission record indicated the facility initially admitted the resident on 5/13/2025 and was readmitted on [DATE], with diagnosis that included Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), encephalopathy (any disease, damage, or malfunction that affects the brain's structure or function, resulting in an altered mental state), and cognitive communication deficit (difficulty communicating because of impaired thinking skills like attention, memory, problem-solving, and organization, often following brain injury, stroke, or conditions like dementia). The same admission record indicated additional diagnoses of pressure ulcers, stage 4 (stage 1 -intact skin with a localized area of redness and/or changes in sensation, temperature, or firmness; stage 2 -partial-thickness loss of skin, presenting as a shallow open sore or wound; stage 3 - full-thickness loss of skin. Dead and black tissue may be visible; Stage 4 - full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone) of the sacral region (the triangular area at the base of the spine, overlying the sacrum, a bone formed by five fused vertebrae connecting the spine to the pelvis and lower body), left and right hips on 10/1/2025.left and right hips on 10/1/2025. During a review of a CP dated 9/12/2025 with a focus, Impaired skin integrity as manifested by resident with stage 4 pressure injury to - right buttocks extending to thigh - right posterior, included the following interventions, Treatment as ordered. During a review of Resident's 1 physician orders dated 9/11/2025, indicated, May provide pressure relieving mattress. During a review of Resident's 1 physician orders dated 9/11/2025, indicated, turn and reposition q [every] 2hrs [hours], patient may refuse, document if patient refuses. During a review of a care plan (CP) initiated 9/12/2025 with a focus, Impaired skin integrity as manifested by resident with stage 4 pressure injury to right buttocks extending to thigh right posterior thigh, indicated interventions which included:Monitor skin daily for any changes and report to physician if T x [treatment] ineffectiveTreatment as ordered and monitor for effectiveness During a review of a care plan (CP) initiated 9/12/2025 with a focus, Impaired skin integrity as manifested by resident with stage 2 pressure injury on sacrum extending to right buttocks-reclassified to stage 4 by wound physician 10/13/2025, indicated interventions which included:Labs [laboratory] as neededObserve and report signs of infectionTreatment as ordered and monitor for effectivenessTum and reposition every 2 hours and as needed During a review of a document titled, Skin Observation Tool, dated 9/12/2025, included the following: Left trochanter (hip) abrasion 4 [centimeters-unit of measure/cm] length and 1 [cm] width. Right buttock shearing injury 20 [cm] length and 8 [cm] width. Sacrum pressure 3 length and 2 width.The same documented indicated, skin and body check done with above findings. stage 2 pressure injury to the sacrum extending to the right buttocks, shearing injury to right buttocks extending to thigh. A review of Resident 1's Minimum Data Set (MDS- a resident assessment tool) dated 10/1/2025, indicated the resident had mild cognitive impairment (noticeable memory or thinking problems that are worse than normal aging but don't significantly interfere with daily life, unlike dementia). The same MDS indicated Resident 1 was mostly dependent on staff for activities of daily living (ADLs) such as toileting hygiene, Shower/bathe, lower body dressing, and putting on/taking off footwear. The MDS indicated Resident 1 had three stage 4 Pus and was at risk of developing more (PUs). During a review of Resident's 1 physician orders dated 12/23/2025, indicated, pressure injury to sacrum: cleanse with NS [a sterile, 0.9% solution of salt {sodium chloride} in water, designed to match the natural salt concentration in human blood widely used to treat dehydration, clean wounds etc.], pat dry, apply Santyl [ a prescription topical medication used to debride chronic skin ulcers and severe burns by breaking down dead tissue to promote healing], pack gently with gauze and cover with foam dressing]. During a review of Resident's 1 physician orders dated 12/23/2025, indicated, right buttocks pressure injury stage 4: cleanse with NS, pat dry, apply Santyl, pack gently with gauze and cover with foam dressing]. During a review of a document titled, Task: Monitor - Turn and reposition, where the Certified Nursing Assistants were required to document when Resident 1 was repositioned every two hours. There was no documented evidence indicating Resident 1 was repositioned during the following times slots:1/1/20264 pm, 6 pm, 8 pm1/2/202612 am, 8 am, 10 am, 4 pm, 8 pm1/3/20268 am, 10, 12 pm, 2 pm, 10 pm1/4/20262 am, 8 am, 10 am, 12 pm, 4 pm, 8 pm, 10 pm1/5/202612 am, 2 am, 6 am, 8 am,1/6/20258 am, 10 am, 12 pm, 4 pm, 6 pm, 10 pm.1/7/202612 am, 2 am, 8 am, 10 am, 4 pm, 10 pm.1/8/20264 pm, 6 pm, 8 pm, 10 pm.1/9/20268 am, 10 am, 2 pm.1/10/202612 am, 2 am, 4 pm, 8 pm, 10 pm.1/12/202612 am, 2 am, 6 am, 8 am, 10 am, 12 pm, 4 pm, 6 pm, 10 pm.1/13/202612 am, 2 am, 8 am, 10 am, 12 pm, 2 pm, 4 pm, 6 pm, 8 pm, 10 pm.1/14/202612 am, 2 am, 4 am, 8 am, 10 am, 12 pm, 4 pm, 6 pm, 8 pm.1/16/20264 am, 8 am, 10 am, 12 pm, 2 pm.1/17/20262 am, 6 am, 8 am, 10 am, 12 pm, 2 pm, 4 pm, 6 pm, 10 pm.1/18/202612 pm, 2 pm.1/19/20262 am, 8 am, 10 am, 12 pm.1/20/20262 am, 4 am, 8 am, 10 am, 12 pm, 4 pm, 6 pm, 10 pm.1/21/20262 am, 4 pm, 6 am, 8 am, 10 am, 12 pm, 4 pm, 6 pm, 10 pm.1/22/20268 am, 10 am, 12 pm, 4 pm, 8 pm.1/23/20264pm, 8 pm.1/24/20268 am, 10 am, 12 pm, 2 pm, 4 pm, 10 pm.1/25/20266 am, 6 pm.1/26/202612 am, 2 am, 4 am, 6 am, 8 am, 10 am.1/27/20262 am, 4 am, 6 am, 4 pm, 10 pm.1/28/202612 am, 2 am, 8 am, 10 am. During a review of Resident 1's Situation, Background, Assessment, Recommendation (SBAR, a communication tool used by healthcare workers) progress note dated 1/23/2026 at 8:07 am, indicated, Pressure injury to left shin and right shoulder. The same SBAR indicated, development of pressure injury due to pillow placement. The SBAR indicated, noted on am rounds with redness on shin concern for unstageable pressure injury. right shoulder noted with concern for dti/uti [unable to determine - a type of serious skin injury where the wound is covered by dead tissue - slough/eschar, making it impossible for a healthcare provider to see the base of the wound to determine how deep it actually is]. During a concurrent observation of Resident 1 and interview with CNA 1 on 1/21/2026 at 1/21/2026 at 12:30 pm, Resident 1 was noted to have an adhesive dressing to the right upper arm as well as the left leg around the shin area. CNA 1 stated that Resident 1 did not speak. CNA 1 stated that Resident 1 had PU to his buttocks, right upper arm and recently (approximately 2 weeks) to the left lower leg. CNA stated that she did her best to reposition Resident 1 but that there were instances when Resident 1 was found in the same position that he had been placed 4 hours prior. CNA 1 denied assisting with dressing change that morning and stated that the Treatment Nurse (TN) 2 completed the wound care treatments daily during Resident 1's care when she was assigned with him. During a concurrent interview and record review of Resident 1's chart with TN 1 on 1/21/2026 at 1:50 pm, TN 1 stated that Resident 1 was currently being treated for four pressure ulcers:Sacrum- stage 4 pressure injury measuring 6.2 cm (length) X 6 cm (width) X 3 cm (depth).Left posterior trochanter -Stage 4 pressure injury measuring 15.3 X 10.5 X 3Right buttocks- Stage 4 pressure injury Measurements 8.3 X 6 X 3Right shoulder- DTPI (Deep Tissue Pressure Injury - a serious form of damage to skin and underlying soft tissue caused by prolonged pressure or shear, often appearing as a persistent, non-blanchable purple or maroon area, or a blood-filled blister) measuring 4.6 cm X 5 cm.TN 1 was unable to state was under the dressing to the right upper arm or to the right shin and stated that Resident 1 had healed PUs in the areas. TN 1 stated that before/during wound care treatments, he also assessed Resident 1's skin from head to toe. On 8/23/2026 at 7:49 am, TN 1 was asked to let this writer know when he was going to complete Resident 1's wound care treatments so that this writer could observed. TN 1 verbalized understanding. During an interview with Family Member (FM) 1 on 1/23/2026 at 8:30 am, FM 1 stated that they only became aware of the PUs to the left shin a few days prior when Resident 1 was being repositioned during a visit. FM 1 stated that the facility had not informed FM 1 about the new PU. During a concurrent observation of Resident 1's wound care treatment and interview with TN 1 1/23/2026 at 9:22 am, the room had a pungent, foul odor. The ulcer to the right upper arm and covered in black-brownish jelly appearing eschar (a thick, black or brown scab of dead tissue that forms on the skin after a severe burn, injury, or infection) tissue and measured about 4 cm x 4 cm with no drainage. The ulcer to the left shin was elongated, almond shaped measuring approximately 7 cm x 3 cm. the wound bed was covered in hard yellow-greyish hard slough ( type of necrotic [dead] tissue found in a wound bed that has transitioned from a soft/moist state to a firm, dry, or leathery texture after prolonged poor circulation which begins in inflammation) which was lifting around the edges and surrounded by a red halo. The was no drainage. During an interview with Licensed Vocational Nurse (LVN) 2 on 1/23/2026 at 11 am, LVN 2 stated that the LAL mattress setting are based on a patient's weight and must be set to as close to their weight as possible. LVN 2 stated that if the mattress is way below the weight of a resident, it becomes too soft and could lead to more pressure injuries. If set too high, it becomes too firm preventing offloading and may lead to more or worsening of pressure ulcers. During a concurrent observation of Resident 1's LAL mattress settings with the Director of Nursing (DON) on 1/23/2026 at 11:04 am, the DON confirmed that the mattress was set to over the maximum of 400 pounds. The DON stated that the LAL mattress is comfort and weight based. The DON stated that all mattress are usually set at 400 to make sure that tubes are inflated. And should not be set lower than 152 pounds (lbs.) which was a weight that was taped to the LAL mattress setting control but was unable to state why. A review of Resident 1's weight log indicated Resident 1 weighed 139 lbs. During an interview with TN 1 on 1/23/2026 11:10 am, TN stated that it would defeat the purpose of a LAL mattress is not set based on weight and could be either too hard or too soft causing it to be untherapeutic. During a follow up interview and record review of Resident 1's CPs and SBARs with TN 1 on 1/23/2026 at 12:25 pm, TN 1 stated that a head-to-toe skin assessment which included a Braden scale and CPs are developed upon admission. TN 1 stated that all resident must have CP for issues such as wounds, treatments which must be updated when it is reclassified to a higher or lower level or when there is a new SBAR. TN 1stated that CPs must be individualized to a resident and factors such as staging must be included. TN 1 stated treatments are not specified and simply indicate, treatment as ordered. TN 1 stated that If there is a new order, then the order will only be reflected in the TAR (Treatment Administration Record) because it would be redundant to include it in the CP. TN 1 stated that an SBAR must be done immediately change happens to ensure that the physician, resident representatives, other staff are aware about the change, and that everything carried out was documented. The TN 1 admitted that the interventions for care plans dated 9/12//2026 for the PU to the sacrum extending to the buttocks, TN 1 stated that it was redundant to indicate the type of treatment that was order for Resident 1 stating, it is redundant to place the actual order on the care plan.TN 1 stated that listing the treatment as ordered was enough for him. TN 1 confirmed that he indicated the same verbiage (treatment as ordered) for the residents that had various treatments ordered. TN 1 stated that the treatments for Resident 1 were for the stage 4 pressure ulcers to the left trochanter, sacrum, right buttocks, and the right shoulder DTI which was initiated on 1/14/2026. TN 1 admitted that there were no SBAR completed for the right shoulder DTI when it was discovered on 1/14/2026. TN 1 stated that the left shin DTI had just been discovered that morning at 8 am and could have developed a few hours ago due to using a regular head soft pillow. TN 1 confirmed that a head to toe assessment could have helped identify the pressure ulcer to the left shin earlier which could have prompted an completion of the SBAR, physician notification as well as Resident 1's representatives. TN 1 stated that he had not performed Resident 1's wound care on 1/21/2026 which was why he did not know about the pressure ulcer to the left shin and that it was completed by LVN 3. TN 1 confirmed that lack of treatment to the left shin could have resulted in wound deteriorate, infection, sepsis, organ failure and/or death.During an interview with LVN 3 on 1/23/2026 at 1:05 pm, LVN 3 confirmed that she had been covering as treatment nurse on 1/21/2026. LVN 3 stated that she had not completed Resident 1's treatment because she (LVN 3) was assigned to station 1 (Resident 1 was on station 2) which was covered by TN 1. During an interview with the Wound Care Specialist (WCS) on 1/23/2o26 at 1:15 pm, the WCS stated that a LAL mattress helped in preventing as well as the development of PUs and that it was weight based. The WCS stated the settings must be set as close to the residents' weight as possible and that setting it to 400 lbs. for a resident who weight 139 lbs. would be like placing them on a table which could result in worsening of current wounds or the development of new PUs. During an interview with TN 1 on 1/27/26 1:34 pm, TN 1 stated that he had just remembered that he was the one who had completed the wound care treatments on 1/21/2026. TN 1 was unable to describe the PU to Resident 1's shin and repeatedly stated, it looked like a DTI, but still unable to describe what a DTI looked like. During an interview with the Medical Director of the facility, (MD) on 1/27/26 at 6:05 pm, the MD stated that the facility staff must notify a physician of a change in condition as soon as possible and urgently for new PUs. The MD stated that a care plan must include clear goals that are individualized to the resident. The MD stated that placing a resident on a hardened surface such as a table for a prolonged period could worsen and possibly cause more PUs.During a review of the facility's policy and procedures (P&P) titled, Pressure Ulcers/Skin Breakdown - Clinical Protocol, reviewed 1/2026, indicated under assessment and recognition, the nurse shall describe and document/report the following:a. Full assessment of pressure sore including location, stage, length, width and depth, presence of exudate or necrotic tissue;b. Pain assessment.c. Resident's mobility status.d. Current treatments, including support surfaces; ande. All active diagnoses.

Based on observation, interview, and record review, the facility failed to ensure dietary staff did not store foods in the kitchen beyond their expiration date and meat was not sitting in a dark reddish liquid. This deficient practice of storing food in the kitchen beyond their expiration date and meat sitting in a dark reddish liquid may cause all residents possible serious complications from foodborne illnesses (refer to illnesses such as nausea, vomiting, and diarrhea, caused by the ingestion of contaminated food or beverages). Findings: During a concurrent observation and interview on 12/01/2025 from 8:02 AM with the Dietary Services Supervisor (DSS - manages daily food service operations, ensuring safe, nutritious, and appealing meals while supervising staff, controlling budgets, and upholding health regulations), then following were identified:Grated parmesan cheese was found inside the refrigerator in its original plastic package open and stored inside a medium plastic bag with a handwritten open date of 11/16/2025 and an expiration date of 11/21/2025. A yellow and white pre-printed label with an expiration date of 1/16/2026 was placed on top of the handwritten expiration date covering the handwritten expiration date. DSS did not answer when asked why the pre-printed label was covering the handwritten expiration date. DSS stated, The cheese needs to be discarded because the handwritten expiration date has already expired. Smoked [NAME] cheese was found in the refrigerator in its original plastic package with a handwritten 11/14/2025 and an expiration date of 11/21/2025. The manufacturer's expiration date was not found on the plastic package. The yellow and white pre-printed label indicated American Cheese with an expiration date of 2/22/2026 was placed on top of the handwritten expiration date covering the handwritten expiration date. DSS again stated the cheese needs to be discarded because then handwritten expiration date has already expired. Five beef patties were found in the refrigerator in its original plastic package opened and stored inside a round plastic container with a handwritten open date of 11/30/2025 and a used by date of 12/02/2025. The five beef patties were observed to be soaking in a dark reddish liquid. DSS stated, The liquid is not normal to me. I will toss the meat now. When asked if the beef patties were safe to cook and serve to residents, DSS stated, No, because the meat is discolored. DSS stated the potential ham that may come to any of the residents was that they will have diarrhea, nausea, and vomiting. A review of the facility policy and procedures (P&P - policy explains the rules and presents them in a logical framework while procedures outline the step-by-step implementation of various tasks) titled Labeling/Date Marking and Safe Storage of Refrigerated and Frozen Foods with a revision date of 10/2023, indicated, Commercially processed foods .must be dated.are good for seven days, or until the expiration date.on the label if [the date] comes before the 7th day. According to the P&P, the recommended storage time for ground meat/patties is 1 to 2 days from package opening.

Based on observation, interview and record review the failed to ensure that one of two sampled resident (Resident 34) was provided with alternative meal/s that was appealing, nutritional, and appetizing. This deficient practice had the potential to result in the resident missing a meal, that could lead to weight loss. A review of Resident 34's admission Record indicated the resident was admitted to the facility on [DATE], with diagnoses that included Malignant Neoplasm of Colon (Abnormal Cell growth in the colon (the final part of the digestive system that absorbs water, from digested food), which may lead to tumors (a lump or mass of extra cells that grow abnormally in the body) in the colon, anemia (blood disorder in which the blood has a reduced ability to carry oxygen to the rest of the body), and muscle weakness (a reduced ability to accomplish everyday tasks). A review of Resident 34's Minimum Data Set (MDS - a resident assessment tool, and care-screening tool) dated 7/1/2025, indicated that Resident 34's cognition (mental ability to make decisions of daily living) was intact. A review of Resident 34's history and physical (H&P) dated 6/30/2025 indicated Resident 34 could make decisions for activities of daily living. During an interview on 12/1/2025, at 10:18am, Resident 34 stated that she was having a difficult time with the food in the facility because she needs a vegetarian diet. Resident 34 stated she is allergic to gluten, oats, and corn, she does not like peas, lentils, fish, eggs, or milk; because those foods make her nauseous (to feel like vomiting), she gets swollen legs, feet and ankles. Resident 34 stated she only gets bread and cheese as alternatives, and she gets noodles about three or four days out of the week. Resident 34 stated she has been recently in cancer remission, is unable to eat certain foods, and is trying to pursue a vegetarian lifestyle to improve her health. During an interview on 12/1/2025, at 12:45pm, Certified Nursing Assistant (CNA) 2 stated, Resident 34 often has difficulty with the food served in the facility and would normally have her own food. CNA2 If Resident 34 eats the facility food then she will usually have the alternative plate, or the kitchen will give her something special. CNA 2 stated, either way, I often go back to ask if they have alternatives to give to (Resident 34), usually the kitchen gives her something she can eat. During an interview on 12/1/2025, at 12:53pm, the Rehabilitation Services Director (RSD) stated that the facility Administrator gave RSD the okay to order food from a restaurant for Resident 34, due to the kitchen staff's inability to accommodate her need for an alternative food choice for lunch. Resident 34 stated, This happens very often, because the kitchen will bring the resident food that she cannot eat. During observation lunch and concurrent record review on 12/1/2025 at 1:05 PM, Resident 34's meal ticket was reviewed. the facility Resident 34 was served a food tray with noodles and red sauce and no other food items on the plate. A review of Resident 34's meal ticket on the tray, indicated, Noon Meal Mon-12/1/2025; Lemon Baked Chicken 2-OZ (ounces-unit of measurement), GF Spaghetti 1-#8 SCP (scoop), Buttered Spinach 1-#8 SCP, GF Garlic Bread 1-Each, Sherbet Cup 1-Each, Water 8-FL OZ, and Butter 1-Each. During an interview and record review on 12/03/2025 at 1:58pm the Dietary Supervisor (DS) reviewed picture of Resident 34's lunch tray served on 12/1/2025. The DS stated Resident 34 refuses the food provided by the kitchen and states that she will throw up if she eats the meal. The DS stated Resident 34's food did not look appetizing and that the food on the tray was not the same as what was described on the meal ticket for Resident 34. During an interview on 12/03/2025 at 2:25pm the Administrator (Adm) stated, he will support Resident 34's needs as best he can while Resident 34 remains in the facility by providing outside food when in-house food is not tolerable or to her preferences. During an interview on 12/04/2025 at 2:37pm the Director of Nursing (DON) stated, the lunch ticket or card describing what is being delivered for lunch is not accurate. The food on the tray should be the same as what is on the meal ticket. A review of the facility policy and procedures (P&P) titled Alternates on the Menu & Meal Substitution dated 01/10/2023, indicated, Policy: To utilize a menu that offers alternates (not to be confused with menu substitutions). These alternatives are for the residents to choose from when they choose not to eat the scheduled menu items. Procedure: 1. The Director of Food & Nutrition Services (DFNS) will provide alternates upon request in a timely fashion. 3. The DFNS places a slip on the tray card denoting that the resident has selected the alternate. 5. The entree alternates will provide 3 oz protein or equivalent portion as specified on the menu for tat meal. 8. Residents who refuse the entire meal may be offered a meal substitute consisting of: a. Appropriate similar portion of protein foods plus vegetable or fruit salad/dessert to complete the meal; b. Therapeutic diets will be followed to the extent feasible.

Based on observation, interview, and record review, the facility failed to ensure one of the two sampled residents (Resident 9) Preadmission Screening and Resident Review (PASRR - a screening evaluation used to determine whether placement in a long term care facility is appropriate for the resident) Level I (a tool that helps identify possible serious mental illness and/or intellectual/development disability) assessment was accurately completed. This deficient practice of failing to accurately complete PASRR Level I assessment for Resident 9, placed Resident 9 at increased risk to not receive the necessary/appropriate care and services. Findings: During a review of Resident 9's face sheet (admission Record- a document containing demographic and diagnostic information) indicated, Resident 9 was admitted to the facility on [DATE] with diagnoses including unspecified dementia with mood disturbance and anxiety (a condition in which a person loses the ability to think, remember, learn, make decisions, and solve problems accompanied by emotional changes like depression [Is a mood disorder that causes a persistent feeling of sadness and loss of interest], anxiety, or irritability), and paranoid schizophrenia (a serious mental disorder characterized by prominent symptoms like intense paranoia, delusions [fixed, false beliefs not based in reality], and hallucinations [seeing, hearing, feeling things that are not there]). During a review of Resident 9's Minimum Data Set, (MDS - a resident assessment tool) dated 11/21/2024, indicated, Resident 9 had moderately impaired cognition (making poor decisions, cues and supervisions required). During a review of Resident 9's PASRR Level 1 screening dated 5/21/2025 indicated Resident 9 did not have any serious mental disorder diagnoses such as schizophrenia. The facility did not ensure PASRR level 1 accurately included Resident 9's medical diagnosis of paranoid schizophrenia. During a review of Resident 9's Care Plan (CP - a guideline for nurses to help them create and achieve a solid plan of action in the treatment of a patient) did not include focus, goals, and interventions related to PASARR Level I and Level II (necessary to confirm the indicated diagnoses noted in the Level I screening, and to determine whether placement or continued stay in a nursing facility is appropriate) tailored to Resident 9's mental health needs. During a review of Resident 9's CP dated 6/15/2025, indicated, Resident 9 uses antidepressant medication related to diagnosis of depression. The CP has a goal of Resident 9 will be free from discomfort or adverse reactions relate to antidepressant therapy and that Resident 9 will show decreased episodes and signs and symptoms of depression. The CP interventions indicated to monitor/document/report any adverse reactions to antidepressant therapy. During a review of Resident 9's Psychiatry (Is the branch of medicine focused on the diagnosis, treatment and prevention of mental, emotional and behavioral disorder) follow up note (a document that records a patient's mental health treatment, observations, and progress) dated 10/8/25, indicated Resident 9 had a history of depression. Resident 9 reported feeling depressed and hopeless due to current situation and health status. Resident 9 had trouble with memory recall. Resident 9 was on Sertraline for depression. During a review of Resident 9's physician's progress notes (a doctor's written record that documents a patient's health status, treatment, and care plan) dated 11/24/2025, indicated Resident 9 had diagnoses of unspecified dementia with behavioral disturbance, anxiety disorder and schizophrenia. Resident 9 was evaluated on an urgent basis due to symptoms or concerns that required immediate attention to avoid serious harm or a visit to the emergency room. Progress notes indicated Resident 9 was having memory loss and that Resident 9 lacks the capacity to make medical decisions. During a review of Resident 9's Medication Administration Record (MAR - a report detailing the drugs administered to a patient by a licensed healthcare professional at a facility) for 12/2025, indicated, Resident 9 was taking Sertraline (Zoloft - treats depression) daily at bedtime for depression. During a concurrent interview and record review on 12/04/2025 at 2:12 PM with Director of Nursing (DON), Resident 9's medical diagnoses on the face sheet, care plans, and PASARR Level 1, Section III, number 9, were reviewed. DON stated Resident 9 had medical diagnoses of paranoid schizophrenia, unspecified dementia with mood disturbance and anxiety. DON stated the facility's admissions coordinator, who is not a licensed nurse, is responsible to check the PASARR Level 1 form for completeness but not for accuracy. DON stated the PASARR Level 1 form was not accurately completed, because [Resident 9] has schizophrenia and depression and that Resident 9 was taking Sertraline for depression. DON stated the facility had the responsibility to get a correct PASARR for Resident 9 if the one the facility received from the hospital was incorrect. DON added, It is our responsibility to correct the PASARR. Bottom line is we need to get a new PASARR for [Resident 9]. DON stated Resident 9 did not have a care plan related to PASARR Level 1 and/or Level II, because PASARR was not done correctly, the care plan will not show that. DON stated Resident 9 needed a care plan, because it is helpful for us to understand [Resident 9's] needs, what interventions we need to employ and what we need to maintain for good mental health. DON stated the potential harm for not accurately/correctly completing PASARR Level I form included not meeting/capturing Resident 9's needs in the care plan. When DON was asked how the facility determined if Resident 9 needed or did not need DON stated completing PASARR Level I screening accurately would determine if the resident qualified for a PASARR Level II screening. A review of the facility policy and procedures (P&P - policy explains the rules and presents them in a logical framework while procedures outline the step-by-step implementation of various tasks) titled PASARR Policy with revision date of 5/2024, indicated, The DON or the RN Supervisor completes the PASARR before admitting a resident on admission date. The facility will complete a PASARR timely according to the time frames required for all recipients initially entering a nursing facility.

Based on observation and interview, the facility failed to provide reasonable accommodation resident preferences and choices for one out of 18 sampled residents (Resident 21). This deficient practice resulted in Resident 21 receiving bed baths instead of showers and had the potential to result in the Resident 21 inability to attain and maintain his/her highest practicable well-being with activities of daily living (ADLs). A review of Resident 21's admission Record indicated the resident was admitted to the facility on [DATE], with diagnoses that include but are not limited to chronic obstructive pulmonary disease (COPD- progressive lung disease characterized by persistent and often worsening airflow limitation, which makes it hard to breathe), anemia (blood disorder in which the blood has a reduced ability to carry oxygen to the rest of the body), morbid obesity (significant amount of excess weight) abnormality of gait and mobility (deviation from a normal walking pattern, , coordination and, balance) and muscle weakness. A review of Resident 21's Minimum Data Set (MDS - a resident assessment tool, and care-screening tool) dated 9/2/2025, indicated the Resident 21's cognition was intact. A review of Resident 21's history and physical (H&P) dated 9/2/2025 indicated Resident 21 can make decisions for activities of daily living. During an interview on 12/2/2025, at 10:42am, Resident 21 stated she would like to take a shower, but she is only receiving bed baths because facility does not have a bariatric shower chair (a heavy-duty, extra-wide, and reinforced seat designed for individuals with larger body sizes, providing safe, stable support for bathing and hygiene by accommodating higher weight capacities (often 300-600+ lbs.), Resident 21 stated that she has not had a shower since admission to the facility During an interview on 10/2/2025, at 11:02 AM., Certified Nurse Assistant (CNA) 1 stated all Residents received showers twice a week on their scheduled days and needed. During an interview on 10/2/2025, at 11:10 AM, the Rehabilitation Services Director (RSD) and Director of Staff Development (DSD) stated staff (unidentified) was unable to provide a shower to Resident 21 because she (Resident 21) was unable to bear weight on her lower extremities and transferring Resident 21 back to bed after a shower is not safe for both the Resident and staff. Facility was observed to have a bariatric shower chair that could accommodate up to 500lbs (Resident 21 is 369 lbs.) and a functional Hoyer lift (a mechanical assistive device used by caregivers to safely transfer individuals with limited mobility from one surface to another (like bed to chair). A review of Resident 21's order summary dated 12/4/2025 indicated an order dated 12/3/2025 for bed bath only for safety. During an interview on 12/4/2025, at 2:20 PM., Director of Nursing (DON) stated facility has a bariatric shower chair that can support up to 500lbs, DON reiterated that the problems is safety concerns for Resident 21 who is unable to bear weight in legs, DON stated facility is seeking options to facilitate Resident 21's need for showers such as a bariatric shower bed, DON stated Resident's rights must be maintained to ensure Residents do not feel like a burden or not allowed to have things they should have access to and for Residents to feel comfortable in the facility A review of facility policy and procedures (P&P) titled showers and bathing policy undated, indicated, Residents are offered two (2) baths and showers per week, with additional bathing based on the resident's preference. Bathing assistance promotes independence, dignity, privacy and choice.

Based on observation, interview, and record review, the facility failed to consistently honor food preferences that had been requested for one (1) out of 18 sampled Resident (Resident 51)These deficient practices had the potential to result in weight loss due to inadequate calories in residents who did not receive the correct amount or food items of their choices of their preference.A review of Resident 51's admission record indicated the Resident was admitted to the facility on [DATE] with diagnoses that include but are not limited to Diverticulosis (small pouches or pockets in the inside walls of your intestines), liver transplant (surgery to replace a diseased liver with a healthy liver from another person), pulmonary fibrosis (scarring and thickening in your lungs that makes it hard to breathe deeply), chronic kidney disease (a long-term condition where kidneys are damaged and gradually lose their ability to filter waste and extra fluid from the blood), abnormalities of gait and mobility (deviation from a normal walking pattern, coordination and, balance) and depression (persistent sadness and loss of interest, affecting how you feel, think, and handle daily life). A review of Resident 51's Minimum Data Set (MDS - a resident assessment tool, and care-screening tool) dated 11/10/2025, indicated the resident 51's cognition was moderately impaired, Resident 51 required supervision or touching assistance with eating and oral hygiene and personal hygiene. A review of Resident 51's order summary dated 12/4/2025 indicated the Resident was on a vegetarian with no added salt diet of regular texture, and thin liquids for drinks, no food likes and/or dislikes were listed. During an initial facility tour on 12/1/2025 at 8:09 AM, Resident 51 stated as he was eating his breakfast, they (facility staff), gave me eggs, I don not eat eggs, every day they bring me eggs. Resident 51 stated he indicated to the Dietary Supervisor (DS) following his admission that he does not eat eggs. A review of Resident 51's breakfast Meal menu ticket dated 12/1/2025 indicated Resident 51 was on a vegetarian Diet of a regular texture with thin liquid consistency for drinks with, Omelet (Omelette) 1 SQ, listed as one of the items served for breakfast. During an interview with the Dietary Supervisor (DS) on 12/4/2025 at 11:34 AM, DS stated she usually visits the newly admitted Residents on the day of their admission, on the following day of Resident is admitted after business hours and/or on a Monday if the Resident is admitted over the weekend. DS stated she had visited Resident 51 following his admission on [DATE], DS stated Residents food dislikes and/or preferences are listed on the Residents meal tickets, DS was unable to state why Resident 51's dislike for eggs was not listed on his (Resident 51's) meal ticket. DS stated failing to honor a residents food preference could cause Resident to avoid eating their meals, leading to lose of weight and resulting in poor health outcomes. A review of facility policy and procedure (P&P) titled Food Procedure, Food Preparation dated 1/1/2018 indicated, The facility must provide each resident with a nourishing palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of reach resident.

Based on interview and record review the facility failed to arrange and confirm transportation to a doctor's appointment for one of three sample residents, (Resident 1). This deficient practice caused Resident 1's appointment to be changed unnecessarily. Findings: A review of the admission record indicated the facility originally admitted Resident 1 on 11/16/2023 and was readmitted [DATE] with diagnoses including presence of right artificial knee joint, diabetes Mellitus type 2 (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), hyperlipemia (high fat in the blood), dementia (a progressive state of decline in mental abilities), abnormality of gait (not walking normal), obesity (overweight), vitamin D deficiency (low in vitamin D), overactive bladder (unable to control sudden urges to urinate) and obstructive sleep apnea (a sleeping disorder). A review of Resident 1's history and physical (H&P- the doctor's physical assessment and plan of care) dated 3/4/2025 indicated Resident 1 had a surrogate decision maker. and that Resident 1 had an appointment scheduled to see the orthopedic (bone) doctor on 3/7/2025. A review of Resident 1's minimum data set (MDS-a resident assessment) dated 3/8/2025 indicated Resident 1's cognition (mental ability to make decisions for daily living) was not intact. The MDS indicated Resident 1 required partial assistance (helper does less than half the effort) with personal hygiene and bathing. Resident 1 required maximal assistance (helper does more than half the effort) with toileting and transfers (moving between surfaces) from bed to chair. Lastly, Resident 1 required moderate assistance (helper does less than half the effort) with ambulating 10-50 feet using walker. On 3/19/2025 the California Department of Public Health (CDPH) received a complaint alleging the facility cancelled a doctor's appointment for Resident 1 without notifying the resident representative. During a concurrent interview and record review on 3/20/2025 at 10:05 a.m. with the social service assistant (SSA), Resident 1's nursing progress note dated 3/7/2025 was reviewed. The nursing progress noted indicated Resident 1 had an appointment with a orthopedic doctor on 3/18/2025. The SSA stated, I documented this appointment when Resident 1 returned from the initial appointment on 3/7/2025. On 3/18/2025 the certified nursing assistant (CNA) came to my office at about 10:50a.m. stating [Resident 1] had an appointment that morning at 10:45a.m. My mistake was I did not have the appointment in my folder, that is how I keep track of them, then I would set up transportation a few days before the appointment, but I did not do that this time. I guess the family was already here to take Resident 1 to the appointment when the CNA told me about the appointment, but I did not know they were here already . I thought Resident 1 had missed the appointment so I called the orthopedic doctor's office and asked if they could push back the appointment to 1:00p.m. and they agreed . SSA stated, After that I contacted our driver to arrange transportation, and the driver agreed to take Resident 1 to the appointment at 1:00 p.m. After this the resident representative (RR) was already standing in front of my office yelling WHY DID YOU CANCEL THE APPOINTMENT YOU ARE NOT FAMILY and seemed very upset not allowing me to tell her that I did not cancel I just rescheduled then went and complained to the Administrator (Adm). After all of the confusion the RR was still able to take Resident 1 to the appointment at 11:30am and they returned approximately one hour later. The SSA stated, I do think this could have been avoided if I had kept track of the appointment and called the family a few days prior like I normally do to confirm the appointment and transportation . During an interview on 3/20/2025 at 11:50 a.m. with the director of nursing (DON), the DON stated on 3/18/2025 Resident 1 had a doctor's appointment and transportation had not been set up so the SSA rescheduled the appointment from 10:45 a.m. to 1:00p.m. I think the family thought we cancelled the appointment but when they spoke to the Administrator, they found out it was not cancelled just rescheduled I did not witness the interaction. I am not sure why transportation was not already arranged I did not look into it, I assumed it was resolved because [Resident 1] still went to the appointment . During an interview on 3/20/2025 at 12:50 p.m. with the resident representative (RR) stated on 3/8/2025 the RR arrived at the facility at 10:30am to take Resident 1 to the ortho appointment scheduled for 10:45 a.m. The RR stated, we scheduled the appointment at that time because it fits my schedule so we would be able to take Resident 1 to the appointment. The RR stated, the SSA was aware of this follow up appointment because we provided them with the appointment date and time when we returned from Resident 1's first appointment on 3/7/2025. The RR stated while they were in the facility on 3/18/2025 waiting to take Resident 1 to the appointment; they got a call from the ortho doctor's office informing them the appointment had been cancelled. The RR then called the Ortho doctor's office and was told the facility cancelled the appointment. The RR stated, That made me upset because we schedule all Resident 1's appointments and no one from the facility communicated with us about cancelling or rescheduling Resident 1's appointment and we were there in the facility. The facility does not know our relationship with the Ortho doctor, we have been late before, and they would still see Resident 1. The RR stated, The facility should not be cancelling and rescheduling appointments without speaking to the responsible party first. During an interview on 3/20/2025 at 3:30 p.m. the CNA stated, On 3/18/2025 between 10:15a.m. and 10:20 a.m. I had just taken [Resident 1] to the bathroom and put her back into bed when I was notified by the unidentified charge nurse (CN) that [Resident 1] had an appointment at 10:45 a.m. Usually when a Resident has an appointment it is listed n the assignment sheet, but I did not see her appointment on the assignment sheet that morning. After the (CN) told me about the appointment I went to check the appointment book, and I did not see it there, so I went to the [SSA] office to confirm the appointment with the [SSA]. I did see the family arrive to the room around 10:40 a.m. A review of the facility job description for social service assistant (no date [n.d.]) indicated the social service assistant job duties include: Arranges residents' appointments including transportation when necessary. A review of the facility policy and procedures titled Transportation dated 2/2025, indicated, It is the policy of this facility to assist residents in accessing transportation according to their needs. RATIONALE: Residents may have appointments outside the facility. While the facility is not obligated to provide this transportation, the facility is expected to help residents evaluate options and access public or private transportation according to their means and abilities to travel safely in the community. PROCEDURE: Social Service staff works with other members of the Interdisciplinary Team to determine a resident's need for transportation. A resident may also request assistance with transportation.

Based on observation, interview, and record review, the facility failed to ensure safe food storage practices in the kitchen for by failing to ensure expired canned food, corned beef hash 6-pound (lbs., unit of measurement) 12 ounce (oz, is a unit of measurement) was not stored in the same location as non-expired food to be served to residents in the food storage area along with all other canned foods not expired. The corned beef hash was expired on ,d+[DATE]. This deficient practice had the potential to result in harmful bacteria growth and the consumption of spoiled food that could lead to foodborne illness (caused by contamination of food and occur at any stage of the food production, delivery, and consumption chain) in 57 of 57 residents who received food from the kitchen. Findings: During an interview and a concurrent observation of the walk-in food storage area on [DATE] at 7:10 AM, the Dietary Supervisor (DS) confirmed the findings and stated expired canned food should be separated from the non-expired food. Some dented cans were also observed. The DS stated the observed expired food should have been separated to ensure that residents are not served expired food. The DS stated that expired food should not be served to the residents because they are elderly and have medical conditions and eating expired food could make them sick and cause digestive issues. During a review of the facility's policy and procedures (P&P) titled Damaged Cans and Packages to be Returned to Vendor, dated [DATE] and revised on [DATE], the P&P indicated under Regulation/Surveyor Guidance- Store, prepare, distribute and serve food in accordance with professional standards for food service safety.Procedure: 1. All foods delivered require inspection 4.Place all damaged goods in specified area labeled Return to Vendor Do Not use . The location of this area is in the storeroom .6. Discard if vendor doesn't want to see product. During a review of the facility's P&P titled Storage of Food and Supplies, dated 2017 and 2018, the P&P indicated Policy: Food and supplies will be stored properly and in safe manner .Procedures for Dry Storage: 8. Food stored should be arranged in food groups to facilitate storing, locating and taking inventories. Similar items such as cereals or fruits should be grouped and alphabetized withing group. (Have a separate area labeled for dented cans and damaged food items.) Labels should be visible, and the arrangement should permit rotation of supplies so that oldest items will be used first. All food will be dated - month, day, year. All food products will be used per the times specified in the .Dry Food Storage Guidelines, in this Policy and Procedure Book. The storage times in the guidelines are intended to be on the safe side .Exception: If you have product information about specific items, (ie., spices, condiments, baking mixes) allowing a longer shelf life than the one in the Dry Food Storage Guidelines, you can use that storage time instead. Keep that documentation on hand in case you are asked for it. No food will be kept longer than the expiration date on the product.

Based on observation, interview, and record review, the facility failed to ensure staff provided dignified dining experience while assisting two of 15 sampled residents (Residents 4 and 58) during meals; by ensuring Residents 4 and 58 were fed at eye level to maintain face-to-face contact with the residents. This deficient practice had the potential to result in feelings of decreased self-esteem and self-worth for Resident 4 and Resident 58). b. During a review of Resident 58's admission record indicated the facility admitted the resident on 9/26/2024 with diagnoses that included dementia (a progressive state of decline in mental abilities), dysphagia (difficulty swallowing) and muscle weakness (a lack of strength in the muscles). During a review of Resident 58's Skilled Nursing Facility Admission History and Physical (H&P), dated 9/27/2024, indicated Resident 58 was recently hospitalized for acute (of sunset onset) or chronic (on going) functional decline, progressive neurologic (relating to the nervous system or nerves) declined, and had experienced a cognitive (the mental ability to make decisions) decline for the past 18 to 20 months. The H&P also indicated Resident 58 could make needs known but could not make medical decisions due to cognitive deficits and dementia (a progressive state of decline in mental abilities). During a review of Resident 58's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 9/30/2024, indicated the resident was able to understand others and was able to make himself understood. The MDS also indicated the resident had severely impaired cognition (ability to think, read, learn, remember, reason, express thoughts and make decisions). Resident 58 was dependent upon staff for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). The MDS indicated Resident 58 was diagnosed with dementia was receiving antipsychotic and antianxiety medication. During a review of Resident 58's Order Summary Report, dated 10/18/2024, indicated a physician's order for a certified nursing assistant (CNA) to assist in feeding Resident 58. During a review of Resident 58's nutritional problem care plan developed on 10/2/2024, indicated the Resident 58's nutritional problem was due to the resident's chewing difficulties. The care plan interventions included for staff to provide and serve diet as ordered and for staff to monitor and record intake of every meal for Resident 58. During an observation on 10/15/2024 at 12:39 PM, Certified Nursing Assistant 1 (CNA 1) was observed on the right side of Resident 58's bed standing over feeding Resident 58. During a concurrent observation and interview on 10/15/2024 at 12:45 PM in Resident 58's room, CNA 1 was observed standing over Resident 58 while feeding the resident. CNA 1 stated CNA 1 should not stand over Resident 58 while feeding the resident to maintain the resident's dignity. During an interview on 10/18/2024 at 3:45 PM, with the Director of Nursing (DON), the DON stated staff should be sitting and at eye level with the resident when feeding the residents. The DON stated, Staff should feed residents at eye level and not stand over the residents while feeding the residents. The DON further stated, we feed the residents at eye level with the resident when feeding to show dignity for the resident. During a review of the facility's policy and procedures (P&P) titled, Dignity, revised 11/2023, indicated, each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. Residents provided with a dignified dining experience. 45455 a. During a review of Resident 4's Admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included hypertension (high blood pressure), major depressive disorder (A mental health condition that involves persistent feelings of sadness, hopelessness, and a loss of interest in activities), congestive heart failure (a serious condition that occurs when the heart can't pump enough blood to meet the body's needs) and, neoplasm (cancer) of the prostate (a gland in the male reproductive system). During a review of Resident 4's MDS, dated [DATE], indicated Resident 4's mental cognition was moderately impaired. The MDS indicated Resident 4 required partial moderate assistance for eating and oral hygiene and upper body dressing, was dependent for toileting hygiene, shower/bathing self, and lower body dressing. During a review of Resident 4's care plan titled, The Resident has Limited Physical Mobility Related to Feeding (R/T) and Needs Assistance with Feeding, initiated on 9/23/2024, indicated Resident 4 had limited physical mobility related to feeding and needs assistance with feeding. During a meal observation on 10/15/2024 at 8:31AM, CNA 5 was observed feeding Resident 4 inside the residents' room. CNA 5 was standing to the right side of Resident 4 while feeding the resident. During an interview on 10/15/2024 at 8:37 AM, CNA 5 stated CNA 5 is supposed to beside the patient while assisting the resident with feeding. During an interview on 10/15/2024 at 12:51 PM with Director of Staff Development (DSD), DSD stated, CNAs are supposed to be seated, have eye level contact with the resident when assisting the resident with feeding. During an interview on 10/18/2024 at 4:43 PM with Director of Nursing (DON), DON stated, CNAs should sit on a chair at eye level on the side that is easy for the resident to eat, ensure the resident is not looking up at the staff and is eating at a comfortable pace for the resident dignity. DON further stated assisting a resident with feeding while standing up diminishes the resident's dignity. During a review of the facility's policy and procedures (P&P) titled, Dignity, revised 11/2023, indicated, each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. Residents provided with a dignified dining experience.

Based on observation, interview, and record review, the facility failed to provide on-going activities, based on comprehensive assessment and resident's preferences, that meets the interests and to support the physical, mental, and psychosocial well-being of 57 of 57 facility Residents. This deficient practice had the potential to result in lack of feelings of well-being and meaningfulness for the resident. Cross Reference F680 Findings: During an observation and concurrent interview on 10/16/2024 at 11:35 a.m. Certified Nursing Assistant 6 (CNA 6) was observed seated in the facility communal dining area monitoring residents as the residents watched Television. During an interview CNA 6 stated CNA 6 was covering for the Activities Director (AD) who was on vacation starting 10/15/2024. CNA 6 stated it was CNA 6's first day covering for the AD and that CNA 6 was trained on resident activities. CNA 6 stated CNA 6 was handed a guide (name not provided) on which activities to conduct with the residents. During an interview on 10/16/2024 at 11:38 a.m., the Director of Staff Development (DSD), stated CNA 6 was covering activities for the AD who was currently on vacation. The DSD also stated CNA 6 had not received training on how to conduct any activities with/for the residents. During an interview on 10/18/2024 at 4:59 p.m., the Director of Nursing (DON) stated the AD was on vacation since 10/15/2024. The DON stated activities help to keep residents' minds active and from further decline. The DON stated CNA 6 had worked with the AD in the past (unable to provide dates). The DON stated the DON did not know where the activity logs were kept. The DON stated the (DON) searched for the activities but could not find them. During a review of the facility's undated AD Job Description indicated, the AD, is responsible for planning, organizing, developing, and directing the overall operations of the Activities Department, responsible for directing and managing an on-going program of activities designed to meet in accordance with assessments, the interest, and the physical, mental, and psychosocial well-being of all Residents. Qualifications include: Associate degree or two years of college level course experience required. Must be a qualified therapeutic recreation specialist or an activities professional who is licensed by the appropriate state and is eligible for said certifications or Must have a minimum of 2 yrs experience in a social or recreation program within the last 5 years .

Based on interview, and record review, the facility failed to create a comprehensive care plan (a resident-specific plan with defined clinical goals and interventions used to manage identified medical issues or other areas of concern) to meet the needs of two of five sampled residents (Residents 58 and 164) by failing to: -Develop a care plan for Resident 58's psychotropic (a medication that affects behavior, mood, thoughts, or perception) medications and their targeted behavior of visual hallucinations for Resident 58. - Develop a care plan for Resident 164's activities and anticoagulant (medication used to prevent blood clots) medication. These deficient practices placed Residents 58 and 164 at increased risk for suboptimal care from facility staff in these care areas leading to diminished physical, mental, and psychosocial well-being. Findings: a. During a review of Resident 58's Admission Record indicated an the facility admitted the resident on 9/26/2024 with diagnoses of dementia (a progressive state of decline in mental abilities) with psychotic disturbance (severe mental disorder that causes a person to lose touch with reality), anxiety disorder (a mental health condition with feeling of worry, anxiety, or fear interfering with one`s daily activities) and cognitive communication deficit (a disorder that affects a person's ability to communicate). During a review of Resident 58's Physician Orders, dated 9/26/2024, indicated the facility to administer the following medications to Resident 58: - Risperidone (an antipsychotic medication) 2 milligrams (mg- unit of measurement) by mouth at bedtime for psychosis manifested by visual hallucinations (involves seeing things that aren't real) - Seroquel (an antipsychotic medication) 25mg - give 3 tablets (for a total of 75mg) by mouth at bedtime for psychosis manifested by visual hallucinations. During a review of Resident 58's Skilled Nursing Facility Admission History and Physical (H&P), dated 9/27/2024, indicated Resident 58 was recently hospitalized for progressive neurologic decline and has experienced a cognitive decline for the past 18 to 20 months. The H&P also indicated Resident 58 could make needs known but could not make medical decisions due to cognitive deficits and dementia. During a review of Resident 58's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 9/30/2024, indicated the resident was able to understand others and was able to make herself understood. The MDS also indicated the resident had severely impaired cognition (ability to think, read, learn, remember, reason, express thoughts and make decisions) and the resident was dependent upon staff for all activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). The MDS also indicated the resident was diagnosed with dementia was receiving antipsychotic and antianxiety medication. During a review of Resident 58's Medication Administration Records (MAR) for 9/2024 and 10/2024, the MARs indicated Resident 58 received the following: - 18 doses of Seroquel 200 mg from 9/27/2024 to 10/18/2024 - 18 doses of Risperidone 75 mg from 9/27/2024 to 10/18/2024 During a review of Resident 58's Care Plans on 10/17/2024 at 9 AM, indicated there were no individualized person-centered care plans with measurable objectives, monitoring, and a timetable to meet the needs that addressed the resident's use of Seroquel and Risperidone or for the behavior of visual hallucinations. During a concurrent interview and record review on 10/17/2024 at 10:20 AM, Resident 58's care plans and physician orders for Seroquel, and Risperidone were reviewed with Registered Nurse Supervisor 2 (RNS 2). RNS 2 stated Resident 58 was currently taking/receiving Seroquel and Risperidone. RNS 2 also stated Resident 58 did not have care plans that addressed Resident 58's indications for Seroquel or Risperidone. RNS 2 stated a care plan should be developed for any psychotropic medication. RNS 2 further stated we have to care plan the behaviors and side effects of the medication and it was possible for Resident 58 to have side effects or for the resident's behavior to go untreated if the medications were not care planned. During an interview on 10/18/2024 at 8:19 AM, MDS 1 stated Resident 58 should have care plans in place that address the use of antipsychotic medication. MDS 1 stated, it is important to care plan the manifestation, behaviors so that the particular symptom(s) can be treated effectively. During an interview on 10/18/2024 at 3:42PM, the Director of Nursing (DON) stated all psychotropic medications and the behaviors being treated by the psychotropics, should be care planned for. The DON stated potential outcome of not initiating a care plan is the lack of care and inability to deliver necessary interventions and monitoring for a resident. During a review of the facility's policy and procedures (P&P) titled, Antipsychotic Medication Use, revised 3/2023, the staff will observe, document, and report to the Attending Physician information regarding the effectiveness of any interventions, including antipsychotic medications. During a review of the facility's P&P titled, Care Plans, Comprehensive Person-Centered, revised 3/2023, indicated, The comprehensive, person-centered care plan: a. includes measurable objectives and timeframes. b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. 45528 b. A review of Residents 164's Admission Record indicated the facility admitted Resident 164 on 10/1/2024 with diagnoses including Major depressive disorder (a mental health condition that causes a persistently low or depressed mood and a loss of interest in activities that once brought joy), atrial fibrillation (Afib- an irregular heartbeat that occurs when the electrical signals in the hearts upper chambers fire rapidly and out of synch with the lower chambers), and dysphagia (difficulty swallowing safely). A review of Resident 164's MDS dated [DATE], indicated Resident 164 had cognitive impairment (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life). The MDS indicated Resident 164 was dependent on staff for toileting, shower, chair to bed transfer and personal hygiene. MDS further indicated Resident 164 had a diagnosis of Afib however, there MDS did not indicate that Resident 164 was on an anticoagulant. A review of Resident 164's Physicians Orders dated 10/1/2024, indicated, Apixaban (used to treat health problems caused by a blood clot) 5miligrams (md -unit of measure) by mouth two times a day for deep vein thrombosis (DVT -a condition that occurs when a clot forms in a large vein deep in the body) prophylaxis (preventative treatment against disease). A review of Resident 164's MAR for 10/2024, indicated Resident 164 received a total of 32 doses of Apixaban 5mg from 10/1/2024 to 10/18/2024. During a concurrent interview and record review, on 10/18/2024, at 11:34 AM., with Registered Nurse Supervisor 1 (RNS 1), Resident 164's chart was reviewed. RNS 1 stated there was no care plan for activates and there was no care plan for apixaban. RNS 1 stated residents need to have care plan so the facility can provide overall and individualized care to the residents. During an interview on 10/18/2024, at 5:20 PM., with the Director of Nursing (DON), the DON stated residents need to have care plans to ensure that the resident is receiving appropriate care. The DON stated, if residents do not have a care plan, resident is not receiving patient centered care. During a review of the facility's P&P titled, Care Plans, Comprehensive Person-Centered, revised 3/2023, indicated, The comprehensive, person-centered care plan: a. includes measurable objectives and timeframes. b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.

Based on interview and record review, the facility failed to provide appropriate monitoring of anticoagulants (blood thinner; a substance that hinders the clotting of blood) and antidepressants (medication used to treat depression [mental health that involves persistent feeling of sadness, loss of interest and low mood that lasts for a long time] for two of ten sampled residents (Resident 6 and Resident 164). These deficient practices had the potential to result in complications from the use of antidepressants and anticoagulants such as bruising, bleeding to Resident 6 and Resident 164. Findings: 1.A review of Resident 6's Admission Record indicated the facility originally admitted the resident on 2/13/2020 and readmitted the resident on 11/1/2023 with diagnoses including atrial fibrillation (AFib - an irregular often rapid heart rate that commonly causes blood clots), transient ischemic attack and cerebral infarction (damage to brain tissues caused by lack of oxygen to the area). A review of the physician order, dated 2/8/2023, indicated staff were to monitor Resident 6 for signs and symptoms of bleeding including prolonged bleeding in the nose, eyes, gums, bruises that don't heal, blood in the urine and black tarry stool. The physician order further indicated staff were to notify the physician if there was bleeding every shift due to use of Eliquis. A review of the Physician's Order, dated 4/4/2023, indicated Resident 6 was to receive Eliquis (medication used to prevent blood clots) 5 milligrams (mg, unit of measurement) by mouth two times a day with breakfast and dinner for AFib. A review of the care plan titled, potential for bleeding, bruising and/or skin discolorations, developed 11/2/2023 indicated Resident 6 was at risk due to the use of anticoagulant therapy secondary to diagnosis of a-fib. A review of the care plan indicated the goals was for the resident to have no episodes of bleeding. The care plan interventions included: 1.To monitor for bruising or bleeding every shift 2.To monitor for blood in the urine or stool 3. Notify the physician of signs of bleeding and 4. To use a soft toothbrush for brushing and watch for any gum bleeding. A review of Resident 6's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 8/7/2024, indicated the resident's cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision-making were moderately impaired. The MDS also indicated Resident 6 required partial assistance to set up assistance with dressing, eating and toileting hygiene and bathing. The MDS further indicated the resident was taking an anticoagulant. During a record review on 10/18/2024 at 7:25 AM, the October 2024 medication administration records ((MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident), Resident 6 received Eliquis twice a day. A review of the MAR also indicated no documented evidence the licensed nurses monitored for side effects of Eliquis. During a concurrent interview and record review on 10/18/2024 at 8:13 AM, Resident 6's electronic chart physician orders and MAR were reviewed with the MDS Nurse. MDS Nurse stated Resident 6 was currently taking Eliquis. The MDS Nurse stated there was no order for the monitoring for side effects or bleeding related to the use of Eliquis. MDS stated Resident 6 previously had an order, but it was not carried over when she was readmitted in November 2023. The MDS Nurse stated staff should monitor for bleeding and there was a high risk for bruising. During an interview on 10/18/2024 at 3:43 PM, the Director of Nursing (DON) stated it is the facility's practice to monitor for bleeding and bruising for those residents' taking anticoagulants. The DON stated the nursing staff should have monitored Resident 6's for bleeding and bruising and document it on the MAR. The DON stated a potential outcome of not monitoring for the side effects of Eliquis was Resident 6 could have an episode of sudden bleeding. According to the Nurse's Drug Handbook, 2022, Eliquis side effects included bleeding and excessive bleeding leading to hemorrhage. The Nursing Drug Handbook indicated to monitor closely for bleeding as Eliquis may cause life-threatening bleeding. During a review of the facility's policy and procedures (P&P) titled, Anticoagulation- Clinical Protocol, reviewed 4/2024, the P&P indicated the staff and physician will monitor for possible complications in individuals who are being anticoagulated and will manage related problems. a. If an individual on anticoagulation therapy shows signs of excessive bruising, hematuria, hemoptysis, or other evidence of bleeding, the nurse will discuss the situation with the physician before giving the next scheduled dose of anticoagulant. 45528 2. A review of Residents 164's Admission Record indicated the facility admitted Resident 164 on 10/1/2024 with diagnoses including major depressive disorder (a mental health condition that causes a persistently low or depressed mood and a loss of interest in activities that once brought joy), Afib., and dysphagia (difficulty swallowing safely). A review of Resident 164's MDS dated [DATE], indicated Resident 164 had cognitive impairment (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life). The same MDS indicated Resident 164 was dependent on staff for toileting, shower, chair to bed transfer and personal hygiene. The same MDS further indicated Resident 164 had a diagnosis of Afib however, there MDS did not indicate that Resident 164 was on an anticoagulant. A review of Resident 164's physicians orders dated 10/1/2024, indicated: Apixaban (used to treat health problems caused by a blood clot) 5mg by mouth two times a day for deep vein thrombosis (DVT -a condition that occurs when a clot forms in a large vein deep in the body) prophylaxis (preventative treatment against disease), mirtazapine 30mg one tablet by mouth at bedtime for depression manifested by poor by mouth intake and escitalopram 5mg one tablet by mouth one time a day for depression manifested by poor by mouth intake. A review of Resident 164's care plan dated 10/2/2024, indicated Medication: Escitalopram, Mirtazapine . Interventions; assess/record effectiveness of drug treatment, monitor and report signs and symptoms of sedation . During a concurrent interview and record review, on 10/18/2024, at 11:50 A.M., with Registered Nurse Supervisor (RNS) 1, Resident 164's physician orders dated 10/1/2024, care plans and MAR for 10/2024 were reviewed. RNS 1 stated, apixaban is an anticoagulant that requires facility to monitor residents of any signs and symptoms of bleeding, finding or lack thereof need to be documented on the MAR every shift. RNS 1 stated monitoring for signs and symptoms of bleeding is part of the facility protocol batch that needs to be ordered automatically by the nursing staff whenever there is an order for anticoagulant for a resident. RNS 1 stated Resident 164 did not have an order to monitor for signs and symptoms of bleeding and therefore there was no monitoring for the apixaban on the MAR that was only be triggered once the order to monitor for bleeding was entered in the orders. RNS 1 states not monitoring for bleeding may lead to possibility of resident bleeding and alter the overall wellbeing of the resident. RNS 1 stated needs to monitor antidepressants so that the facility may not miss any behaviors and their frequency which can ultimately give guidance as to when a medication needs to be discontinued or adjusted. Not monitoring the side effects of the medication can lead to residents' care not being met. During an interview on 10/18/2024, at 5:20 P.M., the DON stated the facility needs to monitor residents that are on anticoagulants and antidepressants, documents the findings on the MAR. The DON stated lack of monitoring and documenting findings for residents on anticoagulants may lead to bleeding that may go unnoticed and possible anemia (a condition that develops when your blood produces a lower-than-normal amount of healthy oxygen carrying blood cells) and hospitalization . The DON further stated resident on antidepressants need to be monitored for behaviors and side effects which need to be documented on the MAR. If there is no monitoring for antidepressants, side effects and behaviors may not be captured, and dosing may not be adjusted appropriately. A review of the facility's P&P titled, Antipsychotic Medication Use, reviewed 3/2023, the P&P indicated The staff will observe, document, and report any of the following side effects and adverse consequences of antipsychotic medications to the attending physician.

Based on observation, interview, and record review, the facility failed to ensure the facility document titled, Facility Verification of Informed Consent, (a principle in medical ethics, medical law, and media studies, that a patient must have sufficient information and understanding before making decisions about their medical care) form was fully completed and properly executed for psychotropic (medications that affect the mind, emotions, and behavior) medication for two of five sampled residents (Residents 58 and 164). This deficient practice had the potential for Residents 58 and 164 not to be fully informed of the risk and benefits of the psychotropic medication they were receiving. Findings: a. A review of Resident 58's admission record indicated Resident 58 was admitted to the facility on [DATE] with diagnoses that included dementia (a progressive state of decline in mental abilities) with psychotic disturbance anxiety disorder (a mental health condition with feeling of worry, anxiety, or fear interfering with one`s daily activities) and cognitive communication deficit (a disorder that affects a person's ability to communicate). During a review of Resident 58's Physician Orders (PO), dated 9/26/2024 , the PO indicated: risperidone (medication used to treats psychosis [a severe mental condition in which thought, and emotions are so affected that contact is lost with reality] 2 milligrams (mg, unit of measurement) by mouth at bedtime for psychosis manifested by visual hallucinations; Seroquel (medication to treat psychosis) 25mg 3 tablets (for a total of 75mg) by mouth at bedtime for psychosis manifested by visual hallucinations During a review of Resident 58's History and Physical (H&P), dated 9/27/2024, the H&P indicated Resident 58 was recently hospitalized for acute or chronic functional decline, progressive neurologic declined and has experienced a cognitive decline for the past 18 to 20 months. The H&P also indicated Resident 58 could make needs known but could not make medical decisions due to cognitive deficits and dementia. A review of Resident 58's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 9/30/2024, indicated Resident 58 was able to understand others and was able to make himself understood. The MDS further indicated the resident had severely impaired cognition (ability to think, read, learn, remember, reason, express thoughts and make decisions). Resident 58 was dependent upon. The same MDS indicated the Resident 58 was diagnosed with dementia was receiving antipsychotic and antianxiety medication. A review of Resident 58's Physician Orders dated 10/16/2024 indicated Ativan (an anti-anxiety medication) 0.5 mg every 12 hours until 10/20/2024 and at bedtime for catatonia (a condition in which a person is awake but does not seem to respond to other people and their environment and is characterized by abnormal movements, behaviors, and withdrawals) manifested by rigidity. A review of Resident 58's September and October 2024 Medication Administration Records (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) indicated the resident received the following: 1. eight doses of Ativan 0.5 mg from 9/27/2024 to 10/18/2024 and 2. five doses of Ativan 1mg from 9/27/2024 to 10/18/2024 3. 18 doses of Seroquel 200 mg from 9/27/2024-10/18/2024 4. 18 doses of Risperidone 75 mg from 9/27/2024-10/18/2024 A review of Resident 58's anti-anxiety medication care plan, developed 10/16/2024, indicated Resident 58 was receiving Ativan for anxiety manifested by catatonia syndrome. The care plan interventions included to document and notify physician if mood state interferes with functioning, develop a meaningful activity for the resident while in the facility to divert attention. During a concurrent interview and record review of Resident 58's active chart on 10/17/2024 at 10:50 AM, a Facility Verification of Informed Consent to Physical Restraints Psychotherapeutic Drug or prolonged use of Active Device Form (Verification of Informed Consent) for Ativan, Risperidone, and Seroquel was reviewed with Registered Nurse Supervisor (RNS) 2. RNS 2 stated all three medications were listed out on the one Verification of Informed Consent Form. RNS 2 confirmed and stated the form was not completed correctly. RNS 2 stated each medication should have its own form and the dosage and frequency should also be written on the form. RNS 2 stated psychotropic medications are high risk medications and the Verification of Informed Consent Form's is used to inform the resident and or family of the medications side effects and risks. During an interview on 10/18/2024 at 4:37 PM, the Director of Nursing (DON) stated Resident 58's form was completed incorrectly. The DON stated each medication should have its own individual form. The DON further stated the medication's dosage, frequency and diagnosis should be written out on an individual form. The DON stated the purpose of obtaining informed consent before administering psychotropic medication was to ensure the resident is aware of the risks and benefits of the medication and so the resident can be monitored for any effects of taking the medication. The DON further stated an incorrectly executed Informed consent could lead to the resident being unaware of the medication or dosage they were taking. 45528 b. A review of Residents 164's Admission Record indicated the facility admitted Resident 164 on 10/1/2024 with diagnoses including Major depressive disorder (a mental health condition that causes a persistently low or depressed mood and a loss of interest in activities that once brought joy), atrial fibrillation (Afib- an irregular heartbeat that occurs when the electrical signals in the hearts upper chambers fire rapidly and out of synch with the lower chambers), and dysphagia (difficulty swallowing safely). A review of Resident 164's MDS dated [DATE], indicated Resident 164 had cognitive impairment (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life). The same MDS indicated Resident 164 was dependent on staff for toileting, shower, chair to bed transfer and personal hygiene. A review of Resident 164's physicians orders dated 10/1/2024, indicated: Mirtazapine (medication to treat depression) 30mg one tablet by mouth at bedtime for depression manifested by poor by mouth intake and Escitalopram 5mg one tablet by mouth one time a day for depression manifested by poor by mouth intake. During a concurrent interview and record review, on 10/18/2024, at 11:34 A.M., with RNS 1, Resident 164's Facility Verification of Informed Consent to Physical Restraints Psychotherapeutic Drug or prolonged use of Active Device Form (Verification of Informed Consent) dated 10/1/2024 was reviewed. RNS 1 stated informed consent needs to be accurately completed reflecting the dose, route, frequency of the medication and each medication needs not have its own informed consent. RNS 1 stated not filling out the consent form accurately may lead to medication errors. During a concurrent interview and record review, on 10/18/2024, at 5:20 P.M., with DON, Resident 164's Facility Verification of Informed Consent to Physical Restraints Psychotherapeutic Drug or prolonged use of Active Device Form (Verification of Informed Consent) dated 10/1/2024 was reviewed. The DON stated consent forms for antipsychotics should not have two medications on one form, each medication needs to have its own consent form that also includes the dose, diagnosis, and behaviors to be treated. DON states inaccurate informed consents forms may lead to resident not knowing that they are taking the medication. DON stated residents needs to be able to have the choice or right to make the decision to take the medication and the dose being prescribed. During a review of the facility's policy and procedures (P&P) titled Informed Consent - Psychotherapeutic Medications and Restraint Devices revised 12/14/2023, the P&P indicated the healthcare practitioner ordering psychotherapeutic medication is responsible for Providing documentation that informed consent was obtained, including the diagnosis/clinical indications for the medication, Ordering psychotherapeutic (chemical) restraint medication and obtaining informed consent for the dosage range/specific dosage for each consent and obtaining informed consent from the resident/surrogate decision maker Prior to receipt of the medication when a psychotherapeutic medication is ordered throughout the resident's stay in the facility.

Based on observation, interview, and record review, the facility failed to provide a homelike environment by failing to ensure a pest free environment for one of six sampled residents (Resident 214). This deficient practice resulted in Resident 214 being bitten by ants and a potential of a facility wide infestation of ants and other residents being affected by a wider infestation. Findings: A review of Resident 214's Admission Record indicated Resident 214 was admitted to the facility on [DATE], with diagnoses that included, anxiety disorder, (restlessness, worried, tense, or afraid of what may happen in the future), muscle weakness (a lack of physical or muscle strength, throughout the body). A review of Resident 214's Minimum Data Set (MDS - a federally mandated resident assessment tool), indicates Resident 214's cognition (the mental ability to make decisions of daily living) was intact, and can make decisions for medical care and perform all activities of daily living. During a concurrent observation and interview on 10/15/24 at 10:43 AM Resident 214 stated there were ants on the wall and at the bottom of the door that leads outside to the rear of the facility from Resident 214's room. During an observation it was noted that ants were crawling on the side of the wall just inside the sliding glass door that leads outside the resident's room to the back walkway of the facility. It was observed that ants were also crawling on the floor just inside the sliding glass door that leads to the back walkway of the facility. During an observation and a concurrent interview on 10/15/24 at 10:55 AM, the Maintenance Supervisor (MS) stated just yesterday, the facility had fumigation services for ants and pests to the outside and inside of the facility. The MS confirmed there were ants in Resident's 214's room. The MS stated that he would do a room to room check of the facility to ensure a homelike environment free of pests. During a review of the facility document titled, Total Maintenance Service Invoice #:14025, dated 10/14/2024 at 9:05 am, the document indicated the following: Performed exterior treatment around facility for heavy ant activity. 4 colonies found in trees by sidewalk. All colonies were treated, please give 72 hours for chemical to fully take effect. Also, interior unites 1, 14, staff lounge, doctors office/lounges, dining, and nurse stations were all bated for ants. Also, interior kitchen was serviced, and no roaches found. Rodent devices have been checked and no mice captured or signs of pest. Fly, light has also been serviced and glue boards replaced. During an interview on 10/16/24 at 2:13 PM, the MS stated he had to spray the ants inside the resident's room himself since the Fumigation company would take at least 24 hours to return. During an interview on 10/18/24 at 2:24 PM, the Director of Nursing (DON) stated fumigation services was called a few days ago for ants reported outside the building. Fumigation company has already sprayed for bugs on the perimeter of the facility. There was no spaying for insects inside the building only on the outside of the facility. Because ants have been discovered inside the facility the staff will do a room to room check for insects and then, if necessary, we will call the fumigation company to come out to spray inside the facility. The DON stated that residents should be able to live in a pest free environment and it was the responsibility of the facility to ensure their rooms and living areas are always pest free. During a review of the facility's policy and procedures (P&P) titled, Homelike Environment revised 9/2023, the P & P indicated Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible .Staff provides person-centered care that emphasizes the residents' comfort, independence and personal needs and preferences.

Based on observation, interview and record review, the facility's interdisciplinary team (IDT-- a group of health care professionals with various areas of expertise who work together toward the goals of their clients) failed to ensure that one of 13 sample residents (Resident 53) did not keep medications at the bedside without a physician's order and/or without being assessed to determine if the resident is capable to self-administer medications. This deficient practice resulted in Resident 53 keeping a white powder like substance inside the medication dispensing cup and self-applying the white powder under the breasts. This deficient also, had the potential for the white powder to be accessed and used by unintended person. Cross Reference F760 Findings: During a review of the admission record indicated Resident 53, was admitted to the facility on [DATE], with diagnoses including acute respiratory failure with hypoxia (a serious medical condition that occurs when the lungs have trouble loading the blood with enough oxygen and body tissues), congestive heart failure (a serious condition that occurs when the heart can't pump enough blood to meet the body's needs.), major depressive disorder (A mental health condition that involves persistent feelings of sadness, hopelessness, and a loss of interest in activities), muscle weakness and dysphagia (medical term for swallowing difficulties). During a review of Resident 53's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 09/21/2024, indicated Resident 5's cognition (The mental ability to make decision of daily living) was intact. The MDS indicated Resident 53 was independent with eating, oral hygiene, and required partial moderate assistance with upper body dressing, was dependent for Toileting hygiene, shower/bathe, lower body dressing, required limited assistance with his activities of daily living. During a concurrent observation and interview on 10/15/2024, at 7:56 AM, Resident 53's bedside drawer was observed with unlabeled medication dispensing cup and a white powder like substance inside the medication dispensing cup. Resident 53 was asked if she knew what the white powder that was inside the unlabeled medication cup. Resident 53 stated, it is antifungal (medication to treat fungal infection/s) powder and that she applies the powder under her breast. During an interview on 10/15/2024, at 7:56 AM., Certified Nursing Assistant 5 (CNA5) stated CNA 5 did not know what was in the medicine cup. CNA5 further stated, it looks like a powder the white powdered substance. During an interview on 10/15/2024 at 8 AM., with the Treatment Nurse 1 (TXN 1), TXN 1 stated TXN 1 did not know what the white powdered substance in the medication dispensing cup on top of Resident 53's bedside drawer was. TXN 1 further stated, the powder in the medication cup is not supposed to be on top of resident's bedside drawer, because it is not labeled and thus unidentifiable. TXN 1 also stated leaving an unlabeled medication cup with an unidentifiable powder in places the Resident at risk of ingesting a white powder that may be unsafe for consumption and if consumed could cause an allergic reaction that could result in anaphylaxis and even death. During an interview on 10/18/2024 at 4:53 pm with the Director of Nursing (DON), the DON stated, Residents are only allowed for have medications at bedside if they have been assessed to be cognitively intact and have physically demonstrated that they can safely be able to do so and have a physician approval. The DON stated without resident assessment, the medication may be applied/administered incorrectly, placing the resident at risk for skin breakdown, irritation, and or redness. The DON also stated medication at bedside should be secured in a locked container. During a review of the Physician Orders dated 10/18/2024, indicated no order to apply antifungal powder under Resident 53's breasts. During a review of the facility's policy and procedures titled Self-Administration of Medication dated 09/2023 indicated, .the IDT, assesses each resident's cognitive and physical abilities to determine whether self-administering medications is safe and clinically appropriate for the Resident. Policy further states self-administered medications are stored in a safe and secure place, which is not accessible by other Residents .

Based on interview and record review, the facility failed to ensure that the residents right to formulate an advanced directive (a legal document indicating resident preference on end-of-life treatment decisions) was recorded for two of 14 sampled residents (Residents 23 and 26). This deficient practice violated Residents 23 and 26 right to be fully informed of the option to formulate advance directives and had the potential to cause conflict with health care wishes for residents 23 and 26. Findings: During a review of Residents 23's Admission Record indicated the facility admitted Resident 23 on 3/8/2023 with diagnoses including hyperlipidemia (high level of fats in the blood), hypertension (HTN - elevated blood pressure), and generalized muscle weakness (lack of physical or muscle strength). During a review of Resident 23's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 9/9/2024, indicated Resident 23 had intact cognitive (mental action or process of acquiring knowledge and understanding) skills. The MDS indicated Resident 23 was dependent on staff for toileting, shower, chair to bed transfer and personal hygiene. During a review of Resident 23's Advanced directive acknowledgement form dated 3/8/2023 sign portion stated verbal. During an interview on 10/16/2024, at 8:59 A.M., with Resident 23, Resident 23 stated the facility did not discuss advanced directive information with him. During an interview and record review on 10/16/2024, at 11:10 AM., with the Social Services Director (SSD), the SSD stated the advanced directive acknowledgement form needs to have the residents' signature to be complete and accurate, the signature of the residents acknowledges the receipt of the information given. During a review of Residents 26's Admission Record indicated the facility admitted Resident 26 on 9/21/2024 with diagnoses including hyperlipidemia, hypertensive chronic kidney disease (a condition where blood pressure damages the kidneys, making it difficult for kidneys to filter blood), and generalized muscle weakness. During a review of Resident 23's MDS dated [DATE], indicated Resident 26 had intact cognitive skills. The MDS indicated Resident 26 was dependent on staff for toileting, shower, chair to bed transfer and personal hygiene. During a review of Resident 23's Advanced directive acknowledgement form dated 3/8/2023 the signature and dated sections were blank. During a concurrent interview and record review, on 10/16/2024, at 10:16 AM., with Resident 26, Resident 26's Advanced directive acknowledgement form, dated 9/21/2024 was reviewed. Resident 26 stated the facility did not discuss advanced directive information with him. During an interview and record review on 10/16/2024, at 11:10 AM., with the SSD, the SSD stated the advanced directive acknowledgement form needs to have the residents' signature and date to be complete and accurate, the signature of the residents acknowledges receipt of the information given. During an interview on 10/18/2024, at 5:20 PM., with the Director of Nursing (DON), the DON stated advanced directives ensure that the wishes of the resident are made known to the facility. The DON stated, lack of an advanced directive or advanced directive acknowledgement form can lead to the facility missing out on what the residents' wishes are ultimately provide care that is not according to the residents wishes. During an interview on 10/18/2024, at 5:40 PM., with the Facility Administrator (FA), the FA stated advanced directives need to be completed by social services. The FA stated Advanced directives or advanced directive acknowledgment form lets the facility know the healthcare wishes of the resident and if not completed may lead to care that does not follow the residents wishes. During a review of facility's undated policy and procedures titled Advanced Directive, indicated, it is the policy of the facility to promote a resident's right to accept or refuse medical or surgical treatment, and the right to formulate an advanced directive .upon admission, all residents and representatives are presented with written information about their rights to .formulate an advanced directive.

Based on interview and record review, the facility failed to ensure one of eight sampled residents (Resident 164's) medical records had accurately documented assessment reflective of the resident's use of an anticoagulant (a substance that prevents or treats blood clots in the heart and blood vessels [tubes that carry blood throughout the body]). This deficient practice resulted in Resident 164's medical records being inaccurate and missing vital information of services being rendered to the resident. Findings: During a review of Residents 164's Admission Record indicated the facility admitted Resident 164 on 10/1/2024 with diagnoses including Major depressive disorder (a mental health condition that causes a persistently low or depressed mood and a loss of interest in activities that once brought joy), atrial fibrillation (Afib- an irregular heartbeat that occurs when the electrical signals in the hearts upper chambers fire rapidly and out of synch with the lower chambers), and dysphagia (difficulty swallowing safely). During a review of Resident 164's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 10/4/2024, indicated Resident 164 had cognitive impairment (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life). The MDS indicated Resident 164 was dependent on staff for toileting, shower, chair to bed transfer and personal hygiene. The MDS further indicated Resident 164 had a diagnosis of Afib however, however, the MDS did not indicate Resident 164 was on anticoagulant. During a review of Resident 164's physicians orders dated 10/1/2024, indicated, Apixaban (medication used to treat blood clots) 5miligrams (mg -unit of measure) by mouth two times a day for deep vein thrombosis (DVT -a condition that occurs when a clot forms in a large vein deep in the body) prophylaxis (preventative treatment against disease). During a concurrent interview and record review, on 10/18/2024, at 3:46 P.M., with MDS nurse, Resident 164's physician orders dated 10/1/2024 and MDS dated [DATE] were reviewed. MDS nurse stated MDS assessment is a comprehensive assessment for the care provided to the residents. MDS stated Resident 164 had an order for Apixaban, but it was not documented in the MDS assessment. MDS nurse stated apixaban should have been documented in the MDS so that the MDS reflective of the care that is being provided to the resident, total care. During an interview on 10/18/2024, at 5:20 P.M., with the Director of Nursing (DON), the DON stated MDS assessments need to be completed accurately and completely to determine the level of care the resident needs, coordinate care based on the assessment and ultimately help in formulating a plan of care that is resident specific. During a review of facility's policy and procedures dated 9/2023 title Resident Assessment, indicated, A comprehensive assessment of every resident need is made at intervals designated by OBRA and PPS requirements . 1. The resident assessment coordinator is responsible for ensuring that the interdisciplinary team conducts timely and appropriate resident assessments . During a review of the Centers for Medicare and Medicaid Services (CMS- a federal agency that provides health coverage to millions of people) Resident Assessment Instrument (RAI) dated 10/2024, title High risk drug classes, indicated, check if an anticoagulant medication was taken by the resident at any time during the 7 day look back period (or since admission/entry or reentry if less than 7 days) .

Based on observation, interview, and record review, the facility failed to ensure Certified Nursing Assistant 6 (CNA 6) was trained and had the appropriate qualifications to serve as a qualified therapeutic recreation specialist or an activities professional to support the physical, mental, and psychosocial well-being of 57 of 57 residents in the facility. This deficient practice had the potential to result in a decline in the physical, mental, and psychosocial well-being the 57 residents. Findings: During an observation and concurrent interview on 10/16/2024 at 11:35 AM., CNA 6 was observed seated in the facility communal dining area monitoring residents as the residents watched Television. During an interview CNA 6 stated CNA 6 was covering for the Activities Director (AD) who was on vacation starting 10/15/2024. CNA 6 stated it was CNA 6's first day covering for the AD and that CNA 6 was trained on resident activities. CNA 6 stated CNA 6 was handed a guide (name not provided) on which activities to conduct with the residents. During an interview on 10/16/2024 at 11:38 AM., the Director of Staff Development (DSD), stated CNA 6 was covering activities for the AD who was currently on vacation. The DSD also stated CNA 6 had not received training on how to conduct any activities with/for the residents. During an interview on 10/18/2024 at 4:59 PM., the Director of Nursing (DON) stated the AD was on vacation since 10/15/2024. The DON stated activities help to keep residents' minds active and from further decline. The DON stated CNA 6 had worked with the AD in the past (unable to provide dates). The DON stated the DON did not know where the activity logs were kept. The DON stated the (DON) searched for the activities but could not find them. During a review of the facility's undated AD Job Description indicated, the AD, is responsible for planning, organizing, developing, and directing the overall operations of the Activities Department, responsible for directing and managing an on-going program of activities designed to meet in accordance with assessments, the interest, and the physical, mental, and psychosocial well-being of all Residents. Qualifications include: Associate degree or two years of college level course experience required. Must be a qualified therapeutic recreation specialist or an activities professional who is licensed by the appropriate state and is eligible for said certifications or Must have a minimum of 2 yrs experience in a social or recreation program within the last 5 years .

Based on observation, interview, and record review, the facility failed to properly prevent and control the spread of COVID-19 (Coronavirus disease, a severe respiratory illness caused by virus and spread from person to person) in accordance with the facility's infection prevention and control program (IPCP) policies and follow infection control practices by failing to: 1. Ensure that all residents with COVID-19 infection confirmed by testing, or those residents who are recovering from COVID are placed in a dedicated COVID-19 positive unit (red zone, area in the facility for residents confirmed with COVID-19 infection). 2. Ensure there was a designated breakroom for staff working in the red zone. 3. Ensure that Resident 200 and Resident 201 who are in a red zone room did not share the same restroom with Resident 208 who is in a green zone (area in the facility for non-COVID-19 resident) room. 4. Ensure staff (Licensed Vocational Nurse 1 (LVN 1), Licensed Vocational Nurse (LVN 2), Certified Nursing Assistant 14 (CNA 14), Physical Therapist 1 (PT 1) and Occupational Therapist 1 (OT 1) follow proper personal protective equipment (PPE, specialized clothing or equipment worn by an employee for protection against infectious materials) protocol prior to entering and exiting a red zone room. 5. Ensure isolation rooms for yellow (area in the facility for residents under investigation for possible COVID-19 infection) and red zones have isolation signages and available PPE isolation carts right outside the door for staff to use for three out of 13 isolation rooms. 6. Ensure staff were wearing proper PPE or fit-tested respirator (mask that protect used by filtering out contaminants in the air) in the facility. 7. Ensure that the trash bags were properly discarded inside the trash bin of Residents 10, 1, and 17's room. 8. Ensure that soiled face shields were properly discarded and not placed on top of PPE isolation cart. 9. Ensure the soiled disposable isolation gown was properly discarded after used. 10. Ensure all staffs were screened prior to entering the facility. 11. Ensure facility staff was properly bagging dirty linen before using the laundry chute (a vertical shaft in a building down which dirty clothes and linens can be dropped, to land in a laundry area on a lower floor) per facility policy. These deficient practices resulted in a total of 27 residents tested positive for COVID-19 within the span of 11 days and have the potential to spread COVID-19 to the other 21 residents, staff, and visitors. On 11/19/2022 at 6:28 p.m., the State Agency (SA) called an Immediate Jeopardy (IJ) Situation (a situation in which the provider's non-compliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment or death of a resident or residents) for not able to established a facility-wide systems for the prevention and control of COVID infections of residents which likely to cause serious complications or death to the 48 in-house residents, staff, and visitors. The facility's Administrator, Director of Nursing (DON) and Infection Preventionist (IPN) were notified of the findings. On 11/23/2022 at 5:31 p.m., the IJ was removed in the presence of the Administrator, DON, IPN, and Registered Nurse Consultant (RNC) after an on-site verification of the implementation of the acceptable IJ Removal Plan (a plan with interventions to correct the deficient practices) through observation, interview, and record review. The facility's acceptable IJ Removal Plan included the following: 1. Facility moved Covid positive patients to designated area to reduce the risk of spread (Moving room [ROOM NUMBER] to room [ROOM NUMBER] in back hallway). Following this room move - all Covid positive patients will be in one hallway with access to isolation staff break room. This was completed at 8:00 p.m. on 11/19/2022 by IPN. 2. Facility created an isolation staff break room in room [ROOM NUMBER] (private bathroom included) - in back hallway immediately next to Covid designated area in facility. This was completed at 8 p.m. on 11/19/2022 by IPN. 3. Moved room [ROOM NUMBER] to room [ROOM NUMBER] solved any issue of bathrooms potentially being shared between isolation rooms and non-isolation rooms. This was completed at 8 p.m. on 11/19/2022 by IPN. 4. All staff in-services provided by DON and IPN as follows: 11/19/2022: Evening (PM) Shift - 7:30 p.m. 11/20/2022: Night (NOC) Shift - 7 a.m. 11/20/2022: Morning (AM) Shift - 7a.m. 11/20/2022: All Departments - 1:30 p.m. Topic: PPE usage in isolation rooms. All working staff members will be in-serviced as they return to work until all are completed. A staff checklist will be used to keep track. IPN and DON will complete in-services. Shift Supervisor will in-service in their absence as needed. Registry staff will be in-serviced on an on-going basis until Covid outbreak has ended. 5. Signage has been corrected and updated: isolation room signage updated, donning ( put on) and doffing (remove) signage updated, break room and dining room capacity signage updated. This was completed at 3 p.m. on 11/20/2022 by IPN. 6. All staff in-services provided by DON and IPN as follows: 11/19/2022: PM Shift - 7:30 p.m. 11/20/2022: NOC Shift - 7 a.m., 11/20/2022: AM Shift - 7 a.m., 11/20/2022: All Departments - 1:30 p.m. Topic: PPE usage in proper masking with N95 and donning/doffing of PPE. All working staff members will be in-serviced as they return to work until all are completed. A staff checklist will be used to keep track. IPN and DON will complete in-services. Shift Supervisor will in-service in their absence as needed. Registry staff will be in-serviced on an on-going basis until Covid outbreak has ended. 7. Housekeeping staff in-service provided by Maintenance Director/Supervisor (MS) as follows: 11/19/22: PM Shift - 7:30 p.m. 11/20/22: AM Shift - 7 a.m. Topic: Proper disposal of PPE trash bins located in the Covid positive patient rooms. CNA to leave PPE trash bin outside the room in the patio area to be picked up by housekeepers at 6 a.m., 3p.m., and 9 p.m., covering all three shifts. All working housekeeping staff members will be in-serviced as they return to work until all are completed. A staff checklist will be used to keep track. MS will complete in-services. 8. All staff in-services provided by DON and IPN as follows: 11/19/22: PM Shift - 7:30 p.m. 11/20/22: NOC Shift - 7 a.m. 11/20/22: AM Shift - 7 a.m. 11/20/2022: All Departments - 1:30 p.m. Topic: Face shield usage and proper disposal of PPE. All working staff members will be in-serviced as they return to work until all are completed. A staff checklist will be used to keep track. IPN and DON will complete in-services. Shift Supervisor will in-service in their absence as needed. Registry staff will be in-serviced on an on-going basis until Covid outbreak has ended. 9. All staff in-services provided by Director of Nursing and Infection Preventionist as follows: 11/19/22: PM Shift - 7:30 p.m. 11/20/22: NOC Shift - 7 a.m. 11/20/22: AM Shift - 7 a.m. 11/20/2022: All Departments - 1:30 p.m. Topic: Proper disposal of PPE All working staff members will be in-serviced as they return to work until all are completed. A staff checklist will be used to keep track. IPN and DON will complete in-services. Shift Supervisor will in-service in their absence as needed. Registry staff will be in-serviced on an on-going basis until Covid outbreak has ended. 10. Facility Visitation Policy: Outside visits for non-isolated residents when possible and if weather permits, and taking each isolated patient visit case-by-case and trying to accommodate if possible, being done safely and outside if possible. This is being followed by our weekend and full-time Activities Coordinator 1 (AC 1) and Activities Coordinator 2 (AC 2). Communicated out to family members via text message through Repticity kiosk (real-time mass text communications) at 9 p.m. on 11/19/2022. Information was also posted in the front. 11. IPN, serving as Director of Staff Development (DSD)/IP and DSD serving as Treatment Nurse (TN)/backup IPN will immediately begin serving in different roles. IPN will immediately be the full-time IPN - 40 hours a week as of 11/20/2022. TN/DSD was previously a treatment nurse but was currently transitioning/training two newly trained treatment nurses. TN/DSD will take over any DSD duties with assistance from the DSD assistant and serve as backup IPN as needed as of 11/20/2022. 12. Administrator sent out a message of the Covid cases and Covid outbreak to all residents and responsible party contacts located in PointClickCare (PCC - cloud-based healthcare software provider) for residents through Repticity kiosk (The Repticity App is exclusively designed for skilled nursing, senior living, assisted living facilities and hospitals. It works in conjunction with a digital visitor kiosk that replaces your pencil and paper visitor sign in sheet with thermal temperature detection for Covid-19) at 9 p.m. on 11/19/2022 ensuring that all have been communicated of any Covid cases within the Facility. Cross Reference: F836, F881, F882, F885, F886, and F888 Findings: 1.During a review of the facility's census, dated 11/18/2022, the census indicated the facility had 48 in-house residents that included nine residents housed in the yellow zone and 16 residents housed in the red zone. During an observation on 11/16/2022 at 6:49 p.m., the facility did not have a clear designation between the eight red zone rooms (room [ROOM NUMBER], 14, 15, 16, 19, 20, 25 and 26) and five yellow zone rooms (room [ROOM NUMBER], 22, 23, 29 and 32). The red zone rooms are scattered in the facility, with yellow zone and green zone rooms in between. In addition, there are no clear signages posted in the facility where the red zone rooms start and ends. During an interview with IPN on 11/19/2022 at 9:43 a.m., IPN stated that it is necessary to have a clear designation between the red zone, the yellow zone, and the green zone. The IPN added This enables the facility staff to distinguish the isolation rooms for proper infection control, to contain the infection, and prevent further spread. A review of facility's policy and procedures (P&P), titled COVID-19 Facility Mitigation Management Plan (a plan to reduce loss of life and impact of COVID-19 in the facility), updated on 1/14/2022, indicated that this mitigation plan is credible attempt to manage as many aspects of the pandemic and regualtions as possible at the current time. The P&P also indicated as a measure to limit the movement of Healthcare Staff and conserve PPE, the facility has designated certain rooms/unit for the purpose of admitting known or suspected COVID-19 patients. Rooms 14, 15, 16, 19, 20, 23 are for confirmed positive COVID-19 patients or red zone; Rooms 4, 6, 8, 9, 10, 11, 12, 18, 21, 22, 25, 26, 27 are yellow zones. A review of the CDC Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic updates as of 9/23/2022, indicated Facilities could consider designating entire units within the facility, with dedicated HCP, to care for patients with [CONDITION(S)]-CoV-2 (virus that cause COVID) infection when the number of patients with [CONDITION(S)]-CoV-2 infection is high. On 11/18/2022 the facility have 16 residents positive for COVID. 2a. During a concurrent observation and interview on 11/19/2022 at 11:19 a.m. with Certified Nursing Assistant 5 (CNA 5) and Certified Nursing Assistant 6 (CNA 6) in employee break room was observed. CNA 5 and CNA 6 were observed eating together in one table. CNA 5 stated she was assigned to red zone and CNA 6 was assigned on both green and yellow zone. CNA 5 stated that the facility did not provide red zone staff with a separate break room. During a concurrent observation and interview on 11/19/2022 at 11:47 a.m. with CNAs 7 and 8 in employee break room was observed. CNA 7 and CNA 8 were observed eating together in one table. CNA 7 stated that she is assigned in red zone. CNA 8 stated she was assigned in green zone. 2b. A review of the facility's daily assignment schedule, dated, 11/18/2022, indicated CNA 4 was assigned with residents in the red zone room and CNA 1 was assigned with residents in the green zone room. During an interview with CNA 4 on 11/18/2022 at 10:23 p.m., CNA 4 stated that facility did not have a designated break room for staff that works in the red zone. CNA 4 verified that on 11/18/2022, from 7 p.m. to 7:30 p.m., CNA 4 was sharing the break room with CNA 1. During an interview with CNA 1 on 11/18/2022 at 11:02 p.m., CNA 1 stated and verified having lunch with CNA 4 since there was no other area to eat separately. During an interview with the IPN on 11/19/2022 at 9:43 a.m., IPN stated that per facility policy, red zone staff should have a designated break room. IPN verified available empty room in the facility and added they can assign a breakroom for the staff who works in the red zone. A review of facility's policy and procedures, titled COVID-19 Mitigation Management Plan, updated on 1/14/2022, indicated that as a measure to limit the movement of healthcare staff and conserve PPE, the facility has designated certain rooms/unit for the purpose of admitting known or suspected COVID-19 patients. It further stated that all dedicated healthcare staff will be assigned to care for suspected or confirmed COVID-19 residents during their shift in the designated COVID-19 rooms/unit. 3. A review of Resident 201's Admission Record indicated the facility admitted Resident 201 on 11/11/2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Minimum Data Set (MDS-standardized screening and assessment tool for all residents of long-term care facilities), dated 11/17/2022, indicated Resident 201's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision-making were intact and required limited assistance from staff for activities of daily living (ADLs- bed mobility, transfer, dressing, toilet use, and personal hygiene). A review of Resident 201's laboratory test result, collected on 11/17/2022, indicated Resident 201 was confirmed positive for COVID-19 with symptoms of cough. During an interview with Resident 201 on 11/18/2022 at 8:20 p.m., Resident 201 stated she tested positive for COVID-19 and symptomatic with cough and congestion. Resident 201 stated, she gets up and uses the restroom for bowel (stool) and bladder (urine) with assistance from staff and they don't clean or disinfect the restroom after use. Resident 201 further stated, she's aware that she shares the restroom with another resident next door. A review of Resident 200's Admission Record indicated the facility admitted Resident 200 on 11/09/2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the MDS dated [DATE], indicated Resident 200's cognitive skills for daily decision-making were intact and required limited assistance from staff for ADLs- bed mobility, transfer, toilet use, and personal hygiene. A review of Resident 200's Situation, Background, Assessment, Recommendation (SBAR- a technique that can be used to facilitate prompt and appropriate communication), dated 11/15/2022, indicated Resident 200 was confirmed positive for COVID-19 with symptoms of non-productive cough. During an interview with Resident 200 on 11/18/2022 at 8:12 p.m., Resident 200 stated she tested positive for COVID-19 and symptomatic with cough. Resident 200 stated, she gets up and uses the restroom for bowel and bladder with assistance from staff and she don't know if staff clean or disinfect the restroom after use. Resident 200 further stated, she's aware that she shares the restroom with her roommate another resident next door. A review of Resident 208's Admission Record indicated the facility admitted Resident 208 on 11/02/2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the MDS dated [DATE], indicated Resident 208's cognitive skills for daily decision-making were moderately intact and required limited assistance from staff for ADLs- transfer, toilet use, and personal hygiene. A review of Resident 208's Care Plan, indicated Resident 208 is at risk for infection related to COVID-19 with interventions to restrict visitors, staff, and residents from being at the facility when presenting with COVID-19 signs or symptoms. An interview with Resident 208 on 11/18/2022 at 6:50 p.m., Resident 208 stated she gets out of bed and uses the restroom with assistance from staff. Resident 208 further stated, she's aware that she shares the restroom with the residents next door, sometimes she doesn't wear surgical mask or face covering because she forgets. During an observation of Resident 200 and 201's restroom on 11/18/22 at 8:31 p.m., the restroom is being shared with Resident 208 who is in a green zone room. The restroom has a durable medical equipment (DME) raised toilet seat and does not have any cleaning and disinfectant supply available for staffs to use. During an interview with IPN on 11/19/2022 at 9:43 a.m., IPN stated and confirmed all three residents, Resident 201, 200 and 208 all shares the same restroom. IPN stated, Resident 201 and Resident 200 should not be sharing the restroom with Resident 208 as this puts Resident 201 and 200 at risk of spreading COVID-19 infection to Resident 208. A review of facility's P&P, titled Cleaning and Disinfection of Resident-Care Items and Equipment, revised October 2019 indicated, DME must be cleaned and disinfected before reuse by another resident. A review of the CDC Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic updates as of 9/23/2022, indicated all non-dedicated, non-disposable medical equipment used for that patient should be cleaned and disinfected according to manufacturer ' s instructions and facility policies before use on another patient. 4a. A review of Resident 26's Admission Record indicated the facility originally admitted Resident 26 on 10/7/2022 and was readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the MDS dated [DATE], indicated Resident 26's cognitive skills for daily decision-making were intact and required limited assistance from staff for ADLs. A review of Resident 26's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 26's laboratory test result dated 11/15/2022, indicated resident was confirmed positive for COVID-19. A review of Resident 40's Admission Record indicated the facility admitted Resident 40 on 10/17/2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the MDS dated [DATE], indicated Resident 40's cognitive skills for daily decision-making were intact and required extensive assistance from staff for ADLs. A review of Resident 40's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 40's laboratory test result dated 11/15/2022, indicated resident was confirmed positive for COVID-19. A review of Resident 154's Admission Record indicated the facility admitted Resident 154 on 11/2/2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the MDS dated [DATE], indicated Resident 154's cognitive skills for daily decision-making were intact and required limited assistance from staff for ADLs. A review of Resident 154's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 154's laboratory test result dated 11/15/2022, indicated resident was confirmed positive for COVID-19. During a concurrent interview with Resident 154 and Registered Nurse 2 (RN 2) on 11/22/2022 at 11:50 a.m., observed Physical Therapist 1 (PT 1) and Occupational Therapist 1 (OT 1), wearing only an N95 mask and face shield, entered Resident 40 and 154's room from the back door of the patio area and ran exiting the residents' room when seen by the surveyor. RN 2 stated that both rehabilitation staff were working in the red zone and needing to go on their lunch break. During an interview with Resident 154, on 11/22/2022 at 12:15 p.m., Resident 154 stated that staff was using her room as the exit for the past days and she was not able to sleep. During a concurrent interview with the Director of Rehabilitation (DOR) on 11/22/2022 at 12:33 p.m., DOR stated that PT 1 and OT 1 was on their lunch break and were unable to interview. DOR stated that PT 1 and OT 1 had completed Resident 26's treatment and unable to exit back from the same room because Resident 26 was symptomatic and PT 1 and OT 1 were uncomfortable going back. DOR stated that PT 1 and OT 1 decided to go to Resident 40 and 154's room instead to exit. DOR also stated and verified that the Director of Nursing (DON) had instructions that staff does not need to don (put on) a gown when entering a red zone if only passing by the room. 4b. During a concurrent observation and interview with the Licensed Vocational Nurse 2 (LVN 2) on 11/22/2022 at 12:08 p.m., observed LVN 2 exited Resident 209 and Resident 26's back door to the patio wearing full PPE (with gown and gloves) and walked over to the sink area. LVN 2 stated, he was going to doff his PPE outside the room but he wanted to walk over to the sink so he can discard his PPE to the trash bin next to the sink and wash his hands after. LVN 2 stated, both residents are COVID-19 positive, and they are in isolation. A review of Resident 209's Admission Record indicated the facility originally admitted Resident 209 on 11/22/2022 and was readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the MDS dated [DATE], indicated Resident 209's cognitive skills for daily decision-making were severely impaired and required extensive assistance from staff for ADLs. A review of Resident 209's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 26's Admission Record indicated the facility originally admitted Resident 26 on 10/7/2022 and was readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the MDS dated [DATE], indicated Resident 26's cognitive skills for daily decision-making were intact and required limited assistance from staff for ADLs. A review of Resident 26's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 26's laboratory test result dated 11/15/2022, indicated resident was confirmed positive for COVID-19. During an interview with the ADON on 11/22/2022 at 1:19 p.m., ADON stated that staffs should not wear their PPE outside the room and immediately doff PPE at the exit door. ADON stated, this puts everyone at risk of spreading the infection throughout the facility. 4c. During a concurrent observation and interview with Certified Nursing Assistant 14 (CNA 14) on 11/23/2022 at 2:27 p.m., CNA 14 was observed exiting Resident 7 and Resident 153's back door to the patio wearing full PPE (with gown and gloves) and was about to enter the room next door. CNA 14 stated, she helped Resident 7 to the bathroom and need to toss the linen to the dirty linen bin, and she doesn't know if should be doffing in the room or outside. CNA 14 stated, both residents tested positive with COVID-19 and they are in the red zone room. A review of Resident 7's Admission Record indicated the facility admitted Resident 7 on 10/24/2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the MDS dated ,d+[DATE], indicated Resident 7's cognitive skills for daily decision-making were moderately impaired and required limited to extensive assistance from staff for ADLs. A review of Resident 7's Care Plan initiated on 11/19/2022 for risk for worsening signs and symptoms of infection due to positive result of COVID-19 test with interventions including observe transmission-based precautions - contact, droplet, airborne and use of indicated PPE. A review of Resident 153's Admission Record indicated the facility originally admitted Resident 153 on 11/8/2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the MDS dated [DATE], indicated Resident 153's cognitive skills for daily decision-making were intact and required limited assistance from staff for ADLs. A review of Resident 153's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview with DON on 11/23/2022 at 3:10 p.m., DON stated staffs should be doffing inside the room prior to exiting a red zone room. DON stated, they will do an in-service and education to the staffs to make sure they are aware of the guidelines on proper PPE protocol. 4d. A review of Resident 153's Admission Record indicated the facility admitted Resident 153 on 11/18/2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the MDS dated [DATE], indicated Resident 153's cognitive skills for daily decision-making were intact and required limited assistance from staff for ADLs- bed mobility, dressing, toilet use, and personal hygiene. A review of Resident 153's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 153's laboratory test result dated 11/18/2022, indicated resident was confirmed positive for COVID-19. During an observation on 11/18/2022 at 7:14 p.m., no isolation signage and no PPE cart was observed right outside Resident 153's room. During a concurrent observation and interview with the Licensed Vocational Nurse 1 (LVN 1) on 11/18/2022 at 7:24 p.m., observed LVN 1 entered Resident 153's room wearing only an N95 mask and an eye protection. LVN 1 stated that as per her knowledge, Resident 153's room did not need donning (putting on) a PPE prior to entering, therefore, no need for an isolation signage and PPE cart since Resident 153 was only in a yellow zone, not in the red zone room. During an interview with the DON on 11/18/2022 at 9:19 p.m., DON stated that Resident 153 was supposed to be in the yellow zone room due to exposure to another resident that tested positive with COVID-19. DON also stated that donning (putting on) a gown and gloves must be done before entering a yellow zone room and removing it prior to exiting the room. During an interview with the IPN on 11/19/2022 at 9:43 a.m., IPN stated that upon entering a yellow and red zone rooms, all staff must don PPE and doff (remove) before exiting the room. IPN also stated and verified Resident 153 was confirmed positive with COVID-19 starting 11/18/2022 at around 3-4 p.m. IPN stated that she was supposed to put the signage and the PPE cart for Resident 153's room but did not and unsure if it was communicated to the licensed staff. IPN stated that it was important to have the proper isolation signage and PPE cart in an isolation room, so staff are aware of the infection due to high risk for exposure. A review of facility's P&P, titled, COVID-19 Facility Mitigation Management Plan, updated 1/14/2022, indicated that residents who test positive for COVID-19 should be isolated. P&P also indicated that signs are posted immediately outside resident rooms indicating appropriate infection control and prevention precautions and the required PPE The same P&P also indicated that the IPN will ensure necessary PPE is immediately available outside the resident room. A review of facility's P&P, titled, Suspected/Confirmed COVID-19 Outbreak Care Protocol, undated, indicated initiating an isolation precaution using PPE prior to entering the room. A review of the CDC Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic updates as of 9/23/2022, indicated health care personnel (HCP) who enter the room of a patient with suspected or confirmed [CONDITION(S)]-CoV-2 (virus that cause COVID) infection should adhere to Standard Precautions (a set of infection control practices used to prevent transmission of diseases that can be acquired by contact with blood, body fluids, non-intact skin and mucous membranes) and use a National Institute for Occupational Safety and Health (NIOSH)-approved particulate respirator with N95 filters or higher , gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front and sides of the face). 5a. A review of Resident 105's Admission Record indicated the facility admitted the resident on 10/28/2022, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 105's MDS dated [DATE], indicated Resident 105 was alert and able to verbalize needs. During a concurrent interview and observation with Resident 105 on 11/18/2022 at 7:12 p.m , outside the room. No isolation signage regarding resident is on green, yellow, or red zone. During an interview with Resident 105, he had been in yellow zone for few days because he was exposed to a COVID 19 resident. Resident 105 stated that the staff was still using his room as a shortcut and continued to enter his room without any PPE. 5b. During an observation of the facility on 11/18/2022 at 6:49 p.m., at the room where Resident 10, Resident 17, and Resident 1 lives, no isolation signages observed outside the room. A review of the Census indicated the room where Resident 10, Resident 17, and Resident 1 lives is an isolation yellow zone room. A review of Resident 10's Admission Record indicated the facility admitted Resident 10 on 2/13/2020 and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the

Based on observation, interview, and record review, the facility failed to ensure food storage in the kitchen area were free of roaches to prevent foodborne illness for 44 of 44 residents residing in the facility. 1. Suppress cockroach population by maintaining an effective pest control service in the kitchen for sanitary food preparation. 2. Follow up with the Registered Dietitian monthly report findings of cracked flooring that had a potential to allow the entry of roaches into the kitchen food starage area. 3. Ensure food items were labeled and stored according to the facility's policy and procedure. 4. Ensure food temperatures were checked consistently prior to serving. For roaches to thrive, they need three components: water (moisture), food and temperature. The facility's wet floor provided the moisture that was needed to keep them thriving. The dirty food storage area and kitchen environment including cracks in the walls and floors provided both food and safe places to harbor and the warm kitchen conditions was the final conditions encouraging the roaches to thrive. The saliva, droppings and decomposing bodies of roaches contain proteins known to trigger allergies [REDACTED]. Roaches are also capable of mechanically transmitting disease causing organisms such as salmonella, and E. coli that can cause food poisoning. Nursing home residents risk serious complications from food poisoning as a result of their compromised health status. Symptoms of food borne illness included diarrhea, vomiting, headaches, fever, and confusion, loss of appetite, abdominal cramping and pain. When those conditions persist they can lead to dehydration and may require hospitalization and in some cases death. On (MONTH) 10, (YEAR) at 5:30 p.m., an Immediate Jeopardy (IJ, a situation in which the provider's non-compliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death to a resident) was called cross refer F925, in the presence of the facility Administrator and Director of Nursing. An unacceptable plan of action was submitted to the survey team on (MONTH) 10, (YEAR) at 7:30 p.m. An acceptable plan of action was submitted to the survey team on (MONTH) 11, (YEAR), at 4:02 p.m., validated through observation, interview, and record review to verify facility compliance. The Immediate Jeopardy was abated on (MONTH) 11, (YEAR) at 4:03 p.m. in the presence of the Administrator, when the facility implemented adequate measures to irradiate and prevent infestation of roaches, provide a sanitary kitchen and food storage area and was able to demonstrate knowledge of services necessary to ensure effective pest control management. Findings: A review of the facility's Resident Census and Condition of Residentsform CMS 672, indicated no residents are feed by tube feeding of 44 residents in the facility. On (MONTH) 10, (YEAR) at 8:45 a.m., during the tour of the kitchen, the dry storage room was soiled with food debris and sticky material on the floor. There was an unlabeled half bag of carrots in the freezer, 2 bags of half used sandwich bread, one half used bag of hot dog buns that was in the refrigerator. Spices that included nutmeg that was dated (MONTH) 15, (YEAR), ground [MEDICATION NAME] was dated (MONTH) 14, (YEAR), ground all spices was dated (MONTH) 25, (YEAR), ground thyme was dated (MONTH) 10, (YEAR), whole bay leaf was dated (MONTH) 3, (YEAR), and granulated garlic had a delivery date of (MONTH) 17, (YEAR) and an open date of (MONTH) 25, (YEAR) were observed on the kitchen shelves. On (MONTH) 10, (YEAR) at 9:00 a.m., during an interview, the Dietary Service Supervisor (DSS) stated that the dietary staff should have labeled the packages when it was opened. DSS also stated he was responsible for checking the spices for expiration dates and rotating the spices. On (MONTH) 10, (YEAR) at 9:40 a.m., upon further observation of the kitchen, two live roaches were observed crawling under the dishwasher area. One roach trap was found under the dishwasher area that was dated (MONTH) 9, (YEAR). Inside the trap was one live roach and 15 different sized dead roaches. Cracked tiles were found under the dishwashing area with standing water pooled in the cracks, cracks in the walls and around the pipe by the dishwashing area allowed for pests and roaches to enter the kitchen. There were cracked tiles were found by the dry storage area and in the storage area allowing for pests and roaches to have shelter and to proliferate. There were gaps on the bottom of the door frame, and the base board was not attached to the wall by the freezer allowing for pests and roaches to enter the kitchen, to have shelter and to proliferate. On (MONTH) 10, (YEAR) at 9:45 a.m., during an interview, Dietary Cook (DC) and Dietary Aide 1 (DA 1) stated they had never seen any roaches in the kitchen. During a concurrent interview, Maintenance Supervisor (MS) stated traps were installed by pest control agent on (MONTH) 9, (YEAR). Traps were for any types of animals. The MS also stated that he has been working at the facility for about three months and did not know when first trap was put in place. The MS further stated that there was no roaches or rodents problem and the pest control agent came on (MONTH) 9, (YEAR). The MS observed one live roach in the trap and stated that this was the first time he had seen a live roach. A review of Pest Control Company 1 (PCC 1) contract dated (MONTH) 15, (YEAR), indicated to cover the interior and exterior areas weekly for 52 services a year. The general pest services included the treatment of [REDACTED]. A review of the PCC 1 Service Summary report indicated the following: 1. From (MONTH) 3, (YEAR) through (MONTH) 16, (YEAR), the pest control company was providing services on a weekly basis and no evidence of pest activity was found. The report indicated the targeted pest included ants, spiders, and roaches. 2. The PCC 1 Service Summary report indicated the targeted pest included ants, spiders, roaches, rats, and mice for (MONTH) 30, (YEAR) and (MONTH) 11, (YEAR) and no evidence of pest activity was found. 3. On (MONTH) 6, 20, 27, (YEAR), PCC 1 Service Summary report indicated the targeted pest included ants, spiders, and roaches for and no evidence of pest activity was found. 4. From (MONTH) 30, (YEAR) through (MONTH) 9, (YEAR), the PCC 1 was providing services on a weekly basis but no evidence of pest activity was found. The report indicated the targeted pest included roaches. On (MONTH) 10, (YEAR) at 2:50 p.m., the survey team and the administrator attempted to call the PCC 1, to no avail. On (MONTH) 11, (YEAR) at 8:45 a.m., the Administrator stated that it was concerning that the pest control agent and the Maintenance Supervisor (MS) did not report any pest activity after placing traps on a weekly basis. A review of PCC 2's Initial Inspection Observation report dated (MONTH) 11, (YEAR), indicated the kitchen had evidence of German roach activity. The recommendation included to seal all gaps and cracks in the tiles along baseboards to reduce harborage spots, repair/replace any broken tiles, remove food and debris from floors, counters, drains and equipment, remove any standing water, keep drains clean and clear of debris. A review of the Registered Dietitian's Sanitation and Food Safety Checklist for the month of January, February, April, May, June, July, October, (MONTH) and (MONTH) of (YEAR), indicated cracked in floor and needs repair. The report also indicated that all flooring was not in place (cracked, chipped, or missing). On (MONTH) 11, (YEAR) at 11:30 a.m., during an interview, the Administrator stated that some of the findings on the Sanitation and Food Safety Checklist were not fixed. No other roaches were observed during subsequent checks to the kitchen on (MONTH) 11, (YEAR) from 3:00 p.m. to 3:30 p.m. All the walls and floor cracks had been repaired and sealed. A review of the Daily Food Temperatures Log indicated the following: 1. (MONTH) 9, (YEAR): mechanical soft entrée, puree entrée, vegetable, puree vegetable for dinner did not have a temperature recorded and were documented as cold plate. 2. (MONTH) 23, (YEAR): puree vegetable for dinner did not have a temperature recorded. 3. (MONTH) 25, (YEAR): puree eggs for breakfast did not have a temperature recorded. 4. (MONTH) 26, (YEAR): puree toast for breakfast did not have a temperature recorded. 5. (MONTH) 27, (YEAR): puree toast for breakfast, salad and puree starch for lunch did not have a temperature recorded. 6. (MONTH) 6, (YEAR): there was a temperature that was record as 36 degrees Fahrenheit, however, there was no soup on the menu for dinner. 7. (MONTH) 15, (YEAR): puree pancake/French toast for breakfast and mechanical soft entrée did not have a temperature recorded. 8. (MONTH) 16, (YEAR): juice for breakfast, mechanical soft entrée, puree vegetable and dessert for dinner did not have a temperature recorded. On (MONTH) 16, (YEAR) at 12:40 p.m., during an interview, RD 1 asked DA 2 if the temperature for the dessert was checked and DA 2 stated that he did not check the temperature. At 12:42 p.m., during a follow up interview on the same day, RD 2 stated the food temperatures should have been checked prior to serving. On (MONTH) 17, (YEAR) at 2:17 p.m., during an interview, the Administrator stated that the Quality Assessment and Assurance (QAA- a review for quality of care and quality of life) committee was not aware of roaches in the facility and should have been aware. He also stated the staff did not notice any activity in the facility. Administrator stated he did not know the pest control company was coming on a weekly basis prior to August. He also stated that it did not make sense for the pest control to come on a weekly basis when there was no pest activity found. The Administrator also stated the RD's recommendation to fix the cracks in the kitchen was not discussed in the QAA meeting. A review of the facility's undated policy and procedure titled, Sanitation and Infection Control, indicated pest control is designed to maintain a sanitary environment which prevents contamination, transmission or spread of disease by insects or rodents. The kitchen will be kept clean, free from litter and rubbish, protected from rodents, roaches, flies and other insects. Store food properly to eliminate food sources for pests. A review of another facility's undated policy and procedure titled, Storage of Food and Supplies, indicated food and supplies will be stored properly and in a safe manner. Store all food and supplies at least 18 inches from the ceiling for fire sprinkler clearance. All food will be dated with month, day and year. All food products will be used per the times specified in the Dry Food Storage Guidelines. According to the facility's Dry Goods Storage Guidelines, indicated opened ground spices can be stored on the shelf for one year.

Based on observation, interview, and record review, the facility failed to prevent the infestation of roaches in the emergency food storage area and kitchen for 44 of 44 residents in the facility when the facility failed to: 1. Suppress cockroach population by maintaining an effective pest control service in the emergency food storage area and in the kitchen. 2. Follow up with the Registered Dietitian the monthly report findings of cracked flooring in the kitchen that allowed for the entry of pests and roaches in the kitchen. 3. Maintain the kitchen in a sanitary manner. For roaches to thrive, they need three components: water (moisture), food and temperature. The facility's wet floor provided the moisture that was needed to keep them thriving. The dirty food storage area and kitchen environment including cracks in the walls and floors provided both food and safe places to harbor and the warm kitchen conditions was the final conditions encouraging the roaches to thrive. The saliva, droppings and decomposing bodies of roaches contain proteins known to trigger allergies [REDACTED]. Roaches are also capable of mechanically transmitting disease causing organisms such as Staphylococcus spp., Streptococcus spp., [MEDICAL CONDITION] virus, and coliform bacteria, salmonella, E. coli that can cause food poisoning. Nursing home residents were at risk for serious complications of food borne illness as a result of their compromised health status. Symptoms of food borne illness included diarrhea, vomiting, headaches, fever, and confusion, loss of appetite, abdominal cramping and pain. When those conditions persist they can lead to dehydration and may require hospitalization and in some cases death. On (MONTH) 10, (YEAR) at 5:30 p.m., an Immediate Jeopardy (IJ, a situation in which the provider's non-compliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death to a resident) was called cross refer F812, in the presence of the facility Administrator and Director of Nursing. An unacceptable plan of action was submitted to the survey team on (MONTH) 10, (YEAR) at 7:30 p.m. An acceptable plan of action was submitted to the survey team on (MONTH) 11, (YEAR), at 4:02 p.m., validated through observation, interview, and record review to verify facility compliance. The Immediate Jeopardy was abated on (MONTH) 11, (YEAR) at 4:03 p.m. in the presence of the Administrator, when the facility implemented adequate measures to irradiate and prevent infestation of roaches, provide a sanitary emergency food area and kitchen and was able to demonstrate knowledge of services necessary to ensure effective pest control management. Findings: A review of the facility's Resident Census and Condition of Residents form CMS 672, indicated no residents are feed by tube feeding of 44 residents in the facility. On (MONTH) 10, (YEAR) at 8:45 a.m., during the tour of the kitchen, the floor under the dishwashing area and the dry storage room was soiled with food debris. The dry storage room had sticky material on the floor. Spices that included nutmeg that was dated (MONTH) 15, (YEAR), ground [MEDICATION NAME] was dated (MONTH) 14, (YEAR), ground all spices was dated (MONTH) 25, (YEAR), ground thyme was dated (MONTH) 10, (YEAR), whole bay leaf was dated (MONTH) 3, (YEAR), and granulated garlic had a delivery date of (MONTH) 17, (YEAR), and an open date of (MONTH) 25, (YEAR), were observed on the kitchen shelves. On (MONTH) 10, (YEAR) at 9:00 a.m., during an interview, the Dietary Service Supervisor (DSS) stated he was responsible for checking the spices for expiration dates and rotating the spices. On (MONTH) 10, (YEAR) at 9:40 a.m., upon further observation of the kitchen, two live roaches were observed crawling under the dishwasher area. One pest trap was found under the dishwasher area that was dated (MONTH) 9, (YEAR). Inside the trap was one live roach and 15 different sized dead roaches. Cracked tiles were found under the dishwashing area with standing water pooled in the cracks, cracks in the walls and around the pipe by the dishwashing area allowed for pests and roaches to enter the kitchen. There were cracked tiles were found by the dry storage area and in the storage area allowing for pests and roaches to have shelter and to proliferate. There were gaps on the bottom of the door frame, and the base board was not attached to the wall by the freezer allowing for pests and roaches to enter the kitchen. On (MONTH) 10, (YEAR) at 9:45 a.m., during an interview, Dietary Cook (DC) and Dietary Aide 1 (DA 1) stated they had never seen any roaches in the kitchen. During a interview, the Maintenance Supervisor (MS) stated traps were installed by pest control agent on (MONTH) 9, (YEAR). The MS stated the traps were for any types of animals. The MS also stated he had been working at the facility for about three months but did not know when the first pest trap was put in place. The MS stated there was no roach or rodent problem and the pest control agent came on (MONTH) 9, (YEAR). The MS observed one live roach in the roach trap and stated this was the first time he had seen a live roach. On (MONTH) 10, (YEAR) at 10:15 a.m., during an observation of the Emergency Food Storage Room in the basement in the presence of the DSS, three black round pellets were found on the shelf. Outside of the Emergency Food Storage Room had a brown paper bag on the floor under the shelf. Upon opening the brown paper bag, one live roach crawled out of the bag and was crawling on the floor. The base board plaster was loose onto the side of the wall. During a concurrent interview, DSS stated he will clean the shelf in the Emergency Food Storage Room, threw the brown paper bag away, and let maintenance know about the live roach that was observed. A review of the pest control company 1 (PCC 1) contract dated (MONTH) 15, (YEAR) indicated to cover the interior and exterior areas weekly for 52 services a year. The general pest services included the treatment of [REDACTED]. On (MONTH) 10, (YEAR) at 5:30 p.m., the Administrator stated he was not aware of the infestation of roaches that was identified. On (MONTH) 11, (YEAR) at 8:45 a.m., the Administrator stated that it was concerning that the pest control agent and the Maintenance Supervisor (MS) did not report any pest activity after placing traps on a weekly basis. A review of PCC 2's Initial Inspection Observation report dated (MONTH) 11, (YEAR), indicated the following: 1. In the emergency food storage room, one German roach was found. 2. In the kitchen, evidence of German roach activity. The recommendation included to seal all gaps and cracks in the tiles along baseboards to reduce harborage spots, repair/replace any broken tiles, remove food and debris from floors, counters, drains and equipment, remove any standing water, keep drains clean and clear of debris. 3. In the laundry room, evidence of German roach activity found. The recommendation included to seal all gaps, around all pipes and wires leading into walls. This will help prevent travel through walls. A review of the Registered Dietitian's Sanitation and Food Safety Checklist for the month of January, February, April, May, June, July, October, (MONTH) and (MONTH) of (YEAR), indicated cracked in floor and needs repair. The report also indicated that all flooring was not in place (cracked, chipped, or missing). On (MONTH) 11, (YEAR) at 11:30 a.m., during an interview, the Administrator stated that some of the findings on the Sanitation and Food Safety Checklist were not fixed, such as the flooring. No other roaches were observed during subsequent checks to the kitchen, the emergency food storage room and in the laundry room on (MONTH) 11, (YEAR) from 3:00 p.m. to 3:30 p.m. All the walls and floor cracks had been repaired and sealed. On (MONTH) 17, (YEAR) at 2:17 p.m., during an interview, the Administrator stated that the Quality Assessment and Assurance (QAA-a review for quality of care and quality of life) committee was not aware of roaches in the facility and should have been aware. He also stated the staff did not notice any activity in the facility. Administrator stated he did not know the pest control company was coming on a weekly basis prior to August. He also stated that it did not make sense for the pest control to come on a weekly basis when there was no pest activity found. The Administrator also stated the RD's recommendation to fix the cracks in the kitchen was not discussed in the QAA meeting (to address the roach activity). A review of the facility's undated policy and procedure titled, Sanitation and Infection Control, indicated pest control is designed to maintain a sanitary environment which prevents contamination, transmission or spread of disease by insects or rodents. The kitchen will be kept clean, free from litter and rubbish, protected from rodents, roaches, flies and other insects. Store food properly to eliminate food sources for pests. A review of the facility's undated policy and procedure titled, Storage of Food and Supplies, indicated food and supplies will be stored properly and in a safe manner. Store all food and supplies at least 18 inches from the ceiling for fire sprinkler clearance. All food will be dated with month, day and year. All food products will be used per the times specified in the Dry Food Storage Guidelines. According to the facility's Dry Goods Storage Guidelines, indicated opened ground spices can be stored on the shelf for one year.