Every finding on record at Buena Vista Care Center

Based on observation, interview and record review, the facility failed to meet the dietary prescription of 1 unsampled resident (Resident 129).This failure had the potential for Resident 129 to have health complications.During a review of the facility's Face Sheet (admission record), Resident 129 was admitted to the facility on [DATE] with diagnoses that included Acute Kidney Failure, unspecified (a sudden loss of kidney function).During a concurrent observation and interview on 4/8/26 at 6:18 a.m., with the Dietary Manager (DM) during tray line, the meal ticket for Resident 129 indicated in part Regular, Fluid Restriction 1500 ml Thin Liquids and Renal Diet. The tray was observed with a salt packet, this observation was validated by the DM and stated will double check the dietary prescription.During a concurrent interview and record review on 4/08/26 at 2:15 p.m., with the Dietician (DIT), the dietary order for Resident 129, was reviewed. The Dietary order indicated in part, No added Salt.During a review of Renal Diet 40-60-80 Gram Protein Low Potassium, Low Salt Menu dated 2025, the Renal Diet indicates in part, The diet should also include other restrictions such as potassium, sodium and fluid, low potassium and low salt diet recommended.

Based on interview and record review, the facility staff failed to follow physician orders related to the monitoring of blood glucose levels for one of 24 sampled residents (Resident 11) when there were no documentation to indicate if blood sugar testing was done as ordered on days missed. This failure has the potential to lead to medication error that can lead to severe hypoglycemia (low blood sugar).During a review of the facility's Face Sheet (admission record), Resident 11 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes mellitus([DM] abnormal blood sugar).During a review of Resident 11's Physician Orders (PO), dated 10/6/25, the PO indicated to administer Insulin Glargine solostar pen-injection 100 unit/ml (milliliter). Inject 22 units at bedtime for DM.During a review of Resident 11's Medication Administration Record (MAR), dated 4/26, there was no documentation to show the blood sugar was taken to obtain blood sugar levels for the 9 p.m., evening dose on 4/1/26, 4/3/26, 4/4/26, 4/5/26 and 4/8/26 prior to resident medication refusals. And there were no documentation related to the omission and that the physician was notified that Resident 11 had refused blood sugar checks on these dates.During a review of Resident 11's Care Plan (CP) dated 10/16/25, indicated, Resident 11 had DM potential for hypo/hyperglycemia. The CP Interventions included, Identify areas of non-compliance or other difficulties in resident diabetic management, modify the problem area so that it may be more manageable to the resident/family. Provide documentation teaching to resident/family, address identified roadblocks to compliance.During a concurrent interview and record review on 4/9/26 at 1:59 p.m. with the Director of Nursing (DON), Resident 11's MAR and progress notes were reviewed. DON confirmed it was the facility's standard of practice to obtain blood sugar reading prior to insulin administration. DON further stated that when a resident refuses blood sugar checks and or insulin, nursing staff are expected to educate the resident, attempt compliance, notify physician, and document all interventions. DON acknowledged there was no documentation in Resident 11's record to reflect blood sugar monitoring, education, attempts to obtain compliance, or physician notification. During a review of the facility's policy and procedure (P&P) titled, Blood Sugar Monitoring, dated 8/25, the P&P indicated, Documentation will be reflected in the EMAR, progress notes, care plan, etc. as it may apply and it may include: Date, time, blood glucose level.Review of [NAME] and [NAME], Tenth Edition, Fundamentals of Nursing, page 365 in the section titled, Informatics and Documentation, indicated, Documentation is a key communication strategy that produces a written account of pertinent data, clinical decisions and interventions, and patient responses in a health record. Documentation in a patient's health record is a vital aspect of nursing practice.

Based on observation, interview, and record review, the facility failed to follow established policies regarding the storage of pharmaceutical products when a medication storage room was equipped with a single-door refrigerator/freezer unit, rather than a pharmacy-grade, two door unit with separate freezer compartment and door, when combine.This failure has the potential to lead to inconsistent temperatures and compromise the potency of stored medications when inuse. During an observation of the medication storage room in Station A on 4/8/26 at 9:14 a.m., a refrigerator used for medication storage had a single door for both freezer and refrigerator. The freezer was observed to have ice buildup.During the interview on 4/9/26 at 2:38 p.m. with the administrator (ADM), ADM stated that the facility does not store medication in the freezer. The ADM also stated that the facility's policy was to provide a pharmacy grade refrigerator specifically for medications to preserve their efficacy. The ADM acknowledged that there should have been separate doors for the freezer and the refrigerator.During a review of facility's policy and procedure (P&P), titled Monitoring for Monitoring of Temperature in Refrigerator/ Freezer Containing Pharmaceutical Products, dated 2018, the P&P indicated Refrigerators and freezers used to store pharmaceutical products ideally shall be of pharmacy grade, be a two door unit with separate freezer compartment and door, when combined and the monthly log should be kept on the outside of the refrigerator/ freezer door.

Based on observation, interview and record review, the facility failed to ensure food safety is maintained when an outdated bottle of juice was left in the refrigerator and spoiled produce were left for use and not discarded. This failure had the potential to expose residents to foodborne illnesses (diseases that are caused by eating contaminated food).During a concurrent observation and interview in the facility kitchen on 4/8/26 at 6:07 a.m. with the Dietary Manager (DM), a bottle of juice was observed in the refrigerator that had a best by date of 4/1/26. During a concurrent observation and interview on 4/8/26 at 6:11 a.m. at the facility kitchen with the DM, cucumbers were noted to have had mold and to be mushy (an unpleasant, stale, or damp smell caused by mold or mildew). DM verbalized that the person responsible for receiving the produce should inspect the foods before storage or use.During a review of Policies and Procedures titled Storing Produce dated 2003, the Storing Produce indicated in part 1. Check boxes of fruit and vegetables for rotten, spoiled items. Throw away spoiled items upon delivery.During a review of policies and procedures titled Labelling and Dating of Foods dated 2022, the Labelling and Dating of Foods indicate in part, The use by date signifies the date in which food must be consumed or discarded.

Based on interview and record review, the facility failed to ensure licensed nurses (LNs) completed wound assessments and developed a care plan that included treatment and monitoring of a surgical incision for 1 of three sampled residents (Resident 1) upon admission to the facility.This failure had the potential to result in delayed healing and infection to Resident 1's surgical wound. During a review of Resident 1's History and Physical (H&P), dated 12/10/24, the H&P indicated, Resident 1 was admitted to the facility on [DATE] with diagnoses that included post fall, had a subdural hematoma (collection of blood between brain and outer surface), and status post craniotomy (surgical procedure that temporarily removes part of skull).During a review of Resident 1's Progress Notes (PN), dated 12/6/24, this indicated, Body assessment done upon admission and noted the following: Right head surgical incision.Skin issue: #001: New skin issue. Location: Right temporal area. Laterality/Orientation: Right. Issue type: Surgical wound. Wound was present on admission. Measurement not documented as part of this assessment. Reason measurements not documented as part of this assessment-Resident will want it to be done another day will want to rest. On further review of the PN, documentation from 12/6/24 through 12/11/24, the above notes Skin issue: 001: New skin issue. Location: Right temporal area. Laterality/Orientation: Right. Issue type: Surgical wound. Wound was present on admission. Measurement not documented as part of this assessment. Reason measurements not documented as part of this assessment-Resident will want it to be done another day will want to rest. was repeated on LN entries during these dates. There was no evidence of wound measurements and/or description of the incision. There was no care plan developed to indicate treatment or care, no hand-off reports or documentation for continuity of care among staff, and no notification made to the physician about the surgical wound incision.During an interview on 12/18/25 at 2:40 p.m., with Registered Nurse (RN 1), RN 1 stated to have completed admissions of residents to this facility. RN 1 further stated the process that was followed if a resident had wounds was to notify the treatment nurse and a full assessment would be performed within 24 hours upon admission; RN 1 also stated .the doctor and family are notified of wounds.admission nurse checks the incision or wounds on admission and takes the measurements and documents what was seen. nurses check the wounds once a shift.nurses monitor and document in the medical record.nothing has changed on how to do wound assessments.During an interview on 12/18/25 at 2:50 p.m. with Director of Nursing (DON), DON agreed Resident 1's medical record was missing the assessment of the surgical wound.During an interview on 1/14/26 at 12:00 p.m. with the DON, DON agreed, there was no care plan developed for Resident 1's surgical incision; and the expectation was, if an incision and wound was present upon admission, the resident's medical record should have monitoring, assessments and care plans.During a review of the facility's policy and procedure (P&P) titled, Care Plan, Comprehensive, dated 8/2014, .PROCEDURE 1. The Care Plan is individualized by identified resident problems, unique characteristics, strengths and individual needs.3. The care plan becomes a comprehensive tool for the Interdisciplinary Team (IDT) to utilize as a reference for resident specific problems and approaches to establish guidance on meeting the individual needs of the resident.

Based on interview and record review, the facility failed to implement a comprehensive, person-centered care plan (a plan that includes clear goals to meet a resident's needs) in one of two sampled residents (Resident 1) with known alcohol dependence (a chronic disease in which a person craves alcoholic drinks and is unable to control his or her drinking), alcohol abuse and opioid dependence (the persistent urge to use legal and illegal drugs that reduce the intensity of pain signals). These failures had the potential of Resident 1 not having the coping mechanisms and support needed to prevent the use of illicit drug use (drugs that are illegal to produce, sell, or possess, or use in an illegal or inappropriate manner) and resulted in Resident 1 having a heroin (highly addictive, illegal opioid drug with high potential for abuse and no accepted medical use) drug overdose.During a review of Resident 1's admission Record (AR), [undated], the AR indicated, Resident 1 was admitted to the facility on [DATE] with diagnoses that included alcohol abuse, alcohol dependence with withdrawal and opioid dependence. Review of Resident 1's admission Minimum Data Set (MDS - a standardized assessment and screening tool) indicated, a Brief Interview of Mental Status (BIMS), score of 15. BIMS is a measurement of cognitive abilities that ranges from 0 to 15 with scores of 13-15 classified as having no significant cognitive impairment). Resident 1's History and Physical (H&P), dated 5/8/25, indicated in part, Alcohol abuse with risk of withdrawal possible. Ativan prn (as needed) to be given. Patient will be referred to County Supportive Group. During a review of Resident 1's Progress Notes (PN), dated 5/6/25 at 2:45 p.m., the PN indicated in part, admitted this [AGE] year old brought in by significant other, ambulatory with walker, from independent living facility [name of facility]. DX (diagnoses) .ETOH (alcohol), heroin and drug abuse .Alert, able to follow commands, disoriented to date, cries out a lot. (Resident 1) apparently was in an independent living situation but unable to function independently anymore. [Resident] requires supervision and cueing, and encouragement to fulfill task. During review of Resident 1's Interdisciplinary Team (IDT) meeting note, dated 5/13/25, The IDT indicated in part, Resident 1's responsible person (RP) mentioned it was unsafe for Resident 1 to live alone due to (Resident 1's) drinking problem. The RP also mentioned that Resident 1 needed a monthly injection to stop the substance abuse craving. During a review of Resident 1's SBAR (situation, background, assessment, recommendation) - Fall Report of Incident form, dated 6/2/25, the SBAR form indicated in part, Resident 1 had an unwitnessed fall Lying on back with head face up .minimal response with deep stimulation.MD (Medical Doctor) notified with order to transfer to hospital .Paramedics unable to arouse.Nasal Narcan (a medication that can rapidly reverse the effects of an opioid overdose) x 2 given.Finally woke up after 20 mins (minutes). Transport to hospital via ambulance. Insulin syringe found in patient's (Resident 1) pocket. Review of Resident 1's ED (Emergency Department) After Visit Summary (AVS), dated 6/02/25, the ED AVS indicated in part, You've (Resident 1) been treated for an overdose of opiates, such as a prescription pain medicine or heroin. During a concurrent record review and interview on 9/25/25 at 9:56 a.m. with the Social Services Director (SSD), Resident 1's Care Plan (CP) and H&P were reviewed. The SSD stated that facility staff did not identify community support groups or county programs for Resident 1 to attend and did not develop and sign a behavior contract with initiatives to assist the resident in staying clean and sober. Furthermore, the SSD acknowledged Resident 1 was not provided and/or assisted in obtaining substance use treatment services, such as behavioral health services, medication-assisted treatment (MAT), or alcoholic/narcotics anonymous meetings to achieve/maintain sobriety as indicated in the CP and in the H&P for the diagnoses of alcohol dependence, alcohol abuse, and opioid dependence. During a concurrent record review and interview on 9/25/25 at 10:50 a.m. with the Assistant Director of Nursing (ADON), Resident 1's IDT note, dated 5/13/2025 and CP for .current/recent history of substance abuse/dependence with heroin., dated 5/06/25 were reviewed. The IDT note indicated in part, Resident 1 .will need a monthly injection so that Resident 1 will not have the craving for substance abuse. The ADON stated there was no documentation in the progress notes or order summary indicating Resident 1 had received the monthly injections for substance abuse and would need to request the records from the [Facility's Name] public health center. The care plan interventions for .current/recent history of substance abuse/dependence with heroin. indicated: staff will monitor for signs of cravings or substance seeking for substance/alcohol for enhanced observation and support, staff will monitor resident's room for any signs of possible substance use (drug paraphernalia) and perform routine room searches, staff will work with resident to identify signs of cravings, relapse, and use and to identify coping mechanisms to reduce cravings, relapse and use and identify coping mechanisms to reduce cravings.The ADON sated there was no documentation in Resident 1's medical record that the interventions were performed or implemented. The ADON was asked why Emergency Medical Services (EMS) staff administered the opioid reversal agent on 6/2/25 instead of facility staff for Resident 1's signs of overdose, as it was indicated in the residents' care plan. ADON stated there was no order for the opioid reversal medication in Resident 1's order summary. ADON acknowledged the facility had identified Resident 1's potential need for an opioid reversal agent, as it was care planned, but there was no follow-through in obtaining a physician's order for the opioid reversal medication. During a review of Resident 1's Office Visit Summaries (OVS), dated 7/21/25 and 8/21/25 from [Facility name] public health center indicated Resident 1 received an injection of Vivitrol (medication used to diminish drug and alcohol cravings). The facility was unable to produce documentation that Resident 1 had received the monthly Vivitrol injections in May or June 2025. During an interview on 9/25/25 at 1 p.m. with the Administrator (ADM), ADM was asked for staff training prior to Resident 1's heroin overdose on 6/2/25 regarding how to care for residents at risk for alcohol and/or drug abuse or dependence, identify the signs and symptoms of possible substance use, withdrawals, and/or drug overdose. ADM stated the training information requested was not readily available. On 9/26/25, ADM sent an email with staff training on substance abuse dated 9/25/25. Despite multiple requests via phone and email with ADM and the Director of Nursing (DON), documentation that facility staff were trained on the signs or symptoms of alcohol and/or drug abuse, dependence, and overdose prior to 6/2/25 was never produced by the facility. During a phone interview on 10/1/25 at 2:41 p.m. with the Minimum Data Set coordinator (MDS), MDS was asked if Resident 1's care plan for substance abuse was assessed for effectiveness after the 6/2/25 overdose incident and MDS stated, All I can tell you is that [Resident 1] did not have any other episodes. The interventions were the same after the incident. They were not updated. During a concurrent record review and phone interview on 10/1/25 at 3:11 p.m. with DON, Resident 1's PNs dated 5/13/25 at 2:39 p.m. and 6/05/25 at 5:36 p.m. were reviewed. DON acknowledged that Resident 1's RP had mentioned before and after the overdose incident that Resident 1 required a monthly injection for substance abuse cravings and that the DON had agreed to follow up with the facility's physician. DON acknowledged there was no documentation that the physician was informed, or that the physician provided any orders or guidance. In addition, the DON stated there is no evidence in Resident 1's record the facility took any actions to provide the resident with a monthly injection to curb substance abuse cravings. During a review of the facilities policy and procedure (P&P) titled, Care Planning dated 8/25, the P&P indicated in part, It is the policy of this facility that the interdisciplinary team (IDT) shall develop a comprehensive Person-Centered Care Plan for each resident based on resident's needs to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being.Based on the interdisciplinary review, the care plan will be implemented, with ongoing revisions as needed.An interdisciplinary approach to individualize the care plan based on specific resident's needs will be an ongoing goal. During a review of the facilities P&P titled, Facility Prohibition Against Recreational Drugs, Substance and Alcohol Abuse, dated 8/25, the P&P indicated in part, It is the policy of [Facility Name], to provide and maintain a safe, efficient, and drug and/or alcohol-free living environment, conducive to the health, safety and well-being of our resident community.Recreational drugs and alcohol are inconsistent with the goal of promoting the health and rehabilitation of each individual resident and are expressly prohibited. Use or possession of, or being under the influence of, alcohol or recreational drugs by any resident of or visitor to the Facility necessarily presents a real and present danger to the health and safety of the general resident community.

Based on observation, interview, and record review, the facility failed to ensure adequate supervision was provided to prevent elopement for one of three sampled residents (Resident 1) when Resident 1, who was assessed as an elopement risk and provided with a Wander Guard (device that alarms), left the facility unmonitored. This failure placed Resident 1 at risk for injury or death. During a review of Resident 1's admission Record (AR), dated 10/2/25, the AR indicated, Resident 1 was admitted to the facility on [DATE] with diagnoses that includes unspecified Schizophrenia (a chronic mental health condition that affects a person's thoughts, feelings, and behaviors) and anxiety disorder (a feeling of fear, dread, and uneasiness). The Minimum Data Set (MDS) dated [DATE] indicated a Brief Interview of Mental Status (BIMS) score of 10, reflecting moderate cognitive impairment with episodes of forgetfulness. Further reviews showed Resident 1 was independent with mobility, specifically walking, and used a Wander Guard device daily.During a review of Resident 1's elopement evaluation, dated 8/1/25, indicated Resident 1 had a history of elopement, with expressions of desire to go home and pack belongings, stays by exit doors and wanders. The evaluation identified a risk for wandering and elopement, with a plan to maintain Resident 1's safety.During a review of Resident 1's physician's orders, dated 3/11/24, the orders revealed, there was an order for Wander Guard placement on left wrist and to be checked every shift. During a review of Resident 1's Care Plan (C/P) dated 8/2/25, tilted Risk for elopement identified, included checking the Wander Guard's placement and functionality as ordered.During an observation on 10/2/25 at 3:35 p.m. of the facility's front and back exit doors, two of the doors were equipped with Wander Guard sensors (a management system used at the facility to prevent residents with cognitive impairments from wandering into dangerous areas). The center of the building houses the main dining area that contains a door leading to a large back patio, which is the designated smoking area. The smoking area is surrounded by a fence approximately 6 ft. tall and has a padlocked iron gate, which leads to the rear parking lot connecting to the city streets.During a record review of the Facility Reported Incident (FRI) dated 10/1/25 indicated Resident 1 was missing between 7:30 a.m. and 7:45 a.m. and was later returned by police at 3:40 p.m. after being found at a shopping center.During a review of the facility record Situation Background Assessment Report (SBAR) dated 10/1/25 at 8:00 a.m., indicated certified nursing assistant (CNA 1), reported Resident 1 was not in their room for breakfast, and a search of the facility was initiated and was unable to locate Resident 1 responsible party (RP) and law enforcement were notified. During a review of Resident 1's Medication Administration Record (MAR) for the month of September 2025, showed the last function check of Resident 1's Wander Guard was on 9/25/25 and the MAR lacked any documentation of the ordered, every-shift placement checks for the Wander Guard ordered.During an interview on 10/2/25 at 4:20 p.m. with Licensed Nurse (LN 1), LN 1 stated Resident 1, when not in his room can be frequently seen at the smoking area. LN 1 stated the gate next to the smoking area in the back patio has no Wander Guard sensor but is always locked with a padlock. LN 1 clarified that there are two doors (front and back doors) that are equipped with Wander Guard sensors and confirmed there was no audible alarm heard from the doors that have the Wander Guard alarms between 7 a.m. and 8 a.m. on 10/1/25, when Resident 1 eloped.During an interview on 10/2/25 at 4:30 p.m., with Licensed Nurse (LN 2), LN 2 stated that on 10/1/25 at approximately 7:15 a.m., a Certified Nursing Assistant (CNA 1) reported Resident 1 was not in his room for breakfast and was not in the designated smoking area where he frequently goes. LN 2 confirmed Resident 1 wore a Wander Guard due to his elopement risk, but no alarm sounded on the morning of 10/1/25 between 7 a.m. and 8 a.m. LN 2 confirmed Resident 1 had a history of an elopement event last year in 2024 and that Wander Guard devices are checked weekly, every Thursday, by nursing staff.During a concurrent observation and interview on 10/2/25 at 4:50 p.m. with ADON, Resident 1 was observed from ADON's office during ADON's interview, smoking alone in the smoking area without any staff supervision. ADON was asked about who supervises the Residents in the smoking area, ADON stated that residents who are smokers and alert were assessed and educated about safe smoking and can smoke by themselves in the designated area and confirmed Resident 1 falls on that criterion. The facility failed to provide adequate supervision to prevent elopement while in the smoking area. During an interview on 10/2/25 at 5:00 p.m. with the Director of Nursing (DON), the DON stated that the facility had seven residents currently using Wander Guard devices and confirmed the devices are checked weekly by nursing staff and not every night shift as ordered. DON acknowledged she was also unaware of the Wander Guard instructions for use indicating to have daily checks.During a review of the facility's Policy and Procedure (P&P) titled, Elopement Prevention/ Unsafe Wandering, dated 8/2025, the P&P indicated, If the Wander Guard system is used, it will be tested on a regular basis (time not specified) for proper functionality.During a review of the Wander Guard instructions for use (IFU's), the manufacture's guidance, dated 2023, the IFU's indicated that signaling devices are to be tested before use and tested daily thereafter, with results documented in the medical record.

Based on observation, interview, and record review, the facility failed to perform daily functional testing of the Wander Guard system (an alert system worn on a resident's wrist that activates an audible alarm when passing doors equipped with sensors to prevent unsafe wandering) per manufacturer's instruction for use.This failure had the potential for seven residents using Wander Guard devices to elope from the facility without being detected.During the interview on 10/2/25 at 4:30 p.m. with licensed nurse (LN 2), LN 2 verified that Wander Guard devices are checked for functionality by nursing staff weekly every Thursday.During an interview on 10/2/25 at 5:00 p.m. with Director of Nursing (DON), DON stated there are seven (7) residents using Wander Guard devices and confirmed that the devices were checked weekly and not checked daily with results documented in the medical record.During a review of Wander Guard instructions for use, dated 2023, indicated, the devices should be tested daily thereafter, with results documented in the medical record. During the review of the facility's Policy and Procedure (P&P) titled, Elopement Prevention/ Unsafe Wandering, dated 8/2025, the P&P indicated, If the Wander Guard system is used, it will be tested on a regular basis (time not specified) for proper functionality.

Based on interview and record review, the facility failed to ensure pain management was provided for one of two sampled residents (Resident 2).This failure had the potential for Resident 2 and other residents to have unrelieved and/or uncontrollable pain. Findings:During the interview on 8/14/25 at 10:10 a.m. with Resident 2, Resident 2 stated she had her last dose of pain medication on 6/27/25 at noon in the hospital but did not get anything for pain from the nursing home until the next day and was told by a staff that your medication has not arrived yet.Resident 2's health record revealed the following:admission Record (Face Sheet) indicated Resident 2 was admitted on [DATE] with diagnosis of aftercare following joint replacement surgery. The Minimum Data Set (MDS- a tool for assessing the health and functional capabilities of residents in the nursing home) facilities section Cognitive (C) indicated a BIMS (Brief Interview for Mental Status- cognitive screening tool to assess memory and orientation in nursing home residents) score of 15 indicating Resident 2 is cognitively intact. Nurses' notes dated 6/27/25 at 1:20 p.m. indicated Resident 2 was alert and oriented, can understand and be understood when speaking, vocal complaints of pain in left knee described as aching, pain level #3.The physician order summary report indicated pain relieving medication orders of:a. Acetaminophen 325 mg give 2 tablets by mouth every 6 hrs. as needed for mild pain (1-3 on the pain scale)b. Roxicodone 5 mg 1 tablet orally every 4 hours as needed for moderate pain (no pain parameter)c. Roxicodone 5 mg 2 tablets every 4 hours as needed for severe pain (no pain parameter). Medication Administration Record (MAR) dated June 2025 indicated no Acetaminophen or Roxicodone was administered on 6/27/25. However, on 6/28/25 at 5:44 a.m., record indicated Resident 2 received Acetaminophen given at level 4 pain and did not have monitoring for the effectiveness of the drug. During the interview on 8/14/25 at 2:15 p.m. with the Director of Nursing (DON), DON stated that the controlled pain medication (Roxicodone) was available from the facility's secured emergency medication supply storage and confirmed that no pain medication was administered on 6/27/25. During the review of facility's policy and procedure (P&P), titled Recognition and Management of Pain, dated 8/2025, P&P indicated, It is the policy of this facility to ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. During the review of facility's policy and procedure (P&P), titled Medication Shortages/ Unavailable Medication, dated 8/2025, P&P indicated a licensed facility nurse should obtain the ordered medication from the Emergency Medication Supply.

Based on interview and record review, the facility failed to ensure staff verified the accuracy of a physician's order in one of 2 residents' medical record (Resident 1). Resident 1 had an order of NPO (nothing by mouth) and another order was to give medication by mouth. This failure had the potential to place Resident 1 at risk for medication related adverse events and complications. Findings: During Resident 1's review of health records: a. Admission record, indicated an initial admission on 9/27/24, readmission on 3/5/25 with diagnosis of dysphagia (difficulty swallowing) following cerebral infarction (a blockage of blood supply to the brain). b. An MDS (comprehensive assessment) on swallowing and nutrition dated 3/12/25 indicated Resident 1 had a feeding tube (a way of providing nutritional needs by way of a tube that is connected straight to resident's stomach). c. Physician's order dated 4/4/25 indicated diet order as NPO. d. Medication Administration Record (MAR) dated April 2025 indicated an order of: * Amoxicillin/ Clavulanate 500/125 mg (antibiotic-medication to neutralize bacterial infection in the body) 1 tablet by mouth every 12 hours for 10 days, initialed by licensed nurses from 4/7/25 to 4/17/25. * Cephalexin (antibiotic) tablet 500 mg, give 10 ml by mouth three times a day for two days, initialed by licensed nurses from 4/30/25 to 5/2/25. During the interview on 5/2/25 at 11:45 a.m. with the Assistant Director of Nursing (ADON), ADON stated Resident 1 had an order not to take anything by mouth (NPO). During the interview on 5/2/25 at 12:00 p.m. with Licensed Nurse (LN 1), LN 1 stated that she was administering Resident 1's medications via gastric tube and not as per the written order by mouth but did not clarify the order with the physician. During the interview on 5/2/25 at 12:15 p.m. with the Director of Nursing (DON), DON acknowledged the antibiotic orders were written in error and was not verified in a timely manner.

Based on observation, interview, and record review the facility failed to maintain a restroom in good repair for one of two sampled residents (Resident 1). This failure had the potential to deny Resident 1 with a homelike environment. Findings: During a concurrent observation and interview, on 3/20/25, beginning at 11:55 a.m., with the Housekeeping Supervisor (HS 1) and Maintenance Assistant (MA 1), Resident 1's restroom was toured. Inside the restroom there was peeling paint, and inoperable ceiling fan, a toilet seat partially without its outer coating, and a loose toilet lever. The HS 1 and MA 1 verbalized and confirmed there was peeling paint, an inoperable ceiling fan, a loose toilet lever and a toilet seat the was partially without its outer coating in Resident 1's restroom. The HS 1 verbalized there were no current work orders in the facility's maintenance system for these issues to be addressed by the maintenance department and they needed to be fixed. During a review of the facility's policy titled Preventative Maintenance dated 8/14, indicated in part The Maintenance Department will maintain the facility's physical plant in accordance with the TELS schedule that will serve to provide a safe, functional, and aesthetically pleasing environment .All maintenance will be scheduled, performed and documented in accordance with the facility's department instruction as noted within the TELS.

Based on record review and interview the facility failed to implement care plan interventions for 1. Feeding assistance needs for one of three sampled residents (Resident 1). 2. Pressure injury care and prevention for one of three sampled residents (Resident 1). This failure had the potential for Resident 1 to experience weight loss and progression of pressure ulcers. Findings: During a review of the admission record (AR) for Resident 1, dated 2/25/25, the AR indicated Resident 1 was admitted on [DATE] with diagnosis including but not limited to hemiplegia and hemiparesis following cerebral infarction affecting left side (weakness or paralysis following blood flow being blocked in brain causing tissue death), dysphagia (difficulty swallowing), unspecified glaucoma (eye disease causing vision loss). During a review of the facility's policy and procedure titled Care Plan, Comprehensive dated 2008, the policy indicated in part .The care plan is directed toward achieving and maintaining optimal status of health, functional ability, and quality of life and .The individualized care plan is accessible to all caregivers to assure resident specific care information is exchanged and the consistent delivery of care and approaches. During a review of the facility's policy and procedure titled Documentation in Medical Record dated 1/20/2024, the policy indicated in part .Each residents medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation and .1. Licensed staff and interdisciplinary team members shall document all assessments, observations, and services provided in the resident's medical record in accordance with state law and facility policy. 2. Documentation shall be completed at the time of service, but no later than the shift in which the assessment, observation, l or care service occurred. 1. During a review of the Nutritional Risk Assessment (NRA) for Resident 1, dated 10/3/24, the NRA indicated in part .biting/chewing difficulties, requires full feeding assistance, goal to consume 70-80% meal intake. During a review of the Care Plan Report (CP) for Resident 1, dated 9/29/24, the CP indicated in part .Focus: Self-care deficit as evidenced by: Needs assistance with ADLs (activities of daily living) related to CVA (cardiovascular accident), weakness. Intervention/Tasks: Eating dependent. During a review of the CP for Resident 1, dated 10/3/24, the CP indicated in part .Focus: Altered nutrition . Goal: Encourage 70-80% meal intake. During a concurrent interview and record review on 3/7/25 at 1:24 pm with the director of nursing (DON), the Documentation Survey Report (DSR) dated December 2024, for Resident 1 was reviewed. The DSR indicated Meal intake percentages for three meals daily for Resident 1. The DSR has no meal intake amount and no signature of staff on 12/5/24 and 12/19/24 at 1:00pm. There is no meal intake amount and no staff signature on 12/18/24 at 6;00 pm. The DON agreed that the DSR is missing this information and should be documented if done. 2. During a review of the Wound Assessment Report (WAR) for Resident 1, dated 12/4/24, the WAR indicated in part . Location: Heel, Length 5.00cm, Width 4.00cm, Depth 0.10cm, etiology: Pressure Injury. During a review of the Wound Assessment Report (WAR) for Resident 1, dated 12/4/24, the WAR indicated in part . Location Sacro coccyx, Length 1.00cm, Width: 050cm, Depth 0.30cm, etiology: Pressure Injury. During a review of the CP for Resident 1, dated 9/29/24, the CP indicated in part .Focus: Potential for impaired skin integrity related to fragile skin . Interventions/Tasks: Pressure redistribution mattress to bed, Pressure redistribution cushion-wheelchair. During a concurrent interview and record review on 3/7/25 at 1:24 pm with the director of nursing (DON), the Documentation Survey Report (DSR) dated December 2024 and January 2025, for Resident 1 was reviewed. The DSR indicated Pressure Redistribution Device presence for day, evening, and overnight shifts daily for Resident 1. The DSR for December 2024 has no indicator of presence or staff signature on day shift 12/19/24, evening shift 12/18/24, and overnight shift 12/1/24, 12/4/24, and 12/6/24. The DSR for January 2025 has no indicator of presence or staff signature on the overnight shift on 1/8/25, 1/11/25, 1/15/25, 1/17/25, 1/20/25, and 1/24/25. The DON agreed that the DSR is missing this information and should be documented if done.

Based on observation, interview, and record review the facility failed to position a wound vacuum pump in accordance with manufacturer guidance for 1 sampled Resident (Resident 1). This failure had the potential to cause a tripping hazard to residents, staff, or visitors as well as a risk of disconnecting the device upon tripping. Findings: During a review of the Order Summary Report (OSR) dated 3/7/25, the OSR indicated an order for Resident 1 dated 3/6/25 for Dressing 1- Apply to wound location: sacrum clean with normal saline pat dry primary dressing; apply the following to the wound bed, NPWT (Negative Pressure Wound Therapy) green sponge, secondary dressing: NPWT drape tertiary dressing 125mm Hg continuous/intermittent therapy every day shift every Thursday, Sunday for pressure ulcer. During an observation on 3/7/25 at 11:29 am in Resident 1's room, the NPWT device's pump which is connected to a power adapter, extension cord and a tube that connects to the wound dressing on Resident 1 is observed sitting on the floor next to Resident 1's bed. There are multiple cables and a tube that come in direct contact with my feet as I stand at bedside. During a review of the Manufacturers Guidance titled (Brand Name) Negative Pressure Wound Therapy System, revised 10/6/21, indicated in part .Position the (Brand Name) Negative Pressure Wound Therapy System and tubing appropriately to avoid the risks of causing a trip hazard. Whenever possible, the device and system tubing should be positioned level with or below the wound. During an interview on 3/7/25 at 12:11 pm with the director of nursing (DON), DON agreed the wound vacuum located on the floor could cause a risk of tripping and or disconnection.

Based on observation, interview, and facility policy review, the facility failed to ensure hair restraints were worn for dietary staff during meal service. This deficient practice had the potential to affect all residents who received food from the kitchen. Findings included: A facility policy titled, Personnel Sanitation Standards, effective 02/2024, revealed, 1. In addition to employee personnel policies, food and dining personnel will be required to adhere to the following sanitary standards: a. hair must be restrained or covered (via hat or hair net). During an observation on 01/15/2025 at 11:11 AM, [NAME] #5 prepared sandwiches and did not wear facial restraint. During an observation on 01/15/2025 at 12:00 PM, [NAME] #4 and [NAME] #5 both had facial hair and were not wearing a facial restraint when they were observed plating the lunch meal for residents. During an interview on 01/15/2025 at 1:23 PM, [NAME] #5 stated the facility did not require him to wear facial restraints because he did not believe his facial hair was long. During an interview on 01/15/2025 at 1:30 PM, [NAME] #4 stated he did have facial hair; however, the facility did not require him to wear a facial restraint. During an interview on 01/15/2025 at 1:38 PM, the Registered Dietician stated [NAME] #4 and [NAME] #5 should have worn facial restraints. During an interview on 01/16/2025 at 1:21 PM, the Dietary Manager (DM) stated the facility policy and procedures were not very clear about the use of hair restraints. The DM stated [NAME] #4 and [NAME] #5 did not require facial restraints as facial restraints were only required if the staff members' facial hair was over a half inch in length. The DM stated he did not know how long [NAME] #4's and [NAME] #5's facial hair was. During an interview on 01/17/2025 at 10:15 AM, the Administrator stated facial restraints should be worn in the kitchen.

Based on observation, interview, record review, and facility policy review, the facility failed to assess 1 (Resident #129) of 24 sampled residents for the ability to self-administer their medication(s). Findings included: A facility policy titled, Self-Administration of Medication, dated 2008, indicated, It is the policy of this facility to allow residents who request self-administration of medication to do so if the facility Interdisciplinary Team has determined that resident is capable of doing so in a safe manner that does not present a risk to other residents of the facility. Per the policy, 2. If the resident expresses a desire to self-administer their medications, or a physician orders self-administration, the facility will not allow the resident to self-administer meds until the following procedures are done: a. A Licensed Nurse will complete the Self-Administration Assessment Review which includes the resident's physical and cognitive ability to safely administer and store their medication(s). b. The assessment will then be routed to the Director of Nursing/designee to review with the Interdisciplinary Team (IDT) for approval. c. The IDT will re-assess the resident to verify they are still able to self-administrate medications quarterly. The resident will do a returned demonstration to the IDT to show they are able to perform this task. An Admission Record revealed the facility admitted Resident #129 on 12/31/2024. According to the Admission Record, the resident had a medical history that included diagnoses of Parkinson's disease and type 2 diabetes mellitus. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/05/2025, revealed Resident #129 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident had intact cognition. Resident #129's Order Summary Report, revealed an order dated 12/31/2024, for a multivitamin oral tablet, give one tablet by mouth one time day for a supplement. Resident #129's medical record revealed no evidence to indicate the resident was able to self-administer their medication(s). During an observation on 01/14/2025 at 10:03 AM and 01/15/2025 at 12:19 PM, the surveyor noted a bottle of multivitamins on Resident #129's bedside table. During a concurrent observation and interview on 01/14/2025 at 10:03 AM, the surveyor noted a bottle of multivitamins on Resident #129's bedside table. Resident #129 stated they took the multivitamin because they were all natural and organic. Resident #129 stated the facility had not assessed them to be able to self-administer their own medications. Resident #129 stated the facility prescribed and administered vitamins in addition to their own once-a-day multivitamin. Resident #129 stated they did want to continue to self-administer their personal multivitamin. During a concurrent observation and interview on 01/16/2025 at 9:37 AM, Licensed Vocational Nurse (LVN) #3 stated that Resident #129 had not been assessed to self-administer medications and that she administered the resident their medications. LVN #3 observed the bottle of multivitamins on the resident's bedside table, picked up the bottle, and verbally verified the label was for a multivitamin. LVN #3 stated the resident was not permitted to have the multivitamin in their room. In an interview on 01/16/2025 at 9:49 AM, the Director of Nursing (DON) stated Resident #129 had not been assessed to self-administer medications. The DON stated that the resident did have an order for a multivitamin. Per the DON, Resident #129 needed a self-administration assessment and a physician's order, if they wanted to keep the medication to be kept at their bedside. In an interview on 01/16/2025 at 2:37 PM, the Administrator stated her expectations for nursing staff were to get an order for self-administration for the resident and then the resident needed to keep the medications secure in a bedside drawer.

Based on interview, record review, and facility policy review, the facility failed to ensure the accuracy of the Minimum Data Set (MDS) for 1 (Resident #16) of 24 sampled residents. Findings included: A facility policy titled, MDS Standard of Practice, dated 01/2024, specified, It is the practice of this facility to conduct accurate coding and delivery of services provided to capture accurate assessment of each resident's functional capacity and health status as per CMS [Centers for Medicare & Medicaid] RAI [Resident Assessment Instrument] MDS 3.0 Manual guidelines. An Admission Record indicated the facility admitted Resident #16 on 11/25/2024. According to the Admission Record, the resident had a medical history that included diagnoses of neurofibromatosis (a condition that caused tumors to form in the brain, spinal cord, and nerves) and encounter for palliative care. A significant change in status MDS, with an Assessment Reference Date (ARD) of 12/31/2024, revealed Resident #16 had a Brief Interview for Mental Status (BIMS) score of 10, which indicated the resident had moderate cognitive impairment. The MDS revealed the resident did not receive hospice care. Resident #16's care plan included a focus area initiated 12/17/2024 that indicated the resident received hospice services related to the diagnosis of neurofibromatosis. Resident #16's Order Recap Report for the time frame 11/01/2024 to 01/31/2024, revealed an order dated 12/20/2024, to admit to hospice. During an interview on 01/16/2025 at 12:22 PM, the MDS Coordinator stated the accuracy of the MDS was important because it reflected the resident's status and drove the care plan. She stated the significant change in status MDS was done for Resident #16 due to the resident being placed on hospice services. The MDS Coordinator reviewed the MDS and confirmed that hospice was not coded on the MDS but stated it should have been. Per the MDS Coordinator, she would have to do a modification of the assessment to accurately reflect the resident being on hospice services. The MDS Coordinator stated it was an oversight. During an interview on 01/17/2025 at 10:36 AM, the Director of Nursing (DON) stated it was important for the MDS to be accurate for reimbursement and it made sure the facility identified and met the resident's needs. The DON stated the MDS Coordinator was responsible for the accuracy of the MDS. During an interview on 01/17/2025 at 10:50 AM, the Administrator stated the MDS needed to be accurate because it triggered the quality measures that initiated the care plan. The Administrator stated the person who completed the specific section of the MDS was responsible to ensure it was accurate, and the MDS Coordinator should do a second check.

Based on interview, record review, and facility policy review, the facility failed to ensure resubmit a new Level I screening when 1 (Resident #22) of 2 sampled residents reviewed for preadmission screening and resident review (PASARR) remained in the facility on the 31st day. Findings included: A facility policy titled, Resident Assessment-Coordination with PASARR Program, revised 05/2024, revealed, This facility coordinates assessments with the preadmission screening and Resident review program under Medicaid to ensure that individuals with a mental disorder [MD], intellectual disability [ID], or a related condition receives care and services in the most integrated setting appropriate to their needs. The policy specified, 5. If a resident who was not screened due to an exception above and the Resident remains in the facility longer than 30 days: a. The facility should screen the individual using the State's Level I screening process and refer any Resident who has or may have MD, ID or a related condition to the appropriate state- designated authority for Level II PASARR evaluation and determination. An Admission Record revealed the facility admitted Resident #22 on 09/20/2022. According to the Admission Record, the resident had a medical history including diagnoses of depression and anxiety disorder. An annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/20/2024, revealed Resident #22 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident had intact cognition. A letter from the State of California - Health and Human Services Agency Department of Health Care Services, dated 09/20/2022, revealed if Resident #22 remained in the facility longer than 30 days, the facility should resubmit a new Level I screening as a resident review of the 31st day. Resident #22's medical record revealed no evidence a new Level I screening was completed when the resident remained in the facility 30 days after 09/20/2022. During an interview on 01/16/2025 at 10:53 AM, the Assistant Director of Nursing stated was not aware Resident #22 required a new Level I screening. During an interview on 01/17/2025 at 9:07 AM, the Director of Nursing stated that after Resident #22 remained in the facility after 30 days, the facility should have resubmitted a Level I screening. During an interview on 01/17/2025 at 10:24 AM, the Administrator stated a Level I Screening should have been completed after the resident's 31st day in the facility.

Based on observation, interview, and record review, the facility failed to ensure medications were stored properly for 1 (Resident #129) of 24 sampled residents. Findings included: An Admission Record revealed the facility admitted Resident #129 on 12/31/2024. According to the Admission Record, the resident had a medical history that included diagnoses of Parkinson's disease and type 2 diabetes mellitus. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/05/2025, revealed Resident #129 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident had intact cognition. Resident #129's Order Summary Report, revealed an order dated 12/31/2024, for a multivitamin oral tablet, give one tablet by mouth one time day for a supplement. During an observation on 01/14/2025 at 10:03 AM and 01/15/2025 at 12:19 PM, the surveyor noted a bottle of multivitamins on Resident #129's bedside table. During a concurrent observation and interview on 01/14/2025 at 10:03 AM, the surveyor noted a bottle of multivitamins on Resident #129's bedside table. Resident #129 stated they took the multivitamin because they were all natural and organic. During a concurrent observation and interview on 01/16/2025 at 9:37 AM, Licensed Vocational Nurse (LVN) #3 observed the bottle of multivitamins on the resident's bedside table, picked up the bottle, and verbally verified the label was for a multivitamin. LVN #3 stated the resident was not permitted to have the multivitamin in their room. In an interview on 01/16/2025 at 2:37 PM, the Administrator stated she expected the nursing staff to secure medication storage. Per the Administrator, after the resident has been assessed to self-administer their medication, she expected the medications to be secured in their bedside drawer.

Based on interview and record review, the facility failed to notify the responsible party (RP) after a fall incident for one of two sampled residents (Resident 1). This failure had the potential to eliminate RP's participation in the development and implementation of Resident 1's person-centered plan of care. Findings: During a review of Resident 1's medical records, Resident 1's medical records indicated, Resident 1 was admitted to the facility on [DATE] with primary diagnosis of general muscle weakness on the right side of the body following a cerebral infarction (condition where the blood flow to some part of the brain is blocked causing brain tissue to die).Resident 1's BIMS (Brief Interview for Mental Status- a tool used to screen and identify cognitive condition of residents upon admission into a long-term care facility) score of 14, indicated Resident 1 has intact cognition. Per Resident 1's history and physical, the physician determined Resident 1 had the mental capacity to make healthcare decisions. The admission record, indicated Resident 1's niece was designated as the decision maker or RP. During a concurrent observation and interview on 8/7/24 at 2:00 p.m., with Resident 1, Resident 1 was observed in room (108 C) sitting on a wheelchair, alert and oriented, pleasant, and cooperative; and stated that a doctor's order to go out on pass (OOP) from the facility is in place. Resident 1 further stated that there was no accident in the past while OOP but remembered falling from wheelchair to the bed from a wrong turn in July and had minor scratch on right arm and right knee. During a concurrent interview and record review on 8/7/24 at 2:30 p.m., with Licensed Nurse 1 (LN 1), Resident 1's fall incident report, dated 7/28/24 was reviewed. The incident report indicated that Resident 1 had unwitnessed fall on 7/28/24 at 5:10 p.m. when missing a turn and lost balance during her self-transfer from wheelchair to bed. It also indicated Resident 1 had skin tear on the right elbow when found by a staff on the floor. The physician was notified but there was no notification made to the RP. LN 1 confirmed there was no notification made to the RP listed in Resident 1's record. During the interview on 8/7/24 at 2:45 p.m. with the administrator (ADM), the ADM stated there was probably verbal information relayed to the RP, but it was not in the documentation. During a review of Resident 1's Power of Attorney (POA), dated April 2, 2024, the POA indicated, My Agent shall have full power and authority to act on my behalf. This power and authority shall authorize my agent to manage and conduct all of my affairs and to exercise all of my legal rights and powers, including all rights and powers that I may acquire in the future. My Agent's powers shall include, but not be limited to, the power to .have access to my healthcare and medical records and statements regarding billing, insurance, and payments. During a review of the facility's policy and procedure (P&P) titled, Promoting the Right of Self-Determination for Healthcare Decisions and Advanced Healthcare Directives, dated Nov. 2016, the P&P indicated in the definition that resident representative was, (1) An individual chosen by the resident to act on behalf of the resident in order to support the resident indecision-making; access medical, social or other personal information of the resident; manage financial matters; or receive notifications; (2) A person authorized by State or Federal law (including but not limited to agents under power of attorney, representative payees, and other fiduciaries) to act on behalf of the resident in order to support the resident in decision-making; access medical, social or other personal information of the resident; manage financial matters; or receive notifications.

Based on record review and interview, the facility failed to assist one of two sampled residents (Resident 1) in making an outside appointment, per a prescriber's order. This facility failure had the potential to result in a delay of care for Resident 1. Findings: During a review of Resident 1's Admission Record undated, indicated in part, Resident 1 was admitted to the facility on [DATE], and discharged on [DATE]. During a review of Resident 1's Order Summary Report undated, indicated in part, an order dated 11/1/23, for Cataract (a medical condition which can cause blurry vision) evaluation by to [outside facility name] Ophthalmology clinic. During an interview on 4/15/24, starting at 3:48 p.m., with the Administrator (Admin 1), the Admin 1 confirmed the facility could not provide documentation indicating facility staff had attempted to make Resident 1's cataract evaluation/ophthalmology appointment prior to Resident 1 being discharged from the facility. During a review of the Job Description/Performance Evaluation form, for the job position of Social Services Assistant, dated 11/13/17, indicated in part, Key/ Essential Duties . Coordinates and sets up appointments including Dental, Podiatrist, Ophthalmologist, Psychiatrist. During a review of the facility's policy and procedure titled Resident Rights dated 10/22, indicated in part, The resident has the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility.

Based on observation, interview and record review the facility failed to ensure their abuse policy and procedure was implemented when one of three sampled residents (Resident 1) was found with facial bruises (bluish, black skin discoloration) and stated Someone a man had kept on punching or hitting me , when asked regarding the bruises on her face. The facility failed to report to the Department not later than 2 hours upon knowledge of the incident, failed to interview staff and other possible witnesses of the incident, and protect the resident from the alleged perpetrator (someone -man) while the facility pursues their investigation. These failures placed Resident 1 at risk for possible further abuse by the alleged perpetrator. Findings: The facility ' s policy and procedure titled Abuse Prevention, Intervention, Investigation & Crime Reporting Policy, dated 11/2016, in part the DEFINITIONS spart indicated Injury of Unknown Source is an injury that was not observed by any person OR the source of the injury could not be explained, AND the injury is suspicious because of the extent of the injury, or location of the injury (in an area that is not normally prone to trauma), or the number of injuries observed at one particular point in time, or the incidence of injuries overtime. Physical Abuse includes, but not limited to, hitting, slapping, pinching and kicking . In the PROCEDURES part in the INVESTIGATION subpart indicated Injuries of unknown source, suspected or alleged abuse . will be investigated with results reported in accordance with facility policies and federal and state regulations. The facility will complete a Verification of Incident Investigation giving a brief description of the allegations, thorough summary of findings including information obtained in interviews, follow-up actions taken, and notifications made. This verification may be provided to federal or state survey agencies upon request The facility will comply with Section 1150B of the Social Security Act (the Act) as established by Section 6703(b)(3) of the Patient Protection and Affortable Care Act in reference to reporting and reasonable suspicion of crimes committed against a resident of afedrally funded long term care facility . Ensure that all alleged violations involving abuse,neglect,exploitation or mistreatment, including injuries of unknown source and misappropiation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that caused the allegation involved abuse or result in serious bodily injury or not later than 24 hours if the events that caused the allegation do not involved abuse and do not result serious bodily injury ; to the administator of the facility and to other officials ( including to the state survey agency and adult protective services wher state law provides for jurisdiction in long term facilities ) in accordance with State law 7. Protection . Suspend staff member(s) believed to be involved, pending the outcome of an investigation . During a review of Resident 1's medical record on 6/9/22, the face sheet indicated the resident's diagnosis included spinal stenosis (pressure on the spinal cord and the nerves causing low back pain, numbness and muscle weakness), deformity of right and left foot ( abnormal shape or form), generalized weakness, and bipolar disorder (mental disorder that causes unusual shifts in mood). The minimum data set ( MDS- assessment ), dated 5/3/22, indicated the resident's brief interview for mental status (BIMS score -a test used to get a quick snapshot of functioning cognitively) was 04 (score of 13 to 15 suggests the patient is cognitively intact, 8 to 12 suggests moderately impaired and 0 to 7 suggests severe impairment). Resident 1 required extensive assistance with two-person physical assist for bed mobility, transfers, toilet use, personal hygiene and did not walk in room or corridor. During an observation and concurrent interview on 6/9/22 at 2:10 p.m., inside Resident 1's room , the resident was laying in bed with a maroon-colored skin area around the left eye, the area around the right eye was with dark purple discoloration extending to right cheek bone, forehead with bump and slightly elevated skin area with minimal dark yellow discoloration, and the right hand middle and ring fingers were swollen. Resident was asked how she sustained the bruises on her face. Resident 1 responded I don't want to talk about it now. During an observation and concurrent interview with CNA2 on 6/9/22 at 2:20 p.m., inside Resident 1's room , CNA2 indicated coming into the resident's room on the morning of 6/8/22 and found the resident (Resident 1) with bruises on the face. CNA2 stated, I found her (resident) like this with bruises on face on 6/8/22. I was not told if the resident fell . I reported (face bruises) it to the nurse (Licensed Nurse -LN3). CNA2 indicated the resident's bed have no siderails, the resident does not try to get up, not strong enough to do so. CNA 2 further indicated not being interviewed by anyone in the facility to find out about what happened to the resident's bruises on the face. During an observation and concurrent interview with CNA3 on 6/9/22 at 2:25 p.m., inside Resident 1's room, CNA3 stated [CNA2 name] called me to help her pull her [resident] up. I saw the bruises on her [resident] face, this is not normal. I went to the nurse [LN3] and reported it. CNA3 indicated resident is not able to move by self, too weak, it takes two people to pull her [resident] up on bed. CNA3 further indicated the facility administrator (FA) and director of nursing [DON] were investigating the incident yesterday (6/8/22) during the day but did not talk to or interview CNA3. During an observation and concurrent interview with certified nursing assistant (CNA1) on 6/9/22 at 2:45 p.m., inside Resident 1's room, CNA1 stated I took care of [resident ' s name] on 6/7/22 from 7:00 a.m., to 3:00 p.m., and her face had no bruises, it was not like that [pointed at resident's face], something happened from 3:00 p.m., to 11:00 p.m., or during the night shift [11p.m.-7:00 a.m.] .The next day I heard [resident ' s name] had bruises on her face. The problem is CNA's do not know how to handle her [resident]. Some CNA's turn [resident ' s name] by themselves and it takes two people to turn her [resident]. When you try to move or turn her [resident] she screams or freaks out . [resident ' s name] does not try to get out of bed, she is too weak. The only thing she can do is reach the bed baseboard to hold on but that's it. CNA1 indicated not being interviewed about what happened to Resident 1's bruised face. During an observation and concurrent interview with LN1 on 6/9/22 at 3:40 p.m., LN1 confirmed taking care of Resident 1 on 6/7/22 from 3:00 p.m., to 11:00 p.m., and also saw the resident around 4:00 p.m., 6:00 p.m., and at 10:00 p.m., of 6/7/22. LN 1 indicated resident did not have any face bruises at that time, resident did not fall during the shift, and nothing was reported to her by any CNA about any fall or bruising. LN1 further indicated seeing Resident 1 on 6/8/22 at around 3:15 p.m., now with bruises on the face . When asked about the resident's bruises on the face, LN 1 stated I heard she (resident) said someone - man kept on hitting her. LN1 indicated not being interviewed by anyone in the facility regarding the bruises on the resdient's face. During an interview with LN2 on 6/10/22 at 8:15 a.m., LN2 confirmed taking care of Resident 1 on 6/7/22 from 11:00 p.m., to 7:00 a.m., on 6/8/22. LN 2 indicated making rounds from 11:30 p.m., to midnight (6/7/22 to 6/8/22) and noted no bruises on the resident's face. LN2 further indicated making another round at 5:30 a.m., (6/8/22) and noted no bruises on the resident ' s face . LN 2 stated CNA did not report any fall or resident hitting self against a dresser. LN 2 confirmed not being interviewed by any facility staff regarding the resident's bruises on the face. During an observation and concurrent interview with LN3 on 6/9/22 at 2:15 p.m., LN3 confirmed taking care of Resident 1 on 6/8/22 from 7:00 a.m., to 3:00 p.m. LN3 indicated CNA3 reported to her that [resident name] face was bruised around eyes, cheek, and forehead. LN 3 stated I came into [resident name] room, saw her face bruised so I went to get another nurse [LN4] to come with me to see [resident name] ' s face. [Resident name] was asked how she got those bruises. Resident stated Someone [a man] was really mad and kept punching me, [a man] . so I went to report this to the assistant director of nursing [ADON] and DON. The DON told me not to worry about it that they [ADON & DON] will take care of it. Resident must have hit herself with the bed rails but . there is no bed rails. [DON name] called me to tell me that I have a lot of things to do, to stop saying that the resident is saying someone was hitting her because the State will have to be contacted and the State will come after me . I'm supposed to report any possible abuse . especially because the resident had said someone a man had punched her. Resident had been taken care by a male CNA [CNA4] on 6/7/22 from 3:00 p.m., and on. LN3 indicated Resident 1 had not fallen before and is not strong enough to move by herself or try to get out of bed and no one from the facility had interviewed LN3 and has not heard of any investigation taking place regarding the bruises on the resident's face. During an observation and concurrent interview with LN4 on 6/9/22 at 2:30 p.m., LN4 stated, [LN3 name] ask me to come with her to see her [resident] face bruises . I told her [LN3] to report it. Since, [administrator ' s name] is the abuse coordinator I told [administrator ' s name] about the abuse allegation, of the resident's face bruises that resident stated yesterday, Someone- a man had kept on punching or hitting her. LN4 indicated FA and DON went to see the resident in her room on 6/8/22 around 2:40 p.m., saw the bruises on the resident's face, seem to be investigating but did not interview LN4 . The facility ' s policy and procedure titled Abuse Prevention, Intervention, Investigation & Crime Reporting Policy, dated 11/2016, stated in part.In the PROCEDURES part in the INVESTIGATION subpart indicated Injuries of unknown source, suspected or alleged abuse . will be investigated with results reported in accordance with facility policies and federal and state regulations. The facility will complete a Verification of Incident Investigation giving a brief description of the allegations, thorough summary of findings including information obtained in interviews, follow-up actions taken, and notifications made. This verification may be provided to federal or state survey agencies upon request Further review of the medical record of Resident 1, a general note, dated 6/8/22 at 3:14 p.m., created by LN3 indicated Pt [patient-resident] is now complaining of head pain .when asking Pt what happened to her, responded someone kept punching and punching me they were really mad writer attempted to further ask questions but Pt stated, I couldn't remember when or who . The facility's SBAR Communication note (change of condition form) for Resident 1, dated 6/8/22 at 11:00 a.m., created by LN3 indicated there was a change in the resident's skin [discoloration]. CNA reported to nurse patient had some change in skin condition. Went to patient's room patient had discoloration on both eyes and inner eyes, bump on forehead and discoloration on right temple. During a review of the facility ' s abuse policy and procedure, dated 11/2016, with the DON and FA on 6/9/22 at 5:45 p.m., stated in part Ensure that all alleged violations involving abuse,neglect,exploitation or mistreatment, including injuries of unknown source and misappropiation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that caused the allegation involved abuse or result in serious bodily injury or not later than 24 hours if the events that caused the allegation do not involved abuse and do not result serious bodily injury ; to the administator of the facility and to other officials ( including to the state survey agency and adult protective services wher state law provides for jurisdiction in long term facilities ) in accordance with State law The DON indicated LN3 documented later in the day on 6/8/22 about the abuse allegation at 3:15 p.m.,. No evidence was located in the documents persented by the facility an abuse allegation investigation had been initiated from 6/8/22 to 6/9/22 . The FA was asked to share the abuse allegation investigation findings, and interviews twice. The FA was not able to provide any evidence an abuse allegation investigation had been initiated or conducted yet.The facility forwarded their facility reported incident (FRI) to the Department only on 6/9/22. During an observation and concurrent interview on 6/9/22 at 3:10 p.m., and 3:15 p.m., CNA4 was going in and out of Resident 1 ' s room . CNA4 was asked if he was assigned to care for [resident ' s name] . CNA4 stated Yes, I am taking care of [resident ' s name]. CNA4 confirmed taking care of Resident 1 on 6/7/22 from 3:00 p.m., to 11:00 p.m., and 11:00 p.m., to 7:00 a.m., on 6/8/22. On 6/8/22 from 3:00 p.m., to 11:00 p.m., and today, 6/9/22 from 3:00 p.m., to 11:00 p.m. CNA4 was asked if he knew how resident sustained the bruises on face. CNA4 stated I don't know. I have been thinking over and over and I have no idea how she [resident] got those bruises. The only thing I can think of is that she [resident] holds the curtain and pulls it towards her face, or her face could have touched the dresser, otherwise I really don't know how she (resident) got those bruises. CNA4 was asked if he saw the resident ' s face touching or hitting the dresser. CNA4 stated No, I didn't see her [resident] face on or hitting the dresser or pulling the curtain. I just think maybe that's what happened. CNA4 was asked the last time he changed resident's brief. CNA4 stated I changed it about 6:15 a.m., (6/8/22). No, she [resident] cannot move by herself, but she helps. She [resident] can be turn side to side by one person. Let me show you. CNA4 then turned Resident 1 to the left side by himself. Resident 1 screamed however CNA4 still proceeded to turn the resident to the other side and stated, See its easy to move her. A review of the Daily Station Assignment binder (DSAB) was conducted on 6/9/22 at 3:35 p.m., the DASB assignment sheets indicated CNA4 was assigned to care for Resident 1 on 6/7/22 from 3:00 p.m., to 11:00 p.m., then from 11:00 p.m., to 7:00 a.m., on 6/8/22, 6/8/22 from 3:00 p.m., to 11:00 p.m. and on schedule for 6/9/22 from 3:00 p.m., to 11:00 p.m. Review of the facility's abuse policy and procedure dated 11/2016 under the PROTECTION subpart indicated To protect residents and employees from harm or retaliation during an investigation, the facility shall: Take prompt measures to remove any resident from immediate harm or danger. Suspend staff member(s) believed to be involved, pending the outcome of the investigation. Further review of the facility ' s abuse policy and procedure, dated 11/2016, and concurrent interview with the DON and FA on 6/9/22 at 5:45 p.m., the incident of Resident 1's facial bruising and allegation of the resident being hit by Someone a man had kept on punching or hitting her was discussed, how it was communicated to the DON and ADON on the morning of 6/8/22 by LN3 and also to the FA. That on 6/8/22 as stated by LN4 around 2:40 p.m., DON and FA went to the resident's room to check the resident's bruised face and were investigating. The DON and FA both knew there was an allegation that some one - a man was really mad and kept on hitting the resident and the someone - probable alleged abuser CNA4 was kept on the schedule and continued to be assigned to care for Resident 1. The FA acknowledged the Resident 1 had not been protected as per facility's abuse policy. On 6/9/22, at 5:45 p.m., an Immediate Jeopardy (IJ) was declared in the presence of the facility ' s Administrator, Director of Nursing, and Ombudsman.

Based on observation, interview and record review, the facility failed to ensure a sanitary environment and safe food handling practices within the food service operation for 108 of 108 residents residing at the facility as evidenced by; 1. Live and dead cockroaches were in the kitchen in which dietary staff reported there was a cockroach infestation. The kitchen flooring had missing, and cracked tiles that prevented adequate cleaning. The facility had been aware of the unsanitary condition of the kitchen flooring that could harbor pests since (MONTH) (YEAR) per a County report. In addition, a sanitizing solution for food contact surfaces was not at an effective concentration to sanitize, and dishes stored as clean had dried food debris. 2. Potentially hazardous foods (foods capable of supporting microbial growth) were not cooled down correctly to ensure food safety, 3. There were undated thawed health shakes and pudding inside the walk in refrigerator that prevented monitoring of shelf life, and a sauce was not stored in accordance with manufacturer's guidelines that could affect food safety and/or quality. These deficient practices had the potential to cause foodborne illness to all of the 108 highly susceptible residents currently residing in the facility. According to the FDA (Food and Drug Administration) Food Code (YEAR), A Highly susceptible population means persons who are more likely than other people in the general population to experience foodborne disease because they are: (1) Immunocompromised; . or older adults; and (2) Obtaining food at a facility that provides services such as .health care . Unsanitary conditions in the kitchen related to a cockroach infestation, in which the facility had been aware of needed repairs for at least the previous nine months to prevent cockroaches from harboring and infesting, resulted in an immediate jeopardy (IJ) situation that could cause foodborne illness to all residents residing in the facility. On 3/6/18 at 11:16 AM, the survey team notified the Executive Director (ED) of the IJ due to the cockroach infestation in the kitchen. On 3/8/18 at 1:08 PM, the IJ was abated in the presence of the ED after an acceptable plan of correction was provided by the ED which included the following; closed the kitchen and removed the food service equipment for a thorough pest control service, sealed the floor around the dish machine area with approved sealants per OSHPD (Office of Statewide Health Planning and Development) guidance, obtained meals for the residents from outside restaurants that had passed their County inspection, use of disposable products, the kitchen was cleaned, and an on-site OSHPD compliance officer inspected the kitchen who provided guidance to the facility to replace a missing cover over an electrical condulet that could have assisted as an entry access for cockroaches. In addition, the plan included a plan for routine monitoring of dietary staff cleaning schedule, the outside pest control service was increased to weekly, and a written timeline to obtain and implement permanent flooring that will be durable, smooth, non-absorbent, and easily cleanable surfaces in accordance with the County, FDA Food Code, and OSHPD requirements was submitted by the facility. Findings: 1. On 03/05/18 at 10:10 AM, during an observation and concurrent interview, in the dry food storage room in the kitchen, a pest control box with a clear cover was located on the floor behind shelving that stored canned food. The Dietary Manager (DM) counted at least ten dead brown colored insects that the DM called cockroaches. Debris build-up was observed in the corner of the floor located underneath a shelf. The DM explained that dietary staff may be sweeping or mopping toward the corner and pushing it under the shelf. The DM acknowledged the floor was not clean. The floor that led into the dry food storage room had cracked and missing tile with a build-up of dry black colored substance. The facility's policy and procedure titled Food Safety in Receiving And Storage (last approved 1/29/18) indicated, Dry storage areas should be well-ventilated and pest free . On 03/05/18 at 10:13 AM, during an observation of the kitchen, a back door that exited to the outside of the facility had gaps preventing an enclosed environment to the kitchen in which pests could enter. According to the Food and Drug Administration, Insects and rodents are vectors of disease-causing microorganisms which may be transmitted to humans by contamination of food and food-contact surfaces. The presence of insects and rodents is minimized by protecting outer openings to the food establishment. (FDA Annex 3 - Public Health Reasons/Administrative Guidelines, 6-202.15 Outer Openings, Protected.) On 03/05/18 at 10:38 AM, during an observation and concurrent interview, a utility cart had mugs, meal trays with napkins and silverware located on the cart near the cook's work area. The DM explained the cart was set up to be used for last minute requests by residents for soup. Several of the mugs were observed with dried food debris, and a meal tray was placed directly on top of a pink colored substance on the lower shelf of the utility cart. The DM was asked to observe the food service equipment, and he stated, I don't know why they (dietary staff) put these here. They should have checked to see if they were clean. On 03/05/18 at 10:42 AM, during an observation and concurrent interview, a red bucket with a liquid solution was on top of a food contact countertop to the right of the stove range. A cook (Cook 1) explained that the solution in the red bucket was a sanitizer used to sanitize the countertop that morning, and was still available for use. Cook 1 was asked how he knew it was effective at sanitizing. In the presence of the DM, Cook 1 proceeded to use a chemistry (chem) test strip and inserted the strip into the solution in the red bucket for ten seconds, and stated, It's 100. Cook 1 had determined 100 by comparing the color of the chem strip to a color coded graph on the chem strip vial. Cook 1 was asked if the chem strip of 100 was okay. The cook stated, Yes, it's okay. I don't really check it to be honest with you. Concurrently, the DM was asked what the expected concentration of the sanitizer should be and he stated 200 PPM (parts per million). According to the manufacturer's guidelines located on the bottle of sanitizer used in the red buckets, the effective concentration to sanitize should be at 150-400 PPM. The chem test strips from the vial that the facility used provided a color coded graph in increments of 100 PPM, 200 PPM, 300 PPM, 400 PPM, and 500 PPM. There was no measurement on the chem strip vial available to determine 150 PPM. According to the Food and Drug Administration, A test kit or other device that accurately measures the concentration in MG/L (milligrams per liter) of sanitizing solutions shall be provided. (FDA Food Code 2013; 4-302.14 Sanitizing Solutions, Testing Devices) On 03/05/18 at 10:48 AM, during an observation of the kitchen, the DM entered the janitor's closet located near the dry food storage room and next to the dish machine area. The sanitizer dispenser hoses (where staff obtained a liquid sanitizer for the red buckets to be used to sanitize the food contact surfaces) was located in the janitor's closet. The walls and doorway of the janitor's closet had missing cracks and opened crevices with black colored substance. On 03/05/18 at 10:52 AM, during an observation and concurrent interview, in the presence of the DM, behind the dish machine were large black insects on the wall and surrounding area. The DM stated, I counted eight cockroaches. The DM shown a flash light on the cockroaches in which they began to scatter, and the DM stated, They are live cockroaches. The DM was asked how long cockroaches had been in the kitchen and he said a long while in which sometimes there are more, sometimes less, and confirmed the cockroaches were a chronic problem. On 03/05/18 at 10:55 AM, dried debris was observed on a lower shelf that stored clean cloths, trays for resident meals, and other food service equipment. The shelf was located across from the dish machine, and next to the dry food storage room, and was approximately six inches off the floor. On 03/05/18 at 11:35 AM, the Executive Director (ED) was informed that live and dead cockroaches were observed in the kitchen. The ED explained that he was aware of pest control issues. ED indicated they have pest control at the building. ED indicated it's (pest control) ineffective because the bigger issue is that the tile/flooring needed to be replaced in the kitchen. ED stated, There's probably no seal left on the floor. The ED showed some tile that had been purchased that was located in a storage shed in the back of the facility. ED explained he needed more tile in order to tile all of the floor in the kitchen. On 03/05/18 at 12:50 PM, the registered dietitian (RD) indicated the facility had not developed a policy and procedure related to sanitizing of the food contact surfaces (i.e.; the use of red buckets that contained the sanitizing solution). The RD provided a copy of the (name of company product) 146 Multi-Quat Sanitizer poster that was located in the janitor's closet above the sanitizing dispenser. The poster contained a picture of the color coded graph to compare colors immediately with colors on the test paper package to determine PPM (parts per million), in which the range of colors/PPM were from 0, 150, 200, 400, 500. The RD acknowledged that the chem test strips the facility used to check the PPM concentration of the sanitizer had not provided the ability to check for the lower end of 150 PPM as indicated in the guidance provided by the manufacturer. According to the manufacturer (name of company), A single cockroach sighted during the day can indicate that there is a significant infestation. Cockroaches, also known as 'roaches,' are nocturnal and prefer to live and breed in dark shelters near food and moisture. But if a harborage site is overpopulated, they can be forced out in daylight, often in search of food ., to get to the food they can tread across the floor and through garbage in search of food, then crawl across the food-contact surfaces ., According to the Centers for Disease Control and Prevention (CDC), the German cockroach is a known vector for diseases including: Salmonellosis - Salmonella food poisoning causes diarrhea, fever, and abdominal cramps within 12 to 72 hours. Symptoms are generally mild, but can be severe, especially for those with a compromised immune system. Staphylococcus infections - This gastrointestinal (stomach and intestines) illness develops soon after food is eaten and usually last about a day. The toxins are heat resistant so are not destroyed by cooking. Escherichia coli (E. coli) bacteria normally lives in the intestines of people and animals and some types can cause illness with diarrhea . [MEDICATION NAME] fever - This life-threatening illness is caused by Salmonella Typhi. When a contaminated food is consumed, the bacteria multiply and spread into the bloodstream. Gastroenteritis - inflammation of the stomach and small and large intestines, generally leading to vomiting or diarrhea. General diarrhea. People may become infected with any of these by eating or drinking a contaminated food or beverage . (http://www.(name of company).com/pages/the-dangers-cockroaches-bring-to-food-safety) On 3/6/18 at 8 AM, the outside company pest control reports, an e-mail provided by the ED, and the County inspection reports were reviewed. Per an e-mail provided by the ED, dated 2/6/18, Attached are some pictures and information regarding our kitchen flooring that we discussed .We have a number of areas, including the closet, that no longer have a seal and water comes up from under the floor. We started purchasing the (name of product)tile as this tile meets all required specifications and we would be able to repair/replace floor with a consistent and permanent product. We have 35 cases of the (name of product) to do the entire kitchen we would need approximately 133 more cases, approximately $6000.00 .Regardless of the directions we decide to move, repairs will need to be initiated sooner than later as we have already been sited by the county and the flooring was verbally mentioned during last survey. A review of a Santa Barbara County -Environmental Health Services Official Food Facility Inspection Report, dated 12/15/17, was reviewed and included, .observed warn out floors throughout the kitchen and non coved (gaps, crevices and/or chipped, not rounded floors from the corner of a floor to the wall to prevent gaps) floors throughout the kitchen including but not limited to main kitchen, walk in cooler and dry storage area. Repair all damaged floors .Ongoing violation from (MONTH) (YEAR) The walls/ceilings shall have durable, smooth, non-absorbent, and easily cleanable surfaces. All floor surfaces, other than the customer service areas, shall be approved smooth durable and made of non-absorbent material that is easily cleanable. Approved base coving shall be provided in all areas, except customer service areas and where food is stored in original unopened containers. Food facilities shall be fully enclosed. All food facilities shall be kept clean and in good repair. Re-inspect date 12/21/17. A review of the re-inspection dated 12/21/17 showed the above comments in regard to the flooring to be the same which included, .observed warn out floors in the kitchen and non coved (missing) floor tiles throughout the kitchen . A review of an outside company pest control report, dated 8/2017 included, Janitor's closet infested with roaches. Conduit and wiring treated with dust. Panels are pulling away from walls. Further review of pest control reports ranging from 8/28/17 to 1/24/18 listed open conditions with repeated comments of Janitor's closet in kitchen, Condition: wall panels peeling off. Action: replace or repair wall panels to prevent roaches from harboring and infesting, janitor's closet condition: baseboards peeling away from wall. Action: Repair or replace to prevent roaches from harboring between wall and baseboards, janitor's closet condition: Wiring taped with duct tape should be removed and replaced, Action: roaches harboring between wires and tape. Zip cord would be preferable to tape. Interior kitchen condition: Food and water in grout lines under dish washing sink. Action: To avoid pest issues clean regularly. Interior kitchen: condition: baseboards and wall panels are peeling away from wall. Action: To prevent roaches from harboring between wall panels and baseboards please repair, interior condition: back door not close properly. Action: Install felt between door to prevent pest entrance. On 03/06/18 at 09:15 AM, the ED was unable to state and/or show that a formalized plan on how to address the above ongoing concerns was in place. The ED stated, So far the discussions have only occurred with the corporate director of construction and environmental services. On 03/06/18 at 09:48 AM, a telephone interview was conducted with the corporate director of construction and environmental services (CDCE) in the presence of the ED. The CDCE confirmed that the floor in the kitchen needed to be removed, and stated he was aware that water was coming from the grout. The CDCE stated the wall to the janitor's closet needed to be patched up. The CDCE was asked if any removing of the plumbing to the dish machine needed to be done in order to replace the floor in that area, and he stated that he would need to reach out to OSHPD to ask that question. A few minutes later, the CDCE stated that he would not need an OSHPD permit to do the floor work in the kitchen, and would just need to let OSHPD know that we are replacing the flooring. The CDCE was asked what the barrier was to beginning replacing of the kitchen floor that was cited by the County in (MONTH) (YEAR) as a sanitation concern, and in which live cockroaches were observed in the kitchen, and he stated, I need to discuss with the Administrator (ED). The CDCE was unable to demonstrate or state a formalized plan was in place to address the immediate unsanitary environment in the kitchen. On 03/06/18 at 10:03 AM, a telephone interview was conducted with the OSHPD area compliance officer (ACO). The ACO stated, I haven't heard from (name of the CDCE) about this project whatsoever, it's quite possible they may need to re-anchor equipment. It's highly probable that equipment would need to be re-anchored and plumbing likely to be involved. No one has called me about the kitchen. I am required to return my calls within 24 hours. The ACO was asked had the facility contacted him to conduct a site visit to determine the extent of the project what time- frame was involved. The ACO stated, Our turn around time is a week. That absolutely cannot be their excuse. On 3/7/18 at 9:38 AM, a telephone interview was conducted with the County's Environmental Health Specialist (EHS) who had originally cited the facility in (MONTH) (YEAR) for unsanitary conditions in the kitchen, which included the damaged floor. The EHS stated, I've been telling the facility that there was no way to get the floor clean as it was damaged, stored food debris and the condition of the flooring was a concern for harborage of pests. The EHS stated, I've been telling them for about nine months and kept being told there was no way to get the funding. I told them I worried about the floor to be safe for food service. On 3/8/18 at 12:05 PM, after the OSHPD ACO conducted an on-site visit of the kitchen on the morning of 3/8/18 per the Department's request, the ACO explained that he informed the facility that an OSHPD permit would be required before replacing the kitchen flooring due to the necessity to re-anchor equipment. On 3/12/18 at 11:10 AM, a call was made to the outside pest control company requesting to speak with the technician that serviced the facility. On 3/14/18 at 7:23 AM, the pest control company technician (PCT) was interviewed by phone. The PCT stated, When I took over in (MONTH) (YEAR) there was already a pretty bad cockroach infestation. The PCT explained that he also routinely placed eight mice traps in different locations throughout the kitchen. The PCT indicated he did not recall seeing a mouse but that the mice traps would be full of dead German cockroaches. The PCT was asked if he saw larger cockroaches that appeared black in color, and he stated, Those type of cockroaches would have come in from the outside. They are likely Oriental or Asian type cockroach. The PCT indicated the facility would frequently leave the back door open that was located down a hallway that lead to the outside wear the garbage dumpster's were. The PCT explained that he would advise the facility to keep the door closed and to make repairs to the door as it had gaps and would not be able to fully enclose. The PCT indicated that he informed the facility it created an access point for pests to enter the facility. On 3/13/18 at 10:41 AM, the RD reviewed the pest control service Inspection Reports for July, (YEAR) and August, (YEAR) and hand written documentation of pest control activities for October, (YEAR), and indicated both she (RD) and the ED were notified and aware of the cockroach infestation, and need for preventive repair. The facility's policy and procedure dated 1/29/18 titled Kitchen Sanitation and Cleaning Schedules indicated, Purpose: Ensure a clean and sanitary food environment. Policy: Maintain a clean, sanitary, and safe kitchen., Procedure: 1. The Food and Dining Services Manager develops, implements, and monitors a cleaning schedule that assigns specific cleaning responsibilities to specific individuals ., The Food and Dining Services Manager/designee will check the cleaning schedule at the end of each shift to assure assignments have been completed., .3 Dish and utensil cleaning are located in a separate area from the food service line to assure that a sanitary environment is maintained ., 6. All floors in the food preparation and storage areas are washable and have a nonslip finish. Walls and ceilings are also washable. The facility's policy and procedure dated 1/29/18) titled Pest Control indicated, Purpose; Maintain a sanitary and clean environment through control of insects and rodents. Policy: There is a program established for the control of insects and rodents. The food and dining services department will institute practices to prevent infestation of pests and prevent the contamination of food. Procedure; .7. Gaps and cracks in doorframes and thresholds, and floors and walls are repaired, using sealants recommended by a pest control operator, health department, or building contractor , 9. Spills are cleaned up as they occur. Keep the kitchen clean (clean as you go) . The facility's undated policy and procedure titled Pest Control indicated, Purpose: To provide an environment free of pests. Policy: II. There will be emphasis on the pest control program in kitchens ., and other areas prone to infestation such as areas of overgrowth in adjoining property. III. Monitoring of the environment will be done by the facility's staff. Pest control problems will be reported promptly to the contractor. IV. Screens will be maintained on all windows that open to the outside. If there are no screens, the windows should not be opened . Reference: CDC. Guidelines for Environmental Infection Prevention in Healthcare Facilities: Recommendations of CDC and the Healthcare Infection Control Practice Advisory Committee (HICPAC). MMWR. 2003;52 (RR-10). According to the Centers for Disease Control and Prevention, Guidelines for Environmental Infection Control in Health-Care Facilities, Cockroaches .are among the typical arthropod and vertebrate pest populations found in health-care facilities. Insects can serve as agents for the mechanical transmission of microorganisms, or as active participants in the disease transmission process by serving as a vector ., .outbreaks of infection attributed to microorganisms carried by insects may occur because of infestation coupled with breaks in standard infection-control practices . (https://www.cdc.gov/infectioncontrol/pdf/guidelines/environmental-guidelines.pdf, page 95 of 240) According to the FDA (Food and Drug Administration) Food Code 2013, Floors that are of smooth, durable construction and that are nonabsorbent are more easily cleaned. Requirements and restrictions regarding floor coverings, utility lines, and floor/wall junctures are intended to ensure that regular and effective cleaning is possible and that insect and rodent harborage is minimized. (Cleanability 6-201.11 Floors, Walls, and Ceilings. 6-201.12 Floors, Walls, and Ceilings, Utility Lines) According to the FDA Food Code 2013, When cleaning is accomplished by spraying or flushing, coving and sealing of the floor/wall junctures is required to provide a surface that is conducive to water flushing. Grading of the floor to drain allows liquid wastes to be quickly carried away, thereby preventing pooling which could attract pests such as insects and rodents or contribute to problems with certain pathogens such as Listeria monocytogenes. (6-201.13 Floor and Wall Junctures, Coved, and Enclosed or Sealed) 2. On 3/5/18 at 10:27 A.M., during a concurrent observation and interview, a cook (Cook 1) and the dietary manager (DM) observed a container of pork with spaghetti type noodles, dated 3/4/18, in the reach-in refrigerator next to the stove range. Cook 1 and the DM both indicated they were leftovers and were heated at the facility yesterday. The DM was asked if the left over pork with noodles should be cooled down and he stated they are just placed in the refrigerator without further temperature monitoring. A review of the cool down log that was hanging from a pin near the cook's station did not have the pork/noodles on the cool down log. The DM explained the cool down log was used for pre-day cooking such as for when they cooked roast beef. The DM indicated they are trying to do less pre-day cooking but they still use that method of cooking at times, such as for roast beef. Concurrently, during a concurrent document review and interview, the DM and Cook 1 reviewed the last entry on the cool down log which was beef, dated 1/8 (January 8th). The cool down log indicated the beef was cooked to an internal cooking temperature of 170 degrees Fahrenheit (F) at 9 AM, The next time the temperature of the beef was taken was at 11:30 A.M. at 88 degrees F. The next time the temperature was checked was at 1 PM and was 42 degrees F. The DM and Cook 1 both stated, The last part of the cool down process was wrong. According to the directions located at the bottom of the cool down log Item should be 70 degrees (F) or less by 2 hrs (hours) and 41 degrees (F) or less by 6 hours. If 70 degrees is not reached in 2 hrs, reheat to 165 and start over. If 41 degrees is not reached in 6 hrs, discard item. On 03/05/18 at 12:50 PM, the RD reviewed the cool down log and stated, The beef should have been thrown out. The RD reviewed the rest of the cool down log that had twelve entries on the log from (MONTH) (YEAR) through (MONTH) (YEAR). The RD acknowledged all twelve entries on the form was not cooled down correctly, and therefore the food had been unsafe. The RD stated, I was not really aware because the goal had been to eliminate the cool down log, and do more same day cooking. The observation of leftovers of pork/noodles that was not on the cool down log was discussed with the RD. The RD verified leftovers should have been cooled down for food safety, and documented on the cool down log. The RD stated the facility did not have a specific policy and procedure for cooling down of potentially hazardous foods other than the cool down monitoring log that had directions. According to the Food and Drug Administration Food Code 2013, (A) Cooked Time/Temperature Control For Safety Food shall be cooled: (1) Within 2 hours from 57ºC (135ºF) to 21ºC (70°F); and (2) Within a total of 6 hours from 57ºC (135ºF) to 5ºC(41°F) or less. (FDA Food Code 3013; 3-501.14 Cooling) The facility's policy and procedure titled Safe Food Handling dated 1/29/18, indicated, Purpose: Avoid cross-contamination in food handling. Policy; Sanitary food handling and practices will be followed .,8. Leftovers must be dated, labeled, covered, cooled rapidly and stored in refrigerator or freezer . 3. On 03/05/18 at 09:49 AM, during an observation and concurrent interview, inside the refrigerator was a bin of thawed individual sized four-ounce health shakes, undated. The dietary manager (DM) that they had fourteen days to use the health shakes once placed in the refrigerator. The DM explained the facility's practice was to receive the healthshakes frozen from the facility and immediately place in the refrigerator. The DM indicated dietary staff were expected to date the bin with the date the healthshakes were placed in the bin to ensure they were used within fourteen days. The DM counted thirty-eight individualized sized four-ounce health shakes in the bin and was unable to calculate how long the healthshakes were in the bin since there was no date. According to the manufacturer's guidelines printed on each carton of health shake the healthshakes should be used within fourteen days once thawed. Concurrently, a tray that contained fifteen individualized portions of pudding in a foam cup were observed, undated. The DM verified the puddings were undated and indicated he was unable to calculate how long the puddings were in the refrigerator. The DM explained the puddings had a shelf life of three days per the refrigerated food storage guidelines. On 03/05/18 at 10:10 AM, in the dry food storage room in the kitchen, a one gallon teriyaki sauce, opened on 3/1/18, was stored at room temp in the dry food storage room. The manufacturer's guidelines located on the bottle of teriyaki sauce indicated Refrigerate after opening. The DM confirmed that the opened bottle of teriyaki sauce would have been stored at room temperature until the gallon of teriyaki sauce was used up. The DM acknowledged the manufacturer's guidelines should have been followed for safety and/or quality. The facility's policy and procedure titled Food Safety in Receiving and Storage dated 1/29/18, indicated, Purpose: Food is received and stored by methods to minimize contamination and bacterial growth .