Every finding on record at California Healthcare and Rehabilitation Center

Based on observation, interview, and record review, the facility failed to ensure that the environment remained as free of accident hazards as possible for one of three sampled residents (Resident 1) when Resident 1's bed was left unattended in the raised position. This failure had the potential to increase Resident 1's risk of falling or injury.Findings: During a review of Resident 1's Face Sheet, the Face Sheet indicated that the facility admitted the resident on 11/8/2008 and readmitted the resident on 9/5/2024 with diagnoses including an unspecified head injury, anoxic brain damage (injury caused by lack of oxygen to the brain), and epilepsy (a brain disorder that causes repeated, unprovoked seizures [a sudden, abnormal surge of electrical activity in the brain that temporarily changes how a person acts, moves, feels, or is aware]). During a review of Resident 1's Minimum Data Set (MDS-a resident assessment tool) dated 6/22/2026, the MDS indicated that Resident 1 was dependent on caregivers for all daily activity, including bathing, toileting, and dressing, and has limited range of motion (a joint or body part cannot move fully or easily through its normal distance and direction) in all four limbs. During a review of Resident 1's History and Physical (H&P) dated 7/3/2026, the H&P indicated Resident 1 had cognitive (mental process of acquiring, storing, and using knowledge) impairment. During a review of Resident 1's Care Plan, last reviewed 6/30/2026, the care plan indicated that Resident 1 is at risk for falls and injury related to impaired cognition, poor body balance and control, poor safety awareness and judgement, seizure disorder, and general weakness. The care plan indicated that Resident 1 had a history of falls. The care plan also indicated that floor mats and padded side rails were used to prevent or reduce injury and falls. During an observation on 7/28/2026 at 12:15 p.m., in Resident 1's room, observed Certified Nursing Assistant 1 (CNA 1) leave Resident 1's bed raised after working with Resident 1 and then left the room and did not return. During a concurrent observation and interview on 7/28/2026 at 12:25 p.m., with Licensed Vocational Nurse 1 (LVN 1) in Resident 1's room, observed Resident 1's bed. LVN 1 stated that Resident 1's bed was not in the low position. LVN 1 stated that the bed should be in the low position for safety reasons, but that Resident 1 wasn't at risk for a fall since padded railing were in place. LVN 1 left Resident 1's bed in raised position after leaving the room. During a concurrent observation and interview on 7/28/2026 at 12:35 p.m., with Director of Staff Development 1 (DSD 1) outside Resident 1's room, DSD 1 entered Resident 1's room and lowered the bed to the low position. DSD 1 stated that Resident 1's bed should be kept in the lowest position as part of standard fall precautions to prevent injury. DSD 1 stated that although there were padded railings on Resident 1's bed, all safety measures should be taken. During an interview on 7/28/2026 at 2:36 p.m., with Registered Nurse 1 (RN 1), RN 1 stated that keeping the bed in the lowest position was a standard part of fall prevention. During an interview on 7/28/2026 at 3:25 p.m., with the Assistant Director of Nursing (ADON), the ADON stated that standard fall precaution interventions include raised side rails, keeping bed in the low position, using a floor mat next to the bed, and responding quickly to call lights. The ADON stated that if a bed was left in the raised position, there was a risk of falls. During a review of the facility's policy and procedure titled, Promoting Safety, Reducing Falls, undated, the policy indicated, Caregivers should always make sure that beds are in the lowest position to the floor and that wheels are locked.

Based on interview and record review, the facility failed to respect personal privacy for one of three sampled residents (Residents 2) when a staff member entered the resident's room without permission. This deficient practice had the potential to result in negatively affecting the safety and security for this resident.Findings: During a review of Resident 2's admission Record, the admission Record indicated the facility admitted the resident on 5/9/2017 and readmitted the resident on 9/17/2025 with diagnoses that include myocardial infarction (MI-heart attack), chronic obstructive pulmonary disease (COPD- a chronic lung disease causing difficulty in breathing), and type two (2) diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 2's Minimum Data Set (MDS- a resident assessment tool) dated 5/28/2026, the MDS indicated that Resident 2 has intact cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) and requires maximal assistance on staff with toileting hygiene, shower or bathing, dressing, and toilet transfer. During an interview on 7/20/2026 at 4:00 p.m., with Resident 2, Resident 2 stated that on 7/10/2026 before 7 a.m., she asked Certified Nursing Assistant 9 (CNA 9) to change her incontinence brief (disposable absorbent garment used to manage moderate to heavy bladder or bowel leakage) when CNA 7 walked into Resident 2's room without knocking. Resident 2 stated that she told CNA 7 to leave the room because CNA 7 was not assigned to her and did not feel comfortable to have CNA 7 in the room while being changed by CNA 9. During an interview on 7/23/2026 at 3:13 p.m., with CNA 7, CNA 7 stated CNA 7 entered Resident 2's room without Resident 2's permission. CNA 7 stated that she followed CNA 9 to help since it was already the end of their 11pm to 7am shift. CNA 7 stated that she should have asked Resident 2 permission to enter her room because it is the resident's right to have their personal privacy and space be respected. During an interview on 7/24/2026 at 3:45 p.m., with the Assistant Director of Nursing (ADON), the ADON stated CNA 7 should have asked Resident 2's permission to enter her room because it is the resident's right to have their personal privacy and space be respected. The ADON stated by violating the resident's personal space and privacy, there's a potential for the resident to feel insecure and not feel safe in the facility. During a review of the facility`s policy and procedure (P&P) titled, Resident Rights, last reviewed on 10/20/2025, the policy indicated the resident has the right to personal privacy and confidentiality of his or her personal clinical records. Personal privacy includes accommodations, medical treatment, written and telephone communications, personal care, visits, and meetings of family and resident groups, but this does not require the facility to provide a private room for each resident.

Based on observation, interview, and record review, the facility failed to ensure the proper use of a low air loss mattress (LALM- a specialty bed that alternates pressure to help heal and prevent pressure ulcer/injuries [ PU/PI-injuries that breakdown the skin and underlying tissue when an area of skin is placed under pressure]) for two of three sampled residents (Resident 2 and Resident 3) when on 6/8/2026 a cloth bed pad and a sheet were placed over the mattress surface while Resident 2 and Resident 3 were also wearing an incontinence (loss of bowel or bladder control) brief (diaper). This deficient practice had the potential to compromise the effectiveness of the LALM by reducing airflow and pressure redistribution, thereby increasing the risk of skin breakdown, development or worsening of PU/PI, excess moisture retention and delayed wound healing.Findings:a. During a review of Resident 2's admission Record, the admission Record indicated the facility admitted Resident 2 on 5/1/2025 with diagnoses that included, but were not limited to, non-traumatic intracerebral hemorrhage ( bleeding inside the brain that was not caused by a head injury or trauma), acute respiratory failure ( a sudden, life threatening condition where the lungs cannot properly exchange oxygen and carbon dioxide), and hemiplegia ( paralysis [loss of movement]) on one side of the body and hemiparesis ( weakness on one side of the body) following cerebral infarction ( a type of stroke caused by a blockage of blood flow to part of the brain). During a review of Resident 2's Minimum Data Set (MDS - a resident assessment tool) dated 5/13/2026, the MDS indicated Resident 2's cognitive (the mental action or process of acquiring knowledge and understanding through thought, experience, and senses) skills for daily decision making were severely impaired. The MDS further indicated Resident 2 was dependent on oral, toileting, and personal hygiene, showering, upper and lower body dressing, and putting on/and taking off footwear. During a review of Resident 2's Braden Scale (tool used for predicting PU/PI risk) score dated 5/11/2025, the Braden Scale indicated Resident 2's score was 9. The Braden Scale further indicated Resident 2 had a very high risk of developing PU/PI. During a review of Resident 2's Physician Order dated 1/23/2026, the Physician Order indicated a LALM mattress was ordered for skin care and management. During a concurrent observation and interview on 6/9/2026 at 8:36 a.m., with Registered Nurse (RN) 1, observed Resident 2 lying on a LALM while wearing an incontinence brief. The LALM was covered with a flat sheet and a cloth incontinence pad. When RN1 was asked what the recommended linen set up for a LALM, RN 1 stated there should only be two layers of linen between the resident and mattress. RN 1 further stated that Resident 1 should not have been wearing an incontinence brief when an incontinence pad and sheet were placed over the LALM to prevent moisture retention and skin breakdown. b. During a review of Resident 3's admission Record, the admission Record indicated the facility admitted Resident 3 on 5/4/2024 and was readmitted on [DATE] with diagnoses that included, but were not limited to, acute respiratory failure ( a sudden, life threatening condition where the lungs cannot properly exchange oxygen and carbon dioxide), traumatic brain injury (TBI-a disruption in the normal function of the brain that can be caused by a bump, blow, or jolt to the head), and functional quadriplegia (paralysis from the neck down, including legs, and arms, usually due to a spinal cord injury). During a review of Resident 3'sMDS dated [DATE], the MDS indicated Resident 3's cognitive skills for daily decision making were severely impaired. The MDS further indicated Resident 3 was dependent on eating, oral, toileting, and personal hygiene, showering, upper and lower body dressing, and putting on/and taking off footwear. During a review of Resident 3's Braden Scale (tool used for predicting PU/PI risk) score dated 5/30/2026, the Braden Scale indicated Resident 3's score was 10. The Braden Scale further indicated Resident 3 had a high risk of developing PU/PI. During an observation on 5/9/2026 at 8:35 a.m. in Resident 3's room, Resident 3 was observed lying on LALM covered with cloth incontinence pad and flat sheet while wearing incontinence brief. During an interview on 5/9/2026 at 9:10 a.m., with Certified Nursing Assistant (CNA) 4, CNA 4 stated Resident 3 should not have a cloth pad placed underneath the resident when wearing a diaper to prevent skin breakdown. CNA 4 further stated Resident 3's cloth pad was removed and only a flat sheet was used between the resident and LALM after putting a clean diaper on Resident 3. During an interview on 5/9/2026 at 2:40 p.m., with the Assistant Director of Nursing (ADON), the ADON stated that according to the facility's policy, there should be no more than two layers of linens used for a LALM. The ADON stated residents on LALM should not be wearing both diapers and cloth pads because it can interfere with the LALM from working properly to reduce moisture which may lead to skin breakdown. During a review of the facility's policy and procedure (P&P) titled, Pressure-reducing mattresses, undated, the P&P indicated, To provide mattresses that will prevent and/or minimize pressure on the skin. Place flat sheet over mattress, while ensuring that no more than two layers of linen are between resident and pressure reducing mattress (this excludes the thin mattress cover from the manufacturer).

Based on interview and record review, the facility staff failed to notify the physician immediately when a resident had decreased meal intake (consumed less than 50 percent of his meal) for one of five sampled residents (Resident 5). This deficient practice had the potential to negatively affect the provision of necessary care and services.Findings: During a review of Resident 5's admission Record, the admission Record indicated the facility admitted the resident on 10/8/2025 with diagnoses that included acute respiratory failure (sudden lack of oxygen to the lungs) unspecified whether with hypoxia (body tissues and organs not getting enough oxygen) or hypercapnia (buildup of too much carbon dioxide), aphasia (a disorder that makes it difficult to speak), and person injured in other specified non collision transport accidents involving motor vehicle (traffic), subsequent encounter During a review of Resident 5's Minimum Data Set (MDS- a resident assessment tool) dated 5/4/2026, the MDS indicated that Resident 5 had severely impaired cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses), and dependent on staff with toileting hygiene, tub/shower transfer, lower body dressing, roll left and right, and chair/bed to chair transfer. During a review of Resident 5's Nutritional Eaten Percentage Amount, Nutritional Eaten Percentage Amount indicated that Resident 5's meal percentage was 40% on 5/16/2026 at 1:00 p.m., 40% on 5/17/2026 at 1:00 p.m., and 20% on 5/17/2026 at 1:00 p.m. During an interview on 6/3/2026 at 12:45 p.m., with Licensed Vocational Nurse 2 (LVN 2), LVN 2 stated that CNA 4 had reported to him (LVN 2) that Resident 5's Nutritional Eaten Percentage Amount on 5/16/2026 at 1:00 p.m., 5/17/2026 at 1:00 p.m., and 5/18/2026 at 1:00 p.m., were less than 50% of his meal. LVN 2 stated he should have completed a change of condition, and by not completing a change of condition it can negatively affect and delay in providing the necessary care and services that Resident 5 needs. During an interview on 6/3/2026 at 2:51 p.m., with the Registered Dietician (RD), the RD stated she (RD) was not aware that Resident 5's meal percentage was 40% on 5/16/2026 at 1:00 p.m., 40% on 5/17/2026 at 1:00 p.m., and 20% on 5/17/2026 at 1:00 p.m. The RD stated if she was aware of Resident 5's meal intake, she would have provided additional recommendations for Resident 5's weight management. During an interview on 6/5/2026 at 3:30 p.m., with Assistant Director of Nursing 1 (ADON1), ADON 1 stated that the nurses should have done a change of condition for Resident 5 because it can negatively affect and delay providing the necessary care and services that the resident needs. During a review of the facility's policy and procedure titled, Change of Condition, last reviewed on 11/25/2025, the policy indicated all changes of condition in a resident shall be handled promptly. Upon a change of condition for any reason, nursing staff members are to take the following actions. Physician shall be called promptly. Documentation of change of condition shall be performed by the Licensed Nurse accordingly.

Based on interview and record review, the facility failed to ensure History and Physical (H&P- contains relevant information about the resident's past medical history, current medical concerns, including review of any pre-existing medical conditions, past hospitalizations and surgeries, allergies, medications being taken, family medical history, physical examination and assessment of mental status) Examinations were completed by the physician for two of five sampled residents (Resident 4 and Resident 5). This deficient practice had the potential to result in incomplete clinical information, inconsistent care coordination, and compromised continuity of care, placing Resident 4 and Resident 5 at risk for unmet care needs and inadequate treatment planning. Findings: a. During a review of Resident 4's admission Record, the admission Record indicated the facility initially admitted the resident on 4/2/2026 with diagnoses that include encephalopathy (a brain disease, damage, or malfunction), acute respiratory failure (sudden lack of oxygen to the lungs) with hypoxia (body tissues and organs not getting enough oxygen), and cerebral infarction (lack of blood flow resulting in severe damage to some of the brain tissue). During a review of Resident 4's Minimum Data Set (MDS- a resident assessment tool) dated 4/16/2026, the MDS indicated that Resident 4 had severely impaired cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses), and dependent on staff with toileting hygiene, tub/shower transfer, lower body dressing, roll left and right, and chair/bed to chair transfer. During a review of Resident 4's H&P dated 4/23/2026, the H&P indicated there was no documented evidence that Resident 4's physician completed and documented an assessment of Resident 4's mental status (assessment of current mental capacity [ability to understand and make decisions]). b. During a review of Resident 5's admission Record, the admission Record indicated the facility admitted the resident on 10/8/2025 with diagnoses that included acute respiratory failure (sudden lack of oxygen to the lungs) unspecified whether with hypoxia (body tissues and organs not getting enough oxygen) or hypercapnia (buildup of too much carbon dioxide), aphasia (a disorder that makes it difficult to speak), and person injured in other specified non collision transport accidents involving motor vehicle (traffic), subsequent encounter. During a review of Resident 5's MDS dated [DATE], the MDS indicated that Resident 5 had severely impaired cognition and dependent on staff with toileting hygiene, tub/shower transfer, lower body dressing, roll left and right, and chair/bed to chair transfer. During a review of Resident 5's H&P dated 4/28/2026, the H&P indicated there was no documented evidence that Resident 5's physician completed and documented an assessment of Resident 5's mental status. During a concurrent interview and record review on 6/5/2026 at 3:45 p.m., with Assistant Director of Nursing 1 (ADON 1), reviewed Resident 4's H&P dated 4/23/2026 and Resident 5's H&P dated 4/28/2026. ADON 1 stated Resident 4's H&P dated 4/23/2025 was incomplete because Resident 4's physician failed to document Resident 4's mental status assessment, which is necessary to establish a baseline for care planning. ADON 1 further stated Resident 5's H&P dated 4/28/2026 was incomplete because the physician failed to document the resident's mental status assessment, which is an important component in developing and implementing an appropriate plan of care. During a review of the facility's policy and procedure (P&P) titled, Physician Services, last reviewed on 11/25/2025, the P&P indicated the medical care of each resident is supervised by a licensed physician. Supervising the medical care of residents includes (but is not limited to): participating in the residents' assessment and care planning and overseeing a relevant plan of care.

Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) was provided with a safe and comfortable environment when wheelchairs (a mobility device consisting of a chair mounted on wheels, designed for individuals who have difficulty or are unable to walk due to illness, injury, disability or age) and hospital beds were stored in the patio area. This deficient practice had the potential to place Resident 1 and other residents, staff, and visitors at risk for unsafe and/or uncomfortable environment. Findings: During a review of Resident 1's Face Sheet, the Face Sheet indicated the facility admitted Resident 1 on 2/3/2026 with diagnoses that included, but were not limited to cerebral infarction (stroke, loss of blood flow to a part of the brain resulting in damage to brain tissue), Guillain-Barre syndrome (a rare condition where the body's immune system attacks the nerves, causing muscle weakness and sometimes paralysis), and osteoporosis (weak and brittle bones due to lack of calcium and Vitamin D). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 4/29/2026, the MDS indicated Resident 1's cognitive (the mental action or process of acquiring knowledge and understanding through thought, experience, and senses) skills for daily decision making were intact. The MDS further indicated Resident 1 was dependent on eating, oral and personal hygiene, toileting and showering, lower and upper body dressing, and putting on/and taking off footwear. During an interview on 5/26/2026 at 10:12 a.m., with Family Member 1 (FM 1), FM 1 stated when looking out of Resident 1's window from their prior room, it looked like a storage unit because of all the equipment that was kept there. During an observation on 5/26/2026 at 2:15 p.m., on the patio located near the sub-acute unit (special area in a nursing facility or rehabilitation center where residents receive short term medical and rehabilitation care after a hospital stay), observed several wheelchairs and three hospital beds, with two of the hospital beds having mattresses covered with dust, dirt, and debris from a nearby tree. The patio can be accessed by anyone including staff, residents, and visitors through a double door that was not locked. During an interview on 5/26/2026 at 2:48 p.m., with Maintenance 2, Maintenance 2 stated the hospital beds should not have been kept in the patio. Maintenance 2 also stated the patio area was not locked and can be accessed by anybody including residents, which posed a potential safety concern. Maintenance 2 stated the patio should be for residents' use. During an interview on 5/26/2026 at 4:00 p.m., with the Assistant Director of Nursing (ADON), the ADON stated the hospital beds and mattresses should have been stored in an enclosed clean area for safety issues and concerns. The ADON further stated the patio should have been secured to prevent residents, staff, or visitors from accidents when wheelchairs and hospital beds were being placed in the patio. During a review of the facility's policy and procedure (P&P) titled, Hazardous Areas, Devices and Equipment, revised 11/2025, the P&P indicated, All hazardous areas, devices and equipment in the facility will be identified and addressed appropriately to ensure resident safety and mitigate accident hazards to the extent possible. A hazard is defined as anything in the environment that has the potential to cause injury or illness. Examples of environmental hazards include, but are not limited to the following:a. Equipment and devices that are left unattended or are malfunctioning.Any element of the resident environment that has the potential to cause injury and that is accessible to a vulnerable resident is considered hazardous. During a review of the facility's P&P titled, Grounds, revised 11/2025, the P&P indicated, Areas around the buildings (i.e., sidewalks, patios, gardens, etc.) shall be maintained in as safe and orderly manner at all times.

Based on interview and record review, the facility's licensed nurses failed to conduct accurate fall risk assessments for two of four sampled residents (Resident 1 and Resident 2).These deficient practices had the potential to increase the residents' risk for falls and fall-related injuries. a. During a review of Resident 1's Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated that the facility originally admitted Resident 1 on 1/27/2025 and readmitted on [DATE] with diagnoses that included left femur (thigh bone) fracture (broken bone), cerebral infarction (stroke, loss of blood flow to a part of the brain resulting in damage to brain tissue), contractures (stiffening/shortening at any joint, that reduces the joint's range of motion [full movement potential of a joint]) left hand, right hand, and left ankle, functional quadriplegia (paralysis [loss of ability to move] from the neck down, including legs, and arms, usually due to a spinal cord injury), and osteoporosis (a medical condition that weakens bones, making them fragile and highly susceptible to fractures). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 4/8/2026, the MDS indicated that Resident 1's cognition (ability to think, reason, and function) was severely impaired. The MDS further indicated Resident 1 was dependent on staff for toileting, personal hygiene, showering/bathing, upper and lower body dressing, and rolling left and right in bed. Resident 1 also required maximal assistance with oral hygiene and required setup or clean-up assistance with eating. The MDS indicated that staff were unable to assess Resident 1's functional status for sitting to lying, lying to sitting on the side of the bed, sitting to standing, toilet transfers, and walking.During a review of Resident 1's Change in Condition (COC - an acute, abnormal alteration in a resident's physical or mental baseline) Evaluation form dated 5/3/2026, the COC Evaluation form indicated the following: Timed at 2:56 p.m., at 10:31 a.m., Resident 1 was found sitting on the floor mat with the resident's back leaning against the bed. Timed at 7 p.m., the facility received a radiology (diagnostic imaging, a series of tests that take pictures or images of parts of the body) report identifying a left distal femur fracture. Resident 1's physician was notified and ordered transfer of Resident 1 to General Acute Care Hospital 1 (GACH 1).During a review of Resident 1's Fall Risk Evaluation dated 4/5/2026, the Fall Risk Evaluation indicated the following:1.In the History, Current Status, Predisposing Conditions Section, the form instructed staff to conduct assessments upon admission and quarterly, at a minimum, thereafter, observe the resident status in the 11 clinical condition parameters listed below by assigning the corresponding score which best describes the resident. If the total score is 10 or greater, the resident should be considered at high risk for potential falls. Prevention protocol should be initiated immediately and documented on the care plan. Systolic Blood Pressure (SBP - the top [higher] number in a blood pressure reading, measuring the maximum pressure in your arteries when the heart contracts and pumps blood) was marked with no noted drop in SBP between lying and standing positions.2.In the Gait (a person's particular manner, style, or pattern of walking or running) and Balance Section, the evaluation indicated Resident 1 was unable to perform the function.During a review of Resident 1's Fall Risk Evaluation dated 5/3/2026, the Fall Risk Evaluation indicated the following:1.In the History, Current Status, Predisposing Conditions Section, the history of falls within the past three (3) months was marked as no falls, despite the COC Evaluation dated 5/3/2026 indicating Resident 1 had a fall on the same date. Additionally, the evaluation indicated no noted drop in SBP between lying and standing positions. 2.In the Gait and Balance Section, the evaluation indicated Resident 1 was not able to perform function.During an interview on 5/14/2026 at 3:47 p.m., with the Assistant Director of Nursing (ADON), the ADON reviewed Resident 1's Fall Risk Evaluations dated 5/3/2026 and stated that the fall risk evaluation was completed following the fall incident, however, the actual fall that occurred on 5/3/2026 was not included on the evaluation. The ADON was unsure whether the fall should have been included and stated she (ADON) would confirm with the facility consultant. The ADON further stated that the section regarding SBP, which was marked as no noted drop between lying and standing was not an appropriate selection for Resident 1 because the resident was unable to stand and was dependent on staff for all Activities of Daily Living (ADLs - activities such as bathing, dressing and toileting a person performs daily) prior to the fall incident. The ADON stated the evaluation form only provided three response options related to lying and standing blood pressure measurements and the electronic system would not allow the evaluation to be completed if the section was left blank; however, the selected response did not accurately reflect Resident 1's condition. b. During a review of Resident 2's Face Sheet, the Face Sheet indicated that the facility originally admitted Resident 2 on 1/7/2025 and readmitted on [DATE] with diagnoses that included acute (sudden, intense flare-up) respiratory failure (the lungs cannot get enough oxygen into the blood or cannot remove a waste gas from the blood), contractures of the left hand and elbow, and anemia (a condition where the body does not have enough healthy red blood cells).During a review of Resident 2's MDS dated [DATE], the MDS indicated that Resident 2's cognition was severely impaired. The MDS further indicated that Resident 2 was dependent on staff for toileting, personal hygiene, showering/bathing, and lower body dressing. The MDS indicated Resident 2 required maximal assistance with oral hygiene, upper body dressing, sit-to-stand activities, and transfers. During a review of Resident 2's COC Evaluation form dated 3/20/2026 timed at 3:28 p.m., the COC Evaluation form indicated, at 11:40 a.m., Resident 2 had a fall and sustained a small abrasion (superficial injury where the outer layer of skin is scraped or rubbed away) to the top of the resident's head. Resident 2's physician ordered a stat (immediately) skull (a collection of bones that form a protective structure for the brain) X-ray (a type of medical imaging that uses radiation to take pictures of the inside of the body) following the incident. During a review of Resident 2's Fall Risk Evaluation dated 3/20/2026, the Fall Risk Evaluation indicated the following:1.In the History, Current Status, Predisposing Conditions Section, the form instructed staff to conduct assessments upon admission and quarterly, at a minimum, thereafter, observe the resident status in the 11 clinical condition parameters listed below by assigning the corresponding score which best describes the resident. If the total score is 10 or greater, the resident should be considered at high risk for potential falls. Prevention protocol should be initiated immediately and documented on the care plan. Despite the COC Evaluation form dated 3/20/2026 indicating Resident 2 had a fall on the same date, the history of falls within the past three months was marked as no falls. During a review of Resident 2's Fall Risk Evaluation dated 3/20/2026, the Fall Risk Evaluation indicated a fall score of nine (indicating the resident was not identified as being at high risk for falls).During an interview on 5/14/2026 at 4:05 p.m., with the ADON, the ADON reviewed Resident 2's Fall Risk Evaluations dated 3/20/2026 and stated that the fall risk evaluation was completed after the fall incident; however, the actual fall that occurred on 3/20/2026 was not included in the evaluation. When the ADON was asked regarding the purpose of completing a fall risk evaluation following a fall incident, the ADON stated the evaluation was intended to reduce the risk of subsequent falls and to identify factors contributing to the resident's current fall incident so the facility could implement new interventions and/or revise existing interventions based on the resident's identified fall risk factors.During a review of the facility's policy and procedures (P&P) titled, Initial Fall Risk Assessment last reviewed on 11/25/2025, the P&P indicated, All residents will be assessed using the initial fall risk assessment tool during admission and readmission. Each resident will be given a score, if the score is 10 or above, the resident will be considered as high risk for fall and a plan of care will be established immediately for implementation of interventions to attempt prevention. The plan of care will be reviewed by the Interdisciplinary Team (IDT - a group of different health professional - such as doctors, nurses, therapists, and social worker who meet regularly to create a single, coordinated care plan for a resident) quarterly and as needed for update of the resident's current needs.During a review of the facility's P&P titled, Promoting Safety, Reducing Falls last reviewed on 11/25/2025, the P&P indicated, If caregivers are to prevent falls, they must first have a working knowledge of the key factors that determine which residents are most at risk. History of falls. Any information about previous falls should be reported immediately to the charge nurse. Important details include the specific activity the resident was doing at the time of the fail, any symptoms experienced just before or at the time of the fall, and any' injuries sustained. Medical treatment issues. Side effects from medications are a major cause if falls in the elderly.

Based on observation, interview, and record review, the facility failed to ensure the confidential personal information of residents were protected by failing to ensure documents (diet typer report) containing protected information ([PHI]- any health information that can be used to identify specific individual which must remain confidential to prevent harmful consequences) were shredded prior to disposing in the waste container. This failure had the potential to violate 125 of 125 residents' rights for privacy and confidentiality of personal and medical records. Findings: During an observation on 4/20/2026 at 8:22 a.m., observed diet type report for all stations, dated 4/13/2026, which contained containing residents' names, room numbers, diet orders, and allergies were disposed of in the trash. During a concurrent observation and interview on 4/20/2026 at 9:13 a.m., with the Dietary Supervisor (DS), observed the trash can by the grill area containing diet type report. The DS confirmed that the diet type report was found in the trash and stated it should not have been discarded in the trash, as it constitutes violation of the Health Insurance Portability and Accountability Act ([HIPPA], a law that sets national standard to protect sensitive health information, making sure it stays private and secure) violation. The DS stated that the diet type report contains residents' information including names, diet orders, and room numbers, which are and these are considered protected information. The DS stated throwing the diet type report in the trash could potentially result in unauthorized exposure of the residents' information and creates a risk that the information could be stolen. During a review of the facility's policies and procedures (P&P) titled Notice of Privacy Practices, dated 11/25/2025, the P&P indicated, The facility adopts this policy requiring that the facility provide notice of the facility's privacy practices to facility patients and the public. The facility has adopted a Notice of Privacy Practices that describes the facility's privacy practices (the Privacy Notice), the use and disclosure of Protected Health Information (PHI) at the facility, and the patient's rights regarding PHI. Training a. Facility staff will be trained on the privacy notices of the facility, including practices outlined in the privacy notice upon hire and annually.

Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen when: 1. A personal iced drink with a straw was stored in the pitcher storage area.2. Kitchen staff failed to perform handwashing when:a. Dietary Aide 1 (DA 1) sneezed and touched his hair, then proceeded to work on the trayline (an area where food is assembled from the steamtable [kitchen appliance that keeps food warm at a safe serving temperature] onto resident's plates) without washing his hands.b. DA 1 transitioned from handling dirty items to clean items in the pot sink area without washing his hands.c. [NAME] 2 touched the lid of the trash can and then handled a pan containing pureed sausages without washing her hands. 3. Refrigerator and freezer temperature monitoring was not consistently performed when: a. The refrigerator and freezer temperature log contained no documented temperature records for 4/13/2026 and 4/19/2026.b. The resident's freezer located by Station 1 did not contain a thermometer, and staff did not monitor the freezer temperature. 4. Kitchen equipment and utensils were not maintained free from dirt, dust and food debris when:a. The reach-in refrigerator contained dried food spills, gelatin residue, dust and dirt debris.b. Dry storage shelves contained dirt, dust particles and debris.c. Sugar, rice and cereal containers in the dry storage area contained food residue, dust and dirt debris.d. Mixer contained whipped cream debris and had not been cleaned after use.e. The vent near the preparation area contained accumulated dirt and dust.f. Black condiment containers located by the trayline contained accumulated sugar, pepper, salt and artificial sweeteners debris.g. The residents' refrigerator located at Station 1 contained food spills.5. Seven (7) dented cans (a hallow, dip, or depression on a surface, caused by blow, impact or pressure) were stored together with non-dented cans in the food storage area. 6. Resident's trays were not air-dried during the lunch trayline process and [NAME] 2 reused a paper towel to wipe the towels dry. 7. Soap splashes were observed in the clean drying area where pans were drying, creating the potential for cross-contamination.8. Staff failed to follow the manufacturer's guidelines for the use and testing of quaternary ammonium (QUAT, a common chemical cleaner used to kill germs, bacteria and viruses) sanitizer when:a. Dietary Aide 1 (DA 1) did not immerse the pots and pans in the sanitizer sink for the required 60 seconds b. DA 1 did immerse the QUAT test strips in the testing solution for the required 15 seconds and did not check the temperature of the testing solution. The Testing solution temperature was not maintained between 65 degrees Fahrenheit ( F, a scale of temperature) to 75 F, as required.c. [NAME] 2 failed to sanitize the Robo Coupe (a high-performance food processor for chopping, mixing, pureeing, and blending large quantities of food) after each use.These failures had the potential to result in harmful bacterial growth and cross contamination (transfer of harmful bacteria from one surface, object, or substance to another) which could lead to foodborne illness (an illness caused by consuming contaminated food or beverages) for 124 of 125 medically compromised residents who received food and ice from the kitchen. Findings: 1. During an initial kitchen tour observation on 4/20/2026 at 8:19 a.m., of the pitcher storage area near the trayline, an iced brown drink with a straw was observed.During an interview on 4/20/2026 at 9:20 a.m., with the Dietary Supervisor (DS), the DS stated the iced drink with a straw by the pitcher storage area was not acceptable because eating and drinking was not allowed in the kitchen as part of the facility's policy. The DS stated dietary staff could not drink or eat in the kitchen as their saliva could potentially contaminate the food causing cross-contamination. The DS stated residents could develop foodborne illness as a potential outcome of cross-contamination. During a review of the facility's P&P titled Sanitation and Infection Control, dated 11/25/2025, the P&P indicated, Food service employees will follow infection control policies to ensure the department operates under sanitary conditions at all times.12. Employee personal belongings (i.e. clothing, food, cellphone, etc.) should be stored in a separate area away from food or items used in food service.During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated, 3-307.11 Miscellaneous Sources of Contamination. Food shall be protected from contamination that may result from a factor or source not specified under subparts 3-391 - 3-306.2. a. During an observation of DA 1 on 4/20/2026 at 8:23 a.m., near the trayline, DA 1 sneezed and covered his mouth with his gloved hands, then removed his gloves and put on a new glove, without handwashing prior to going back to serving the breakfast trayline.During an observation on 4/20/2026 at 8:32 a.m., of breakfast trayline, DA 1 touched his hair with bare hands, put on gloves then proceeded to continue serving food in the trayline. During an observation on 4/20/2026 at 12:57 p.m., of the lunch trayline, DA 1 touched his mask with his left hand and returned to working at the trayline without washing his hands. During an interview on 4/21/2026 at 3:26 p.m., with the DS, the DS stated removing dirty gloves with the use of a paper towel after sneezing then putting on gloves without handwashing was not acceptable. The DS stated DA 1 should have removed his dirty gloves after he sneezed, and then he should have washed his hands before changing his gloves and going back to work. The DS stated DA 1 needed to follow this procedure because hands carry germs, and residents could become ill from foodborne illness if germs are spread through cross-contamination. The DS further stated that DA 1 could not touch his hair or mask and continue working without washing his hands, as this could result in cross-contamination of food and potentially lead to foodborne illness among residents. The DS stated that DA 1 had received handwashing training a long time ago but could not recall the exact training date.During a review of the facility's policy and procedure (P & P) titled, Sanitation and Infection Control, dated 11/25/2025, the P&P indicated that handwashing should be performed after using the toilet, sneezing, using a handkerchief or tissue, and after touching the face and hair.b. During an observation on 4/21/2026 at 2:52 p.m., of the dishwashing process in the two (2)-compartment sinks, DA 1 washed the pans in the 2- compartment sink near the preparation area then transferred them to the 2- compartment sink near the DS office. DA 1 was observed placing the pans into the sanitizer and drying area without washing his hands.During an interview on 4/21/2026 at 3:10 p.m. with the DS, the DS stated DA 1 should have completed the dishwashing process at the first two compartment sinks before proceeding to the second two compartment sinks, so he would not need to go back and forth between dirty and clean areas. The DS stated DA 1 failed to change his gloves and wash his hands and should have washed his hands when going to dirty to clean to prevent cross contamination. During an interview on 4/21/2026 at 3:20 p.m. with DA 1 and the DS, DA 1 stated he should have washed his hands and changed his gloves when moving from the 2-compartment sink by the preparation area to the 2-compartment sink by the office. DA 1 stated he had received training in handwashing and was supposed to wash his hands but forgot. DA 1 further stated he needed to wash his hands for infection control purposes. During a review of the facility's policy and procedure (P & P) titled, Sanitation and Infection Control, dated 11/25/2026, the P&P indicated, handwashing should be done after handling the carts, soiled dishes and utensils.During a review of the facility's P&P titled, Manual Dishwashing - 2 or 3 Compartment Sink, dated 11/25/2026, the P&P indicated, To prevent cross-contamination, wash hands and change gloves when handling clean dishes.c. During an observation on 4/22/2026 at 6:37 a.m., of the puree food preparation, [NAME] 2 prepared puree food then went to throw away a plastic wrap and touched the lid of the trash can in the preparation area. [NAME] 2 went back to work and touched the pan containing puree food and placed it on the steamtable. During an interview on 4/22/2026 at 6:48 a.m., with the DS stated garbage is considered dirty and once a kitchen staff touched a garbage container, they should immediately wash their hands then change gloves to prevent cross contamination.During a review of the facility's P&P titled, Safe Food Transfer and Cross-Contamination Prevention Policy dated 11/25/2025, the P&P indicated, Staff must wash their hands with soap and water or use a facility-approved hand sanitizer before handling food or containers.Gloves must be work during the transfer process. Gloves must be changed if they become torn, contaminated, or after handling non-food items.During a review of the facility's P&P titled, Sanitation and Infection Control, dated 11/25/2025, the P&P indicated, handwashing should be done after handling any waste and waste products, and before and after handling of foods. The P&P further indicated, staff should avoid cross-contamination.During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated 2-301.14 When to Wash. FOOD EMPLOYEES shall clean their hands and exposed portions of their arms as specified under S 2-301.12 immediately before engaging in FOOD preparation including working with exposed FOOD, clean EQUIPMENT and UTENSILS, and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLESP and: (A) After touching bare human body parts other than clean hands and clean, exposed portions of arms; P (B) After using the toilet room; P (C) After caring for or handling SERVICE ANIMALS or aquatic animals as specified in 2-403.11(B); P (D) Except as specified in 2-401.11(B), after coughing, sneezing, using a handkerchief or disposable tissue, using TOBACCO PRODUCTS, eating, or drinking; P (E) After handling soiled EQUIPMENT or UTENSILS; P (F) During FOOD preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; P (G) When switching between working with raw FOOD and working with READY-TO-EAT FOOD; P (H) Before donning gloves to initiate a task that involves working with FOOD; P and (I) After engaging in other activities that contaminate the hands.3. a. During an observation on 4/20/2026 at 8:53 a.m., of the refrigerator log, the refrigerator 2 log did not indicate refrigerator temperature for 4/13/2026.During an observation on 4/20/2026 at 8:58 a.m., of the refrigerator log, there were no temperatures indicated for 4/13/2026 for PM shift and 4/19/2026 in the PM shift.During an interview on 4/20/2026 at 9:25 a.m., with the DS, the DS stated kitchen staff take the refrigerator and freezer temperatures once in the morning and once in the afternoon to make sure the food is safe. The DS stated if the refrigerator and freezer temperatures were not taken and monitored, it could be out of temperature range causing the food to spoil and go bad for residents. The DS stated when food gets spoiled and consumed by the residents, it could potentially cause foodborne illness. The DS stated he checked the temperature logs everyday, but he did not see that there were no temperatures documented on 4/13/2026 and 4/19/2026.During a review of the facility's P&P titled, Refrigerator/Freezer Storage, dated 11/25/2025, the P&P indicated, Dietary staff will check and record temperatures of all refrigerators and freezers to ensure the equipment is within appropriate temperature for food storage and handling. Dietary staff will record and initial temperature log at the beginning of the shift.Refrigerator and freezer temperatures will be checked, recorded, and initialed by dietary staff on both the AM and PM shift to ensure temperatures remain in acceptable ranges.b. During a concurrent observation and interview on 4/22/2026 at 9:59 a.m., of the residents' refrigerator with the DS and Licensed Vocational Nurse 1 (LVN 1), ice buildup was observed in the freezer and there was no thermometer inside it. LVN 1 stated there was no thermometer inside the freezer, and they do not monitor the temperature of the freezer. The DS stated they need to monitor the freezer temperature so ensure that the food stays frozen, and will not melt and spoil. The DS stated there was ice buildup in the freezer, and it should not be to ensure the freezer works properly and keeps its temperature During a review of the facility's P&P titled, Refrigerator/Freezer Storage dated 11/25/2025, the P&P indicated (1) Dietary staff will check the inside temperature of the refrigerator and freezers. Each refrigerator and freezer must have a clear visible thermometer placed inside the unit, located near the door or warmest area. During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated 4-204.112 Temperature Measuring Devices. (A) In a mechanically refrigerated or hot FOOD storage unit, the sensor of a TEMPERATURE MEASURING DEVICE shall be located to measure the air temperature or a simulated product temperature in the warmest part of a mechanically refrigerated unit and in the coolest part of a hot FOOD storage unit. (B) Except as specified in (C) of this section, cold or hot holding EQUIPMENT used for TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be designed to include and shall be equipped with at least one integral or permanently affixed TEMPERATURE MEASURING DEVICE that is located to allow easy viewing of the device's temperature display. 4. a. During an observation on 4/20/2026 at 8:58 a.m., of the refrigerator, there was a sticky Jello like debris spill on the refrigerator wall, dust, dirt and spills were observed at the bottom of the refrigerator shelf.During a concurrent observation and interview on 4/20/2026 at 9:04 a.m., of the reach-in refrigerator with the DS, the DS stated the last time the reach-in refrigerator was cleaned was yesterday, however, he did not think it was cleaned yesterday because there was food debris, and a dried-up spill from gelatin. The DS stated it was important to maintain the cleanliness of the refrigerator to keep food safe and for infection control purposes, as they do not want food debris mixed with ready-to-eat food or cross-contamination. The DS stated residents could develop foodborne illness as a result of cross-contamination. During a review of the facility's P&P titled, Refrigerator/Freezer Storage, dated 11/25/2026, the P&P indicated, 17. The refrigerator and freezer area will be clean, dry, well-ventilated at all times.During a review of Food Code 2022, dated 1/18/2022, the Food Code 2022 indicated, 4-601.11 (A) Equipment Food Contact Surfaces and utensils shall be cleaned: (1) Except as specified in (B) of this section, before use with a different type of raw animal food such as beef, fish, lamb, pork or poultry; (2) Each time there is a change from working with raw foods to working with ready-to-eat food; (3) Between uses with raw fruits and vegetables and with time/temperature control for safety food. (4) Before using or storing a food temperature measuring device, and (5) At the time during the operation when contamination may have occurred.b. During a concurrent observation on 4/20/2026 at 12:17 a.m., of the dry storage shelves with the DS, dust and dirt was observed on the storage shelves where foods are stored. The DS stated there was dust and dirt on the shelf's surfaces, and the expectation was to have a clean storage area for food, free from dust and spills to prevent pest and contamination. The DS stated residents could potentially develop food borne illness from cross-contamination of food.During a review of the facility's P&P titled, Storage of Canned and Dry Good, dated 11/25/2026, the P&P indicated, The storage area will be clean, dry, well ventilated at all times.c. During a concurrent observation and interview on 4/20/2026 at 12:20 p.m., of the sugar, rice and cereal container with the DS, dust particles and sugar crystals were observed on the containers. The DS stated there were sugar particles on the covers of the sugar container and rice container. The DS further stated Raisin Bran and [NAME] Krispies containers had dust particles. The DS stated they should keep the food containers clean to keep food safe to prevent cross-contamination and foodborne illnesses. During a review of the facility's P&P titled, Kitchen Cleanliness and Sanitation Policy, dated 11/25/2026, the P&P indicated, To ensure the safety and well-being of residents, staff, and visitors, this facility is committed to maintaining a clean, sanitary, and complaint kitchen environment.During a review of Food Code 2022, the Food Code 2022 indicated, 4-601.11 (E) Except when dry cleaning methods are used as specified under S 4-603.11, surfaces of utensils and equipment contacting food that is not time/temperature control for safety food shall be cleaned: (1) At anytime when contamination may have occurred; (2) At least every 24 hours for iced tea dispensers and consumer self-service utensils such as tongs, scoops, or ladles; (3) Before restocking consumer self-service equipment and utensils such as condiment dispensers and display containers; and (4) In equipment such as ice bins and beverage dispensing nozzles and enclosed components of equipment such as ice makers, cooking oil storage tanks and distribution lines, beverage and syrup dispensing lines or tubes, coffee bean grinders, and water vending equipment: (a) At a frequency specified by the manufacturer, or (b) Absent manufacturer specification, at a frequency necessary to preclude accumulation of soil or mold.d. During a concurrent observation and interview on 4/21/2026 at 2:33 p.m., of the mixer with the DS, the mixer was observed with white debris. The DS stated the mixer looked like it had whipped cream debris and it was not clean. The DS stated the mixer was used for whip cream 2-3 days ago and it had to be clean after use so that there would be no food particles or splashes. The DS stated it was important to clean the mixer after every use to keep the food clean avoiding cross-contamination that could lead to foodborne illness as a potential outcome. During a review of the facility's P&P titled, Cleaning Schedule, dated 11/25/2026 the P&P indicated, All areas and equipment in the kitchen should be cleaned daily.During a review of Food Code 2022, the Food Code 2022 indicated, 4-602.12 Cooking and Baking Equipment. (A) The food contact surfaces of cooking and baking equipment shall be cleaned at least every 24 hours. This section does not apply to hot oil cooking and filtering equipment if it is cleaned as specified subparagraph 4-602.11 (D)(6).e. During a concurrent observation and interview on 4/21/2026 at 2:39 p.m., of the hood vent near the ice machine with the DS, dust buildup on the vent surfaces was observed. The DS stated they clean the vent once a week but there was dust buildup on the vent. The DS stated it was important to maintain the cleanliness of the vent because dust and dirt could fall into the food from the vent causing cross-contamination. During a review of the facility's P&P titled, Sanitizing Equipment and Surfaces, dated 11/25/2025, the P&P indicated, 6. Dietary staff should ensure that all equipment, shelves, serving utensils, utility carts, cutting boards, vents, and surfaces areas are clean and in good condition.During a review of Food Code 2022, the Food Code 2022 indicated,4-602.13 Nonfood-Contact Surfaces. Nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues.f. During a concurrent observation and interview on 4/21/2026 at 4:01 p.m., of the salt, sugar, pepper and artificial sweetener containers, salt, sugar, pepper and artificial sweetener debris and particles were observed on each container. The DS stated kitchen staff clean the containers once a day however they did not clean it today because they did not get to it. The DS stated it was important to maintain cleanliness of the condiment containers to prevent pests because pests could spread diseases. The DS stated pests could go to the trash and it carries bacteria making resident sick of diseases and infection.During a review of the facility's P&P titled, Kitchen Cleanliness and Sanitation Policy, dated 11/5/2026, the P&P indicated, Dietary Staff must sanitize all food-contact surfaces, utensils, preparation tables, and equipment after each use or as needed throughout the service. All surfaces must be kept clean, dry, and free of debris or grease.g. During a concurrent observation and interview on 4/22/2026 at 9:59 a.m., of the resident's refrigerator with LVN 1 and the DS, the freezer was observed with ice buildup and the refrigerator had food debris and a red dried spill. LVN 1 stated the refrigerator was not clean because there was dried red spill. The DS stated it was important to maintain the cleanliness of the resident's refrigerator to prevent cross-contamination. During a review of the facility's P&P titled, Refrigerator/Freezer Storage, dated 11/25/2025, the P&P indicated, 17. The refrigerator and freezer area will be clean, dry, well-ventilated at all times.18. Freezer must be maintained free of excessive ice or frost buildup to ensure proper air circulation and temperature control. Dietary staff will report any ice buildup to the Dietary Supervisor and Maintenance.During a review of Food Code 2022, the Food Code 2022 indicated, 4-701.10 Food Contact Surfaces and Utensils shall be sanitized. 4-702.11 Before use After cleaning. Utensils and Food-Contact Surfaces of Equipment shall be sanitized before use after cleaning.5. During an observation on 4/20/2026 at 12:04 p.m., of the dry storage area, a cart was observed and an area by the door labeled dented cans. Three (3) dented cans were stored with non-dented cans.During an interview on 4/20/2026 at 12:07 p.m., with the DS, the DS stated dented cans are separated and labeled because they return it to the vendor and they could not use them. The DS stated dented cans are hazardous to the residents because it could potentially contaminate the can and the food inside is already bad. The DS stated there were 7 dented cans stored with non-dented cans and it was not acceptable.During a review of the facility's P&P titled, Safe Food Transfer and Cross-Contamination Prevention Policy, dated 11/25/2025, the P&P indicated, All cans must be checked for swelling, dents, rust, or signs of contamination.During a review of the facility' P&P titled, Storage of Canned and Dry Goods, dated 11/25/2025, the P&P indicated, 10. Canned items should be inspected for damage such as dented, leaking or bulging cans. These items should be stored separately in the designated area-DENTED CANS for return to the vendor or disposed of properly.During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated, 3-101.11 Safe Unadulterated, and Honestly Presented. Food shall be safe, unadulterated, and, as specified under 3-601.12, honestly presented. 3-201.11 Compliance with Food Law. A primary line of defense ensuring that food meets the requirements of S3-101.11 is to obtain food from approved sources, the implications of which are discussed below. However, it is also critical to monitor food products to ensure that, after harvesting, processing, they do not fail victim to conditions that endanger their safety, make them adulterated, or compromise their honest presentation. The regulatory community, industry, and consumers should exercise vigilance in controlling the conditions to which foods are subjected and be alert to signs of abuse. FDA considers food in hermetically sealed containers that are swelled or leaking to be adulterated and actionable under the Federal Food, Drug, and Cosmetic Act. Depending on the circumstances, rusted, and pitted or dented cans may also present a serious potential hazard.6. During an observation on 4/20/2026 at 12:59 p.m., of the lunch trayline, residents' food trays had water particles and were stacked wet. [NAME] 2 wiped the wet trays with a napkin and used the same napkin for wiping multiple trays.During a concurrent observation and interview on 4/20/2026 at 1:01 p.m., during the lunch trayline process, the DS stated [NAME] 2 was wiping residents' trays with a paper napkin and that kitchen staff did not allow the trays to air dry before placing them into the trayline. The DS stated the trays still contained water droplets and it was important to allow the trays to air dry to prevent moisture buildup that could promote bacterial growth. The DS stated residents could potentially develop foodborne illnesses due to cross-contamination associated with bacterial growth on the trays.During an interview on 4/20/2026 at 1:05 p.m., with the DS, the DS stated [NAME] 2 used a napkin to dry a tray, then reused the same napkin to wipe other trays. The DS stated the proper drying process is to allow the trays to air dry or to use a paper towel and dispose of it and use a new one. The DS stated it was not appropriate to use the same napkin to wipe multiple trays to prevent cross-contamination.During a review of the facility's P&P titled Manual Dishwashing-2 or 3 Compartment Sink, dated 11/25/2026, the P&P indicated, 6. Pots, pans, dishes and utensils must be completely air dried before storage. Items shall not be stacked or nested together while wet. All equipment must be allowed to air dry, clean, sanitized racks with adequate spacing to allow air circulation.During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated, 4-901.11 Equipment and Utensils, air-drying required. After cleaning and sanitizing equipment and utensils: (A) Shall be air-dried or used after adequate draining as specified in the first paragraph of 40 CFR 180.940 Tolerance exemptions for active and inert ingredients for use in antimicrobial formulations (food-contact surface sanitizing solutions), before contact with food and; (B) May not be cloth dried except that utensils that have been air-dried may be polished with cloths that are maintained clean and dry.7. During an observation on 4/21/2026 at 2:52 p.m. of the 2-compartment sink located by the preparation area, pans were observed stacked wet drying and the drying area had soap bubbles and residues.During a concurrent observation and interview on 4/21/2026 at 3:10 p.m., DA 1 was observed manually washing dishes with the DS, the DS stated the pans are stacked wet and it should not be stacked wet and must be dried individually. The DS stated the pot washing area is a dirty area and the drying area is a clean area. However, DA 1 did not maintain the cleanliness of the drying area because there were dish soap residues on the edge of the drying area. The DS stated the pans that were currently drying were contaminated because the dirt (dish soap) spills onto the clean pans.During an interview on 4/21/2026 at 3:20 p.m. with DA 1 and DS, DA 1 stated the 2-compartment sink is a clean area because he cleans it every time he starts working and the soap in the drying area was not dirty. The DS stated he did not agree with DA 1 statement.During a review of the facility's P&P titled, Manual Dishwashing- 2 or 3 Compartment Sink, dated 11/25/2025, the P&P indicated to place washed dishes onto a clean surface and allow to air dry.During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated, 3-307.11 Miscellaneous Sources of Contamination. Food shall be protected from contamination that may result from a factor or source not specified under subparts 3-391 - 3-306.8. a. During an observation on 4/21/2026 at 2:52 p.m., of the DA 1 pot washing process, DA 1 transferred the pans from the 2-compartment sink by the preparation area to the 2-compartment sink near the office then turned on the water and rinse the pans. DA 1 dipped the pans for 30 seconds (surveyor timing using a wristwatch) then placed the pans in the drying area.During an interview on 4/21/2026 at 3:00 p.m., with DA 1, DA 1 stated after transferring the pans to the 2-compartment sink by the office, he placed the pans in the first compartment and rinsed them with 110 F water temperature. DA 1 stated he dipped the pans in the sanitizer for 40 seconds and he knows it's 40 seconds by just observing and counting in his head.During an interview on 4/21/2026 at 3:10 p.m., with the DS, the DS stated while looking at the QUAT sanitizer poster in the 2-compartment sink, he was trained to follow the manufacturer guidelines of the QUAT sanitizer, and the pots and pans must be dipped for 60 seconds or no longer than one (1) minute. The DS stated 40 seconds of dipping the pans in the sanitizer was not enough. The DS stated the sanitizer kills bacteria and if the pans were not dipped for 60 seconds, the sanitizer would not kill bacteria. The DS stated residents could develop foodborne illness as a potential outcome.During a review of the facility's P&P titled, Manual Dishwashing-2 or 3 Compartment Sink, dated 11/25/2026, the P&P indicated, Two compartment sink procedures: Fill sink 1 with warm water and soap to proper level to complete wash process. Scrub all surfaces to clean and remove food and other debris Drain Sink 1 and rinse all sink walls with fresh water. Refill sink 1 to proper level to freely rinse all items with fresh water only. Fill sink 2 with fresh water to proper level with water from cold line and add Quaternary sanitizer. Test to ensure proper solution of no less than 200ppm to no more than 400 ppm is available with proper test strips. Place all items in solution for no less than one minute.During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated, 4-501.116 Warewashing Equipment, Determining Chemical Sanitizer Concentration. Concentration of the sanitizing solution shall be accurately determined by using a test kit or other device.b. During a concurrent demonstration and interview on 4/21/2026 at 3:32 p.m., of the QUAT sanitizer testing with DA 1, DA 1 demonstrated testing the concentration of QUAT sanitizer by putting on gloves, and taking a test strip from the container and dipping the test strip in the QUAT sanitizer testing solution for 15 seconds (surveyor timing using wristwatch). DA 1 stated he dipped the test strips for 10 seconds and he knew it was 10 seconds by counting 1 then would pause for 1-2 seconds then count again. DA 1 did not test the temperature of the testing solution prior to dipping the test strip.During a concurrent demonstration and interview on 4/21/2026 at 3:44 p.m., of the QUAT sanitizer testing with DA 1 and the DS, the DS stated they do not check the water temperature of the QUAT testing solution. The DS stated the testing solution temperature was at 76.3 F (when temped using a thermometer) and did not follow the manufacturer's instructions because testing solution temperature should be at 65-75 F. The DS stated it was important to follow the manufacturer's instructions to make sure that sanitizer concentrations were at its accurate reading and the sanitizer would work properly to kill germs. The DS stated cross contamination, and foodborne illness would be the potential outcome of not having QUAT sanitizer concentration accurate.During a review of the facility's manufacturer's instruction, titled Hydrion Quat-10 Test Paper, with expiration date of 10/1/2026, the instruction indicated, Instructions: Dip paper in quat solution. Not foam surface for 10 seconds. Do not shake. Compare colors at once. Testing solution should be between 65-75 F Testing solution should have a neutral pH. Follow manufacturer's dilution instructions carefully.During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated, 4-501.114 Manual and Mechanical Warewashing Equipment, Chemical Sanitation- Temperature, pH, Concentration, and Hardness. A chemical sanitizer used in a sanitizing solution for a manual or mechanical operation at contact

Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan (a document that outlines a resident's healthcare needs, goals, and the interventions planned to achieve those goals) by failing to:1. Develop a care plan that address monitoring of resident's behavior for three (Resident 1, Resident 8, Resident 14) of four sampled residents on physical restraints (any physical device attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of normal access to one's body) when the restraints were removed in accordance with the physician's order (called holidays). This failure had the potential for those residents to pull out their life sustaining tubes such as a tracheostomy tube (is a curved, hollow tube inserted into a surgically created opening in the neck [stoma] and trachea to provide an alternative airway for breathing) and gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) tube (GT). 2. Implement care plan interventions on oxygen use for two (Resident 191, Resident 90) of three sampled residents reviewed under respiratory care area. This deficient practice had the potential to negatively affect the provision of care and services related to oxygen therapy for Residents 191 and 90.3. Implement a care plan intervention to monitor and assess residents for signs and symptoms of bleeding for one of one sampled resident (Resident 191) on anticoagulant therapy. This deficient practice had the potential to delay timely intervention and result in health complications such as bleeding.4. Failing to develop a care plan for one of five sampled residents (Resident 76) investigated for immunizations (the process where a person is made resistant to a disease) when Resident 76 refused vaccination (medications used to prevent diseases usually given by injection or by mouth) for influenza (flu, a contagious respiratory illness caused by influenza viruses that infect the nose, throat, and lungs). This deficient practice had the potential to delay the delivery of necessary care and services to Resident 76, placing the resident at risk for respiratory disease. Findings: 1.a. During a review of Resident 14's Face Sheet (the front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated the facility originally admitted Resident 14 to the facility on 9/20/2025 and re-admitted on [DATE] with diagnoses that included acute respiratory failure with hypoxia (a long-term, ongoing condition where the lungs cannot adequately transfer oxygen into the blood, resulting in a low oxygen levels and requiring oxygen for bodily functions). During a review of Resident 14's Minimum Data Set (MDS-resident assessment tool) dated 4/04/2026, the MDS indicated Resident 14 was severely impaired in cognition (the process of acquiring knowledge and understanding through thought, experience, and the senses) with skills required for daily decision making. The MDS indicated Resident 14 was dependent (helper does all the effort; resident does none of the effort to complete the activity) on staff for toileting, dressing, and personal hygiene. The MDS indicated Resident 14 required the use of a limb restraint (physical restraint on an arm). During a review of Resident 14's Physician's Orders, dated 1/09/2026, the Physician's Orders indicated an order for a freedom splint (a soft, cushioned limb immobilizer designed to restrict elbow movement; used to prevent patients from pulling at tubes) to the left upper extremity (left arm) to minimize pulling out of life sustaining tubes; released every two hours for 15 minutes for circulation and to check skin integrity. Holidays off on Wednesdays and Sundays. During a review of Resident 14's Supportive and Safety Devise/Physical Restraint Assessment, dated 1/16/2026, the assessment indicated Resident 14 had an order for a freedom splint to be applied to the left upper extremity due to interference with specific medical treatments (pulling out life sustaining devices such as tracheostomy, and GT. During a review of Resident 14's Care Plan Risk For Injury, initiated 1/25/2026, the care plan indicated Resident 14 is at risk for injury due to tendency to pull out life sustaining tubes. The care plan indicated a goal to minimize the risk of Resident 14 pulling out life sustaining tubes daily through the next assessment. The care plan indicated the interventions to apply freedom splints as ordered, and holiday off every Wednesdays and Sundays. During an observation of Resident 14 on 4/22/2026 at 10:50 a.m., observed Resident 14 in his bed not wearing the freedom restraint because it was his holiday day. Observed Resident 14 scratching his face. During an interview with the Assistant Director of Nursing 2 (ADON 2) for the subacute unit on 4/22/2026 at 11 a.m., the ADON 2 stated Resident 14 required the use of the freedom restraint on the left arm to prevent him from pulling at his tracheostomy and gastrostomy tubes. The ADON 2 stated Resident 14 does not wear restraints on the holiday days which are Wednesdays and Sundays. The ADON 2 stated that residents have holiday days so they can feel free and not feel restrained. The ADON 2 stated those residents on their holiday days have frequent visual checks but was unable to specify what frequent meant. The ADON 2 stated frequent visual checks are conducted both on the days restraints are on and when there is a holiday. The ADON 2 did not have an answer when asked what intervention(s) are done in addition to what licensed and unlicensed (such as certified nursing assistant) nursing staff already do on holiday days. During an interview with the Director of Nursing (DON) on 4/23/2026 at 12:10 p.m., she stated there are no additional interventions done on the holiday days for residents with orders for freedom restraints During a review of the facility's P&P titled, Care Plans, Comprehensive Person-Centered, last reviewed 11/25/2025, the P&P indicated Care Plans should include interventions that recognize standards of practice for problem areas and conditions for residents to maintain highest physical, mental and psychosocial well-being. During a review of the facility's policy and procedure titled, Restraints: Holiday, last reviewed 11/25/2025, the policy indicated the following: This facility will provide a temporary break period or holiday from restraint use as appropriate for residents. The holiday from restraints is not required, nor intendent to replace assessments completed for use of restraints, effectiveness, or reduction as scheduled or needed. Its purpose is to provide those residents who are not appropriate for restraint reduction a temporary break as indicated/tolerated. 1. b. During a review of Resident 1's Face Sheet, the Face Sheet indicated Resident 1 was admitted on [DATE] with diagnoses that included acute respiratory failure with hypoxia, tracheostomy, gastrostomy, and encephalopathy (a brain dysfunction often characterized by altered mental status, confusion, or memory loss). During a review of Resident 1's MDS, dated [DATE], the MDS indicated Resident 1 has severely impaired cognitive skills for daily decision making. The MDS indicated Resident 1 was dependent on staff for toileting hygiene, shower/bathe, dressing, sitting to lying, and lying to sitting on the side of bed. During a review of Resident 1's physician's order for freedom splints, dated 4/16/2026, the physician's order indicated to apply freedom splints to the right upper extremity to minimize pulling out of life sustaining tubes. The order further indicated to release the freedom splint every two hours for 15 minutes and holidays (Wednesday and Sunday) off restraints. During an observation on 4/22/2026 at 10:20 am in Resident 1's room, Resident 1 was lying in bed wearing a right upper extremity freedom splint. During a concurrent interview and record review on 4/22/2026 at 11:57 a.m. with the ADON 2, Resident 1's Care Plan Report, active through 4/22/2026 was reviewed. Resident 1's care plan did not indicate specific interventions on how to monitor the resident on Wednesdays and Sundays when the freedom splint is not in place. ADON 2 stated Resident 1's care plan needs to be updated with interventions for monitoring Resident 1's behavior when the freedom splint is not placed during holidays. During an interview on 4/23/2026 at 12:10 pm with the DON, the DON stated the facility should obtain guidance from the physician on how to monitor the residents more closely during holidays, when the restraints are not in the place and incorporate these interventions into the care plan. 1.c. During a review of Resident 8's Face Sheet, the Face Sheet indicated the facility originally admitted Resident 8 on 5/04/2024 and readmitted on [DATE] with diagnoses that included acute respiratory failure with hypoxia, tracheostomy, gastrostomy, and traumatic subdural hemorrhage (bleeding in the out lining of the brain usually due to severe head injury such as accidents or falls). During a review of Resident 8's MDS, dated [DATE], the MDS indicated Resident 8 has severely impaired cognitive skills for daily decision making. The MDS indicated Resident 8 was dependent on staff for toileting hygiene, showering/bathing, dressing, sitting to lying, and lying to sitting on the side of bed. During a review of Resident 8's Order Summary Report dated 4/22/2026, the Order Summary Report indicated an order dated 1/12/2026 for the following: -Apply hand mitten to left hand to prevent pulling out tracheostomy tube and scratching. Release every two (2) hours for 15 minutes for circulation and to check for skin integrity. Hand hygiene will be provided during release. Monitor placement (Holidays off on Wednesdays and Sundays). Check every shift every Monday, Tuesday, Thursday, Fri, and Saturday. During an observation on 4/22/2026 at 10:21 a.m. in Resident 8's room, Resident 8 was observed sleeping in bed with a left-hand mitten on. During a concurrent interview and record review on 4/22/2026 at 11:57 a.m. with the ADON 2, Resident 8's Care Plan Report, active through 4/22/2026, was reviewed. Resident 8's Care Plan Report did not indicate specific interventions on how to monitor the resident on Wednesdays and Sundays when the left-hand mitten is not in place. ADON 2 stated Resident 8's care plan does not indicate interventions for monitoring Resident 8's behavior when the left-hand mitten is not placed during holidays. ADON 2 stated that the family had requested for the hand mitten to be worn every day, but the order and care plan still needs to be updated. During an interview on 4/23/2026 at 12:10 pm with the DON, the DON stated the facility should obtain guidance from the physician on how to monitor the residents more closely during holidays, when the restraints are not in the place and incorporate these interventions into the care plan. During a review of the facility's policy and procedures (P&P) titled, Restraints: Holiday, last reviewed 11/25/2025, the P&P indicated consideration for holiday from restraints should be in the care plan. During a review of the facility's P&P titled, Use of Restraints, last reviewed 11/25/2025, the P&P indicated care plans should include interventions and measures to reduce restraint usage. During a review of the facility's P&P titled, Care Plans, Comprehensive Person-Centered, last reviewed 11/25/2025, the P&P indicated Care Plans should include interventions that recognize standards of practice for problem areas and conditions for residents to maintain highest physical, mental and psychosocial well-being. 2. a. During a review of Resident 191's Face Sheet, the Face Sheet indicated the facility originally admitted the resident on 10/23/2016 and re-admitted the resident on 2/20/2026, with diagnoses including hypertension (high blood pressure), chronic respiratory failure (long-term condition where the lungs cannot adequately exchange oxygen and carbon dioxide, leading to low oxygen), and functional quadriplegia (complete loss of ability to move all four limbs—arms and legs). During a review of Resident 191's MDS, dated [DATE], the MDS indicated Resident 191's cognitive skills (mental abilities that enables a person to think, learn, remember, and solve problems) was severely impaired) for daily decision making was severely impaired. During a review of Resident 191's Physician Phone Order Report, the report indicated an order with a start date of 2/21/2026for for humidified (passed through water to add moisture) oxygen at 5 liters per minute (L/min, a unit of measurement for oxygen). The scheduling detail indicated routine every day, every 6 hours. During a review of Resident 191`s care plan (CP) on oxygen, initiated on 1/14/2021 and last revised on 4/04/2026, the CP indicated Resident 191 is receiving oxygen therapy due to respiratory failure and the goal is for Resident 191 to remain free of adverse effects related to use of oxygen daily. The CP indicated interventions to change oxygen weekly or as needed and provide oxygen as ordered. During a concurrent observation and interview on 4/20/2026 at 10:55 a.m., with Respiratory Therapist (RT 1), inside Resident 191's room, Resident 191 was observed in bed without oxygen in place (use), while the oxygen concentrator (a medical device that provides continuous supply of oxygen through a nasal cannula or mask) was on and delivering oxygen at 5 L/min; the Resident 191's oxygen tubing (a flexible, clear hose that delivers oxygen to a patient during oxygen therapy) was not connected to the oxygen concentrator. The oxygen tubing was lying on the left side of Resident 191, touching the pillow and was not dated. RT 1 confirmed the observation and stated that Resident 191 oxygen was not connected to Resident 191; the oxygen tubing was placed on the bed next to Resident 191 and not dated. RT 1 stated Resident 191 has a physician order for continuous oxygen, and the oxygen should have been connected to the resident to prevent a decrease in oxygen levels, which could result in respiratory distress. RT 1 further stated that the oxygen tubing is disposable and should be dated to ensure staff replace it every seven days and to allow staff to easily verify when the tubing was last replaced. During an interview on 4/20/2026 at 10:58 a.m., with Certified Nursing Assistant (CNA 1), CNA 1 stated Resident 191 is on continuous oxygen. CNA 1 stated she showered Resident at 8:45 a.m. today and forgot to ask a licensed staff to place Resident 191 back on oxygen. CNA 1 stated she was informed by RT 1 that Resident 191 is on continuous oxygen. CNA 1 stated Resident 191's oxygen saturation (measurement of oxygen in the blood) can go down and result in complications. During interview and record review on 4/21/2026 at 4:19 p.m., with RT 2, Resident 191's Physician Phone Order Report (PPOR), dated 2/21/12026, was reviewed. RT 2 stated the order indicated humidified oxygen at 5 L/min with the scheduling detail marked as routine. RT 2 stated routine mean Resident 191 should receive continuous oxygen at 5 L/min, and the every 6 hours instruction refers to documenting every 6 hours that the resident is receiving the oxygen. RT 2 stated if the order was intended to be administered every 6 hours, the scheduling detail would have been marked as PRN (as needed). RT 2 stated that continuous oxygen is important to prevent drops in oxygen levels, which could lead to respiratory distress. During a concurrent interview and record review on 4/22/2026 at 11:08 a.m. with ADON 1, Resident 191's CP report on oxygen, initiated on 1/14/2021 and last revised on 4/04/2026, was reviewed. ADON 1 stated the care plan indicated Resident 191 was receiving oxygen therapy due to respiratory failure and the CP interventions were to change oxygen tubing weekly or as needed and provide oxygen as ordered. ADON 1 stated, based on Resident 191's CP, Resident 191 should be receiving continuous oxygen as ordered and the oxygen should be changed weekly and as needed. ADON 1 stated that licensed nursing staff should date the oxygen tubing, so they (nursing staff) know when it is due for change, and to prevent Resident 191 from developing an infection. ADON 1 stated Resident 191's CP interventions were not implemented. During an interview on 4/22/2026 at 12:02 p.m. with the DON, the DON stated the oxygen tubing should be dated and change weekly per facility policy. During a review of the facility's P&P titled Oxygen Administration, last reviewed on 11/25/2025, the P&P indicated oxygen will be administered to a resident as needed per attending Physician's orders by licensed personal. The oxygen tubing should be changed weekly and as needed. The policy indicated the date time and initials should be noted on oxygen equipment when it is initially used and when changed. 2.b. During a review of Resident 90's Face Sheet, the Face Sheet indicated the facility originally admitted Resident 90 on 3/21/2023 and re-admitted the resident on 12/31/2025, with diagnoses including acute respiratory failure (condition where the lungs cannot adequately exchange oxygen and carbon dioxide, leading to low oxygen), dysphagia (difficulty swallowing), and encephalopathy. During a review of Resident 90's MDS, dated [DATE], the MDS indicated Resident 90's cognitive skills for daily decision making was severely impaired. During a review of Resident 90's Order Summary Report dated 4/21/2026, the Order Summary report indicated an order, dated 12/31/2026, for humidified oxygen at 5 L/min via TBar/Tmask (oxygen tracheostomy mask and T shaped connector to the tubing that is connected to the oxygen tank) every six hours. During a review of Resident 90`s CP on oxygen, initiated on 4/11/2023 and last revised on 2/26/2026, the CP indicated Resident 90 is receiving oxygen therapy due to respiratory failure and the goal is for Resident 90 to remain free of adverse effects related to use of oxygen daily. The CP interventions were to change oxygen tubing weekly or as needed. During a concurrent observation and interview on 4/20/2026 at 10:44 a.m., with the ADON 2, inside Resident 90's room, Resident 90 was observed in bed receiving oxygen from the oxygen concentrator at 5 L/min via TBar/Tmask. Observed Resident 90's oxygen tubing was not dated. ADON 2 stated it was important to date the oxygen tubing so staff would know when the tubing is due for a change per policy and for infection control. During a concurrent interview and record review on 4/22/2026 at 11:00 a.m. with ADON 1, Resident 90's CP on oxygen initiated on 4/11/2023 and last revised on 2/26/2026, was reviewed. ADON 1 stated the CP indicated Resident 90 was receiving oxygen therapy due to respiratory failure. The care plan intervention indicated to change oxygen tubing weekly or as needed. ADON 1 stated that licensed nursing staff should date the oxygen tubing to ensure the tubing is changed weekly and to help prevent infection. During a concurrent interview and record review on 4/22/2026 at 12:02 p.m. with the DON, the DON stated oxygen tubing should be dated and change weekly per facility policy. During a review of the facility's P&P titled Oxygen Administration, reviewed on 11/25/202, the P&P indicated oxygen will be administered to residents as needed per attending Physician's orders by Licensed personal. The oxygen tubing should be changed weekly and as needed. The date, time, and initials should be noted on oxygen equipment when it is initially used and when changed. 3. During a review of Resident 191's Face Sheet, the Face Sheet indicated the facility originally admitted Resident 191 on 10/23/2016 and re-admitted the resident on 2/20/2026, with diagnoses including hypertension, chronic respiratory failure, and functional quadriplegia. During a review of Resident 191's MDS, dated [DATE], the MDS indicated Resident 191's cognitive skills for daily decision making was severely impaired. During a review of Resident 191's Physician Order Summary Report dated 4/21/2026, the Physician Order Summary Report indicated an order dated 2/20/2026, with a start date of 2/21/2026 to administer apixaban (anticoagulant, medication to prevent blood clots) 2.5 milligrams (mg, metric unit of measurement, used for medication dosage and/or amount) tablet, two times a day for deep vein thrombosis (DVT, a serious condition where a blood clot forms in a deep vein), prophylaxis (prevention). During a review of Resident 191`s CP on anticoagulant, initiated on 12/04/2023 and last revised on 4/04/2026, the CP indicated Resident 191 is at risk for bleeding and bruising due to anticoagulant therapy medication apixaban, with risk factors of gastrointestinal (GI) distress bleeding, abnormal bleeding, easy skin bruising or discoloration. The care plan indicated a goal that Resident 191 will have no unrecognized sign and symptoms of bleeding or GI distress daily until the next assessment. The care plan indicated an intervention to assess signs and symptoms of bleeding such as blood in the urine or stool and/or coffee ground emesis (vomit) and notify the physician. During a concurrent interview and record review on 4/22/2026 at 11:12 a.m. with the ADON 1, Resident 191's CP on anticoagulant, initiated on 12/04/2023 and last revised on 4/04/2026, was reviewed. ADON 1 stated that the care plan indicated Resident 191 is at risk for bleeding and bruising due to anticoagulant therapy medication apixaban with an intervention to assess for sign and symptoms of bleeding such as blood in the urine or stool and/or coffee ground emesis and notify the physician. ADON 1stated she cannot provide any documentation to show that nursing staff assessed and monitored Resident 191 for signs and symptoms of bleeding. The ADON 1 stated monitoring should be done on the electronic medication administration record (eMAR, a computerized daily documentation record used by a licensed nurse to document medications and treatments given to a resident). The ADON 1 stated Resident 191's care plan intervention to assess and monitor the resident for signs and symptoms of bleeding was not implemented. During a review of the facility's P&P titled Anticoagulation - Clinical Protocol, last reviewed on 11/25/2025, the P&P indicated for licensed nurses to assess for any signs or symptoms related to adverse drug reactions due to the medication alone or in combination with other medications. The policy indicated the staff will monitor for possible complications in individuals who are being anticoagulated and will manage related problems. The policy indicated if an individual on anticoagulation therapy shows signs of excessive bruising, hematuria, hemoptysis, or other evidence of bleeding, the nurse will discuss the situation with the physician before giving the next scheduled dose of anticoagulant. The policy indicated that the physician will order measures to address any complications, including holding or discontinuing the anticoagulant as indicated. During a review of the facility's policy and procedure titled Care Plans Comprehensive Person-Centered, last reviewed on 11/25/2025, indicated a comprehensive, person-centered care plan that includes measurable objective and timetables to meet the residents' physical, psychosocial, and functional needs is developed and implemented for each resident. 4. During a review of Resident 76's Face Sheet, the Face Sheet indicated the facility admitted the resident on 4/18/2025 with diagnoses including, but not limited to, benign neoplasm (a non-cancerous tumor that does not invade nearby tissue or spread to other parts of the body) of the meninges (protective layers that surround the brain and spinal cord) and intracerebral hemorrhage (bleeding inside the brain tissue). During a review of Resident 76's Physician Progress Note, dated 4/19/2025, the progress note indicated Resident 76 had the capacity to understand and make decisions. During a review of Resident 76's MDS, dated [DATE], the MDS indicated Resident 76 was cognitively intact and required substantial assistance (helper does more than half of the effort) with most activities of daily living (ADLs, activities such as bathing, dressing and toileting a person performs daily). During a concurrent interview and record review on 4/23/2026 at 10:57 a.m. with the Infection Preventionist Nurse (IPN), Resident 76's Vaccine Consent Form, indicated Resident 76 refused the 2025/2026 influenza vaccine on 10/07/2025. The IPN stated when a resident refuses a vaccine, she should create a care plan that addresses the resident's vaccine refusal. The IPN stated there was no care plan documenting the resident's refusal of the flu vaccine. The IPN stated the care plan should include interventions to educate the resident about why the vaccination is needed and to monitor the resident for signs and symptoms of the flu. The IPN stated the care plan would also be needed so staff is aware that the resident refused the vaccine. During an interview on 4/23/2026 at 3:24 p.m. with the DON, the DON stated when a vaccine is refused there should be a care plan that includes education to the resident of why the vaccine is needed and for staff to reoffer the flu vaccine. During a review of the facility's policy and procedure (P&P) titled Care Plans, Comprehensive Person-Centered, last reviewed 11/25/2025, the P&P indicated a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident. The P&P indicated care plans are revised as information about the residents and the residents' conditions change.

Based on observation, interview, and record review, the facility failed to provide residents with necessary respiratory care and services that is in accordance with professional standards of practice to two of three sampled residents (Resident 90 and Resident 191) reviewed under the respiratory care area by failing to:1.Ensure Resident 90 and Resident 191's oxygen tubing (a flexible, clear hose that delivers oxygen to a patient during oxygen therapy) was labeled with the date it was last changed.2. Administer oxygen to Resident 191 as ordered by the physician. These deficient practices had the potential to negatively affect the provision of care and services related to oxygen therapy and placed the residents at increased risk for respiratory distress and infection.Findings:1.a. During a review of Resident 90's Face Sheet, the Face Sheet indicated the facility originally admitted Resident 90 on 3/21/2023 and re-admitted the resident on 12/31/2025, with diagnoses including acute respiratory failure (condition where the lungs cannot adequately exchange oxygen and carbon dioxide, leading to low oxygen), dysphagia (difficulty swallowing), and encephalopathy. During a review of Resident 90's MDS, dated [DATE], the MDS indicated Resident 90's cognitive skills for daily decision making was severely impaired. During a review of Resident 90's Order Summary Report dated 4/21/2026, the Order Summary report indicated an order, dated 12/31/2026, for humidified oxygen at 5 L/min via TBar/Tmask (oxygen tracheostomy mask and T shaped connector to the tubing that is connected to the oxygen tank) every six hours. During a review of Resident 90`s CP on oxygen, initiated on 4/11/2023 and last revised on 2/26/2026, the CP indicated Resident 90 is receiving oxygen therapy due to respiratory failure and the goal is for Resident 90 to remain free of adverse effects related to use of oxygen daily. The CP intervention indicated to change the oxygen tubing weekly or as needed. During a concurrent observation and interview on 4/20/2026 at 10:44 a.m., with the ADON 2, inside Resident 90's room, Resident 90 was observed in bed receiving oxygen from the oxygen concentrator at 5 L/min via TBar/Tmask. Observed Resident 90's oxygen tubing was not dated. ADON 2 stated it was important to date the oxygen tubing so staff would know when the tubing is due for a change per policy and for infection control. During a concurrent interview and record review on 4/22/2026 at 11:00 a.m. with ADON 1, Resident 90's CP on oxygen initiated on 4/11/2023 and last revised on 2/26/2026, was reviewed. ADON 1 stated the CP indicated Resident 90 was receiving oxygen therapy due to respiratory failure. The care plan intervention indicated to change the oxygen tubing weekly or as needed. ADON 1 stated that licensed nursing staff should date the oxygen tubing to ensure the tubing is changed weekly and to help prevent infection. During a concurrent interview and record review on 4/22/2026 at 12:02 p.m. with the DON, the DON stated oxygen tubing should be dated and change weekly per facility policy to prevent infection. During a review of the facility's P&P titled Oxygen Administration, reviewed on 11/25/202, the P&P indicated oxygen will be administered to residents as needed per attending Physician's orders by Licensed personal. The oxygen tubing should be changed weekly and as needed. The date, time, and initials should be noted on oxygen equipment when it is initially used and when changed.During a review of the facility's policy and procedure(P&P) titled Changing Disposable Equipment, reviewed on 11/25/2025 the P&P indicated to minimize the risk of infection disposable equipment is for single patient use only and will be change as regularly scheduled and a PRN basis. 1.b.and 2.During a review of Resident 191's Face Sheet, the Face Sheet indicated the facility originally admitted the resident on 10/23/2016 and re-admitted the resident on 2/20/2026, with diagnoses including hypertension (high blood pressure), chronic respiratory failure (long-term condition where the lungs cannot adequately exchange oxygen and carbon dioxide, leading to low oxygen), and functional quadriplegia (complete loss of ability to move all four limbs-arms and legs). During a review of Resident 191's Minimum Data Set (MDS - a resident assessment tool), dated 2/27/2026, the Minimum Data Set (MDS-resident assessment tool) indicated Resident 191's cognitive skills (mental abilities that enables a person to think, learn, remember, and solve problems) was severely impaired. During a review of Resident 191's Physician Phone Order Report, the report indicated an order with a start date of 2/21/2026for for humidified (passed through water to add moisture) oxygen at 5 liters per minute (L/min, a unit of measurement for oxygen). The scheduling detail indicated routine every day, every 6 hours. During a review of Resident 191`s care plan (CP) on oxygen, initiated on 1/14/2021 and last revised on 4/04/2026, the CP indicated Resident 191 is receiving oxygen therapy due to respiratory failure and the goal is for Resident 191 to remain free of adverse effects related to use of oxygen daily. The CP indicated interventions to change oxygen weekly or as needed and provide oxygen as ordered. During a concurrent observation and interview on 4/20/2026 at 10:55 a.m., with Respiratory Therapist (RT 1), inside Resident 191's room, Resident 191 was observed in bed without oxygen in place (use), while the oxygen concentrator (a medical device that provides continuous supply of oxygen through a nasal cannula or mask) was on and delivering oxygen at 5 L/min; Resident 191's oxygen tubing was not connected to the oxygen concentrator. The oxygen tubing was lying on the left side of Resident 191, touching the pillow and was not dated. RT 1 confirmed the observation and stated that Resident 191 oxygen was not connected to Resident 191; the oxygen tubing was placed on the bed next to Resident 191 and not dated. RT 1 stated Resident 191 has a physician order for continuous oxygen, and the oxygen should have been connected to the resident to prevent a decrease in oxygen levels, which could result in respiratory distress. RT 1 further stated that the oxygen tubing is disposable and should be dated to ensure staff replace it every seven days and to allow staff to easily verify when the tubing was last replaced. During a concurrent observation and interview on 4/20/2026 at 10:55 a.m., with Respiratory Therapist (RT 1), inside Resident 191's room, Resident 191 was observed in bed without oxygen in place (use), while the oxygen concentrator (a medical device that provides continuous supply of oxygen through a nasal cannula or mask) was on and delivering oxygen at 5 L/min; the Resident 191's oxygen tubing (a flexible, clear hose that delivers oxygen to a patient during oxygen therapy) was not connected to the oxygen concentrator. The oxygen tubing was lying on the left side of Resident 191, touching the pillow and was not dated. RT 1 confirmed the observation and stated that Resident 191 oxygen was not connected to Resident 191; the oxygen tubing was placed on the bed next to Resident 191 and not dated. RT 1 stated Resident 191 has a physician order for continuous oxygen, and the oxygen should have been connected to the resident to prevent a decrease in oxygen levels, which could result in respiratory distress. RT 1 further stated that the oxygen tubing is disposable and should be dated to ensure staff replace it every seven days and to allow staff to easily verify when the tubing was last replaced.During an interview on 4/20/2026 at 10:58 a.m., with Certified Nursing Assistant (CNA 1), CNA 1 stated Resident 191 is on continuous oxygen. CNA 1 stated she showered Resident at 8:45 a.m. today and forgot to ask a licensed staff to place Resident 191 back on oxygen. CNA 1 stated she was informed by RT 1 that Resident 191 is on continuous oxygen. CNA 1 stated Resident 191's oxygen saturation (measurement of oxygen in the blood) can go down and result in complications. During interview and record review on 4/21/2026 at 4:19 p.m., with RT 2, Resident 191's Physician Phone Order Report (PPOR), dated 2/21/12026, was reviewed. RT 2 stated the order indicated humidified oxygen at 5 L/min with the scheduling detail marked as routine. RT 2 stated routine mean Resident 191 should receive continuous oxygen at 5 L/min, and the every 6 hours instruction refers to documenting every 6 hours that the resident is receiving the oxygen. RT 2 stated if the order was intended to be administered every 6 hours, the scheduling detail would have been marked as PRN (as needed). RT 2 stated that continuous oxygen is important to prevent drops in oxygen levels, which could lead to respiratory distress. During a concurrent interview and record review on 4/22/2026 at 11:08 a.m. with ADON 1, Resident 191's CP report on oxygen, initiated on 1/14/2021 and last revised on 4/04/2026, was reviewed. ADON 1 stated the care plan indicated Resident 191 was receiving oxygen therapy due to respiratory failure and the CP interventions were to change oxygen tubing weekly or as needed and provide oxygen as ordered. ADON 1 stated, based on Resident 191's CP, Resident 191 should be receiving continuous oxygen as ordered and the oxygen should be changed weekly and as needed. ADON 1 stated that licensed nursing staff should date the oxygen tubing, so they (nursing staff) know when it is due for change, and to prevent Resident 191 from developing an infection. ADON 1 stated Resident 191's CP interventions were not implemented. During an interview on 4/22/2026 at 12:02 p.m. with the DON, the DON stated the oxygen tubing should be dated and change weekly per facility policy to prevent infection.During a review of the facility's P&P titled Oxygen Administration, last reviewed on 11/25/2025, the P&P indicated oxygen will be administered to a resident as needed per attending Physician's orders by licensed personal. The oxygen tubing should be changed weekly and as needed. The policy indicated the date time and initials should be noted on oxygen equipment when it is initially used and when changed.

Based on observation, interview, and record review, the facility failed to maintain accurate and current daily nurse staffing postings for the Skilled Nursing Facility (SNF) and Subacute unit, in accordance with the facility's policy titled Posting Direct Care Daily Staffing Numbers. Specifically, the facility: 1. Failed to post the required daily staffing information for the SNF on 4/21/2026 and 4/22/2026. The form displayed on both dates was outdated and reflected 4/20/2026. 2. Failed to document and post the actual hours worked by licensed and unlicensed nursing staff directly responsible for resident care, per shift for 4/20/2026 on both the SNF and Subacute unit.3. Posted projected staffing hours labeled as Actual Hours Worked for the day, evening, and night shifts on 4/22/2026 in the Subacute unit.4. Completed the daily staffing forms in pencil, rather than black ink, for actual hours worked on 4/20/2026 and 4/22/2026 for both the SNF and Subacute unitThis deficient practice resulted in residents, visitors, and staff not having access to accurate and up-to-date staffing information, including the total number of staff on duty and the actual hours worked by licensed and unlicensed nursing personnel responsible for resident care. Findings: During a concurrent observation and interview on 4/22/2026 at 11:27 a.m. with the Director of Staff Development (DSD) in the SNF's Nurse's Station 1, a framed facility document titled Daily Staffing Posting, dated 4/20/2026, was observed posted. The DSD stated the form on display Daily Staffing Posting, is dated 4/20/2026 and it is the projected hours even though it is labeled as Actual Hours Worked and that the posting was missing the actual resident census and the actual total hours worked by Registered Nurses, Licensed Vocational Nurses, and Certified Nursing Assistants for 4/20/2026 in the SNF and subacute unit. The DSD stated the facility's practice is to post projected nursing hours rather than actual hours, and the Accounts Payable/Payroll staff calculate actual hours on the following business day for filing. The DSD further stated the facility does not post the actual nursing hours worked by licensed and unlicensed nursing staff and who is responsible for resident care per shift and that she was not aware this was required. In addition, the DSD stated she did not post the nursing staffing information for 4/21/2026 and 4/22/2026 in the SNF area as required by facility policy. The DSD explained that she completes the sections for Date, Census at Start of Shift, Projected PPD, Actual Hours Worked, and staffing totals for both the SNF and Subacute unit using pencil for the date 4/20/2026.During a concurrent observation and interview on 4/22/2026 at 11:38 a.m. with the DSD in the Subacute Nurse's Station, a framed facility document titled Daily Staffing Posting, dated 4/22/2026, was observed posted. The DSD stated the form Daily Staffing Posting, in the section labeled Actual hours worked, for the day, evening, and night shifts in the Subacute unit was incorrect because it reflected projected hours rather than the actual hours worked by staff. The DSD confirmed that actual hours can only be entered after the shift is completed, and therefore the information posted for actual hours worked was inaccurate for 4/22/2026. The DSD explained that she completes the sections for Date, Census at Start of Shift, Projected PPD, Actual Hours Worked, and staffing totals for both the SNF and Subacute unit using pencil for 4/22/2026 for the subacute unit.During a concurrent observation and interview on 4/22/2026 at 11:44 a.m. with the Director of Nursing (DON) in Nurse's Station 1 of the SNF, a framed facility document titled Daily Staffing Posting, dated 4/20/2026, was observed posted. The DON stated that the staffing posting displayed was dated 4/20/2026 and that, according to facility policy, staffing must be posted daily. The DON stated Nurse's Station 1 of the SNF area is the designated area by the Administrator to post the form.During a concurrent interview and record review on 4/23/2026 at 10:14 a.m. with the DON, the Daily Staffing Posting dated 4/20/2026 was reviewed. The DON stated, the Daily Staffing Posting indicated a date of 4/20/2026. The DON stated that the nursing staffing information should be posted and updated daily within two hours of the beginning of each shift in Nursing Station 1, to inform the public of the total number of staff and the hours worked by Registered Nurses, Licensed Vocational Nurses, and Certified Nursing Assistants for each shift in the SNF and the Subacute unit. The DON stated the DSD should have posted the staffing information for 4/21/2026 and 4/22/2026. The DON further stated the posting for 4/20/2026 was missing the actual resident census and the actual hours worked by licensed and unlicensed nursing staff. The DON reported the facility's practice is to post projected hours rather than actual hours.During concurrent interview and record review on 4/23/2026 at 10:20 a.m. with the DON, the Daily Staffing Posting dated 4/22/2026 was reviewed. The DON stated the Daily Staffing Posting dated 4/22/2026 indicated Actual Hours Worked for the day, evening, and night shifts in the Subacute unit. The DON stated the Actual Hours Worked was labeled incorrectly and it is projected hours. The DON stated actual hours worked cannot be entered prior to the shift's completion.During a concurrent interview and record review on 4/23/2026 at 10:28 a.m. with the DON, the facility's policy and procedure titled Posting Direct Care Daily Staffing Numbers was reviewed. The DON stated that based on the facility policy, the nursing staffing data must be posted daily within two hours of the beginning of each shift and must include the resident census and the total number and actual hours worked by licensed and unlicensed nursing staff directly responsible for resident care per shift. The DON stated the facility did not follow policy, which resulted in residents, staff, and visitors being unable to determine how many staff worked on 4/21/2026 and 4/22/2026 in the SNF area. The DON stated the forms should have been completed in black ink rather than pencil to prevent any changes to the information, as required by policy. During a review of facility's policy and procedure titled, Posting Direct Care Daily Staffing Numbers, revised on 11/25/2025, the P&P indicated our facility will post on a daily basis for each shift nurse staffing data, including the number of nursing personnel responsible for providing direct care to residents. Within two (2) hours of the beginning of each shift, the number of licensed nurses (RNs, LPNs, and LVNs) and the number of unlicensed nursing personnel (CNAs and NAs) directly responsible for resident care is posted in a prominent location (accessible to residents and visitors) and in a clear and readable format. 2). Directly responsible for resident care means that individuals are responsible for residents' total care or some aspect of the residents' care including but not limited to: assisting with activities of daily living (ADLs), administering medications, supervising care provided by CNAs, and performing nursing assessments. Medication aides, feeding assistants, hospice staff, private duty aides and administrative staff are not calculated in direct care staffing numbers. Shift staffing information is recorded on a form for each shift. The information recorded on the form shall include the following:a. The name of the facility;b. The current date (the date for which the information is posted);c. The resident census at the beginning of the shift for which the information is posted;d. Twenty-four (24)-hour shift schedule operated by the facility.e. The shift for which the information is posted;f. Type (RN, LPN, L VN, or CNA) and category (licensed or non-licensed) of nursing staff working during that shift who are paid by the facility (including contract staff);g. The actual time worked during that shift for each category and type of nursing staff. h. Total number of licensed and non-licensed nursing staff working for the posted shift.3) Within two (2) hours of the beginning of each shift, the charge nurse or designee computes the number of direct care staff and completes the Nurse Staffing Information form. The charge nurse completes the form and posts the staffing information in the location(s) designated by the administrator.4) The form may be typed or handwritten. If the information is handwritten, it must be legibly printed in black ink and written so that staffing data can be easily seen and read by residents, staff, visitors or others who are interested in our facility's daily staffing information.

Based on interview and record review the facility failed to: 1.Have an available supply of oyster shell calcium (a medication used as a dietary supplement to provide support to bones) in the facility affecting 1 (one) of six (6) observed residents (Resident 87) for medication administration. As a result, Resident 87 did not receive oyster shell calcium on 4/21/2026 at 9:45 a.m. 2. Have an available supply of menthol-methyl salicylate cream (a medication used for pain) and glipizide (a medication used to lower blood sugar levels,) in the facility affecting 1 (one) of six (6) observed residents (Resident 201) for medication administration. As a result, Resident 201 did not receive menthol-methyl salicylate cream between 4/9/2026 and 4/20/2026 and did not received glipizide between 4/16/2026 and 4/20/2026. 3. Resident 84 did not have previous lidocaine (a medication used to relieve pain) topical (on the skin) patch removed 12 hours after application, for 1 (one) of six (6) observed residents for medication administration, as ordered by Resident 84's physician. These deficient practices had the potential to result in Resident 84 to experience medication adverse effects (unwanted, uncomfortable, or dangerous effects that a medication may have) and in Residents 87's and 201's health and well-being to be negatively impacted. Cross referenced with F759 and F760 Findings: During an observation on 4/20/2026 at 9:40 a.m., in Medication Cart Station 3, Licensed Vocational Nurse (LVN) 2 was observed removing a lidocaine five (5) % patch labeled 4/19/2026 with a black pen from Resident 84's right shoulder. During a concurrent interview, LVN 2 stated the lidocaine patch labeled 4/19/2026 was still on Resident 84's right shoulder that day (4/20/2026) at 9:40 a.m. LVN 2 stated lidocaine patches needed to be removed 12 hours after administration, per Resident 84's physician orders. LVN 2 stated LVN 5 failed to remove the lidocaine patch from Resident 84's right shoulder on 4/19/2025 at 9 p.m. LVN 2 stated not removing the lidocaine patch 12 hours after administration increases the risk of adverse effects, such as receiving too much medication, skin irritation and rash for Resident 84. LVN 2 stated LVN 2 will not administer the new patch and need to contact the physician and obtain any new orders as necessary. During an observation on 4/20/2026 at 10:10 a.m. in Medication Cart Station 3, LVN 2 was observed administering gabapentin (a medication used for nerve damage) and metformin (a medication used for high blood sugar level) orally to Resident 201. Resident 201 was observed swallowing the gabapentin and metformin tablets with a glass of water. LVN 2 was observed not administering glipizide (a medication used for high blood sugar levels) and menthol-methyl salicylate cream (a medication used for pain) to Resident 201. During a concurrent interview and record review on 4/20/2026 at 2:25 p.m. with LVN 2, LVN 2 reviewed Resident 201's April 2026 Medication Administration Record ([MAR] - a record of mediations administered to residents.) LVN 2 stated LVN 2 did not administer menthol-methyl salicylate and glipizide that day (4/20/2026) at 10:10 a.m. to Resident 201, as prescribed by Resident 201's physician, since menthol-methyl salicylate and glipizide were not available in Medication Cart Station 3 or in the facility. LVN 2 stated that medications should be ordered four (4) to seven (7) days in advance of last dose, and followed up as needed with pharmacy, to ensure timely availability of medications and prevent missing doses. LVN 2 stated menthol-methyl salicylate cream was a medication used to relieve pain and not administering can harm Resident 201 by not relieving the pain leading to worsening of the pain. LVN 2 stated glipizide was a medication used to control blood sugar levels and not administering and/or missing a dose could harm Resident 201 by causing high or low blood sugar levels, and unresponsiveness resulting in potential hospitalization. LVN 2 stated facility failed to ensure glipizide and menthol-methyl salicylate were readily available in the facility at time of scheduled dose, resulting in omission of doses for Resident 201. LVN 2 also acknowledged the April 2026 MAR indicated Resident 201 was not administered glipizide between 4/16/2026 and 4/20/2026. LVN 2 stated LVN 2 will follow up with pharmacy to expedite the refills and notify Resident 201's physician the morning doses were not administered and obtain additional orders as necessary. During an observation on 4/21/2026 at 9:45 a.m. in Medication Cart Subacute Cart 2, LVN 4 was observed administering amlodipine (a medication used for high blood pressure,) cholecalciferol (a medication used as a dietary supplement to provide support to bones,) docusate (a medication used for constipation,) polyethylene glycol (a medication used for constipation,) levetiracetam (a medications used for epilepsy,) potassium chloride (a medication used for low blood potassium levels,) and acetaminophen (a medication used for pain) via gastrostomy tube ([G-tube] - a tube inserted through the belly that delivers nutrition and medications directly to the stomach) to Resident 87, and was observed not administering oyster shell calcium to Resident 87. During an interview on 4/21/2026 at 10 a.m., with LVN 4, LVN 4 stated LVN 4 did not administer oyster shell calcium earlier at 9:45 a.m. to Resident 87, as prescribed by Resident 87's physician, since oyster shell calcium was not available in Medication Cart subacute Cart 2 or in the facility. LVN 4 stated that medications should be readily available in the facility to ensure timely administration at the scheduled times and prevent missed administration. LVN 4 stated oyster shell calcium was house supply (supply intended for facility resident use) medication used for bone strength and not administering can place Resident 87 at risk of osteoporosis (a condition with fragile bones and fractures.) During an interview on 4/21/2026 at 11:57 a.m., with the Director of Nursing (DON,) the DON stated per facility policies medications should be ordered seven (7) days in advance and be readily available in the facility for administration of doses at their scheduled times as prescribed. The DON stated that licensed nurses should follow medication administration guidelines and five (5) rights of medication administration to ensure physician orders were followed and medications were administered to residents as prescribed. The DON stated that LVN's were expected to re-order medications timely and follow-up on the refills to ensure medications were available to residents. During the same interview, the DON stated LVN 4 failed to administer oyster shell calcium to Resident 87 on 4/21/2026 at 9:45 a.m. since oyster shell calcium was not available in the facility. The DON stated that the DON was not notified that oyster shell calcium was unavailable for ordering as house supply and that the facility failed to notify the physician to obtain an alternate order of calcium for Resident 87. The DON added that LVN 2 failed to administer glipizide and menthol-methyl salicylate to Resident 201 on 4/20/2026 at 10:10 a.m. since glipizide and menthol-methyl salicylate were not available in the facility. The DON stated menthol-methyl salicylate was prescribed for pain and glipizide was prescribed for high blood sugar levels by Resident 201's physician, and not administering both medications can potentially harm Resident 201 by not relieving the pain and increasing or decreasing the blood sugar levels. The DON stated the facility failed to follow policy and procedures for medication reordering and administration resulting in significant medication errors, unavailability and interruption of medication administration and continuity of care for Resident 87 and 201, thereby increasing the risk of worsening pain, imbalance in blood mineral levels, uncontrolled blood sugar levels and potential hospitalization. During a concurrent interview and record review on 4/21/2026 at 3:48 p.m., the DON reviewed the Manifest records from pharmacy for the delivery of glipizide dated 3/13/2026 and electronic prescription transmission record for menthol-methyl salicylate cream dated 4/9/2026. The DON stated the Manifest indicated glipizide for Resident 201 was last delivered to the facility on 3/13/2026 with quantity 31 (a 31-day supply.) The DON acknowledged pharmacy had not provided additional manifests for glipizide for Resident 201. The DON acknowledged the facility had not received and pharmacy had not delivered glipizide since 3/13/2026 for Resident 201. The DON stated as a result, Resident 201 did not have a supply of glipizide for administration after the 31-day supply finished on 4/15/2026, therefore missing doses between 4/16/2026 and 4/20/2026. The DON stated there were no manifests or record of delivery for menthol-methyl salicylate cream from pharmacy. The DON acknowledged the facility had not received and pharmacy had not delivered menthol-methyl salicylate cream for Resident 201 since 4/9/2026. The DON stated as a result, Resident 201 did not have a supply of menthol-methyl salicylate cream for administration, therefore missing doses between 4/9/2026 and 4/20/2026. The DON stated that there was no consistent system in place to ensure timely re-ordering and follow-up of medications. The DON stated that the facility and pharmacy needed to create a better communication system to prevent these failures from affecting other residents in the future. During the same interview, the DON stated LVN 5 failed to remove the lidocaine patch from Resident 84's right shoulder on 4/19/2026 at 9 p.m. The DON stated leaving the lidocaine patch on the skin longer than 12 hours may place Resident 84 at risk for overdose (receiving more than the intended dose) and developing skin irritation. The DON stated that LVN's should follow facility medication administration guidelines and the five (5) rights of medication administration to ensure physician orders are followed. During a review of Resident 84's admission Record (a document containing demographic and diagnostic information,) dated 4/20/2026 the admission Record indicated Resident 84 was originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnosis including multiple fractures. During a review of Resident 84's Order Summary Report (a report listing the physician order for the resident,) dated 4/19/2026, the report indicated Resident 84 was prescribed lidocaine patch 5 % apply to right shoulder in a.m. off at HS (bedtime) for pain management and remove per schedule, starting 2/25/2026. During a review of Resident 84's MAR for April 2026, the MAR indicated Resident 84 was prescribed lidocaine patch 5 % apply to right shoulder for pain management, to apply at 9 a.m. and remove at 9 p.m. During a review of Resident 87's admission Record, dated 4/21/2026, the record indicated Resident 87 was originally admitted to the facility on [DATE] and re-admitted on [DATE] with a diagnosis including dysphagia (difficulty swallowing.) During a review of Resident 87's Order Summary Report, dated 4/20/2026, the report indicated Resident 87 was prescribed oyster shell calcium 500 MG one (1) tablet via G-tube once a day for supplement, starting 5/25/2024. During a review of Resident 87's MAR for April 2026, the MAR indicated Resident 87 was prescribed oyster shell calcium 500 MG one (1) tablet via G-Tube once a day for supplement, to give at 9 a.m. During a review of Resident 201's admission Record, dated 4/20/2026, the record indicated Resident 201 was originally admitted to the facility on [DATE] with a diagnosis including type two (2) diabetes mellitus (DM 2-a disorder characterized by difficulty in blood sugar control), and low back and right hip pain. During a review of Resident 201's Order Summary Report, dated 4/19/2026, the report indicated Resident 201 was prescribed glipizide 2.5 mg one (1) tablet orally once a day for DM Type 2, starting 1/13/2025, and menthol-methyl salicylate cream to left hand twice a day for left hand middle and ring finger pain, starting 4/9/2026. During a review of Resident MAR for April 2026, the MAR indicated Resident 201 was prescribed glipizide 2.5 mg one (1) tablet orally once a day for DM Type 2, to give at 9 a.m., and menthol-methyl salicylate cream to left hand twice a day for left hand middle and ring finger pain, to give at 9 a.m. and 5 p.m. During a review of the facility's Policy and Procedures (P&P,) titled Medication Administration -General Guidelines, last reviewed 11/25/2025, the P&P indicated: Medications are administered as prescribed in accordance with good nursing principles and practices. -Medications are administered in accordance with written orders of the attending physician. -The Individual who administers the medication dose records the administration on the resident's MAR after the medication is given. During a review of the facility's P&P titled Transdermal Drug Delivery System (Patch) Application, last reviewed 11/25/2025, the P&P indicated: Remove old patch from body and cleanse site if necessary. During a review of the facility's P&P titled Ordering and Receiving Medications from the dispensing Pharmacy, last reviewed 11/25/2025, the P&P indicated: Medications and related products are received from the dispensing pharmacy on a timely basis. 2.a. Reorder medications five days in advance of need to assure an adequate supply is on hand. During a review of the facility's P&P titled House-Supplied (Floor Stock) Medications, last reviewed 11/25/2025, the P&P indicated: The facility maintains a supply of commonly used over-the-counter medications considered as floor stock or house medications as permitted by state regulation. C. Floor stock medications are ordered from the provider/dispensing pharmacy or other provider according to facility policy. During a review of the facility's P&P titled Ordering of Supplies and Equipment, last reviewed 11/25/2025, the P&P indicated: 7. If supplies are not available, the facility will make reasonable efforts including but are not limited to: Contact available resources for the requested items Notify the physician and provide alternatives as indicated. During a review of the facility's P&P, titled Adverse consequences and Medication Errors, last reviewed 11/25/2025, the P&P indicated: 1. An 'adverse consequence' refers to an unwanted, uncomfortable or dangerous effect that a drug may have, such as a decline in mental or physical condition, or functional or psychosocial status. An adverse consequence may include: a. Adverse drug/medication reaction; b. Side effect; 2. The staff and practitioner strive to minimize adverse consequences by: a. Following relevant clinical guidelines and manufacturer's specifications for use, dose, administration, duration, and monitoring of the medication. During a review of facility provided lidocaine patch 5% medication package (unopened package containing medication,) the manufacturer indicated on the back of the package Apply the prescribed number of patches only once for up to 12 hours within a 24-hour period.

Based on observation, interview, and record review, the facility failed to ensure that its medication error rate was less than five (5) percent (%). Four (4) medication errors out of 26 total opportunities contributed to an overall medication error rate of 15.38% affecting three (3) of six (6) residents observed for medication administration (Resident 84, 87 and 201.) The medication errors were as follows: 1.Resident 84 did not receive sevelamer (a medication used for hyperphosphatemia [having high blood levels of phosphate, a mineral] for people on dialysis [treatment that removes waste and excess fluid from the blood,]) on 4/20/2026, as prescribed by Resident 84's physician. 2. Resident 87 did not receive oyster shell calcium (a medication used as a dietary supplement to provide support to bones), on 4/20/2026, as prescribed by Resident 87's physician. 3.Resident 201 did not receive menthol-methyl salicylate cream (a medication used for pain) and glipizide (a medication used to lower blood sugar levels,) on 4/20/2026, as prescribed by Resident 201's physician. These failures had the potential for Residents 84, 87 and 201 to experience adverse effects (unwanted, uncomfortable, or dangerous effects,) and health complications such as continuous and unrelieved pain, uncontrolled blood sugar levels, and blood mineral imbalance resulting in Resident 84's, 87's and 201's health and well-being to be negatively impacted. Cross referenced with F755 and F760.Findings: During an observation on 4/20/2026 at 9:40 a.m., in Medication Cart Station 3, Licensed Vocational Nurse (LVN) 2 was observed administering amlodipine (a medication used for high blood pressure,) aspirin (a medication used for deep vein thrombosis [DVT - formation of one or more blood clots] prophylaxis [PPX - measures designed to preserve health,]) clopidogrel (a medication used for DVT PPX,) cranberry (a supplement used for urinary tract infection PPX,) gabapentin (a medication used for neuropathy [nerve damage,]) cinacalcet (a medication used for hypercalcemia [having high blood levels of calcium,) Rena Vite (a medication used for vitamin deficiencies for people on dialysis) tablets orally and Cosopt (a medication used for glaucoma [a condition of increased pressure in the eyeball,]) eye drops to Resident 84 . Resident 84 was observed swallowing the amlodipine, clopidogrel, cranberry, gabapentin, cinacalcet, Rena Vite tablets with a glass of water. LVN 2 was not observed administering sevelamer tablet orally to Resident 84. During an observation on 4/20/2026 at 10:10 a.m. in Medication Cart Station 3, LVN 2 was observed administering gabapentin and metformin (a medication used for high blood sugar level) orally to Resident 201. Resident 201 was observed swallowing the gabapentin and metformin tablets with a glass of water. LVN 2 was observed not administering glipizide (a medication used for high blood sugar levels) and menthol-methyl salicylate cream (a medication used for pain) to Resident 201. During an interview on 4/20/2026 at 2:25 p.m. with LVN 2, LVN 2 acknowledged that Resident 84's physician order specified to administer sevelamer at 9 a.m. LVN 2 stated that LVN 2 failed to follow five (5) rights of medication administration and failed to prepare and administer sevelamer as prescribed by Resident 84's physician that day (4/20/2026) at 9:40 a.m., even though LVN 2 documented as administered. LVN 2 stated omitting the administration of sevelamer to Resident 84 may not be beneficial to Resident 84's health and may cause adverse effects such as further imbalance of phosphate by increasing blood phosphate levels. LVN 2 stated this was considered a medication error. During the same interview, LVN 2 stated LVN 2 did not administer menthol-methyl salicylate and glipizide that day (4/20/2026) at 10:10 a.m. to Resident 201, as prescribed by Resident 201's physician, since menthol-methyl salicylate and glipizide were not available in Medication Cart Station 3 or in the facility. LVN 2 stated that medications should be ordered four (4) to seven (7) days in advance of last dose, and followed up as needed with pharmacy, to ensure timely availability of medications and prevent missing doses. LVN 2 stated missing administration of doses were considered medication errors. LVN 2 stated menthol-methyl salicylate cream was a medication used to relieve pain and not administering can harm Resident 201 by not relieving the pain leading to worsening of the pain. LVN 2 stated glipizide was a medication used to control blood sugar levels and not administering and/or missing a dose could harm Resident 201 by causing high or low blood sugar levels, and unresponsiveness resulting in potential hospitalization. LVN 2 stated the facility failed to ensure glipizide and menthol-methyl salicylate were readily available in the facility at time of scheduled dose, resulting in omission of doses and medication errors for Resident 201. LVN 2 stated LVN 2 will follow up with pharmacy to expedite the refills and notify Resident 201's physician the morning doses were not administered and obtain additional orders as necessary. During an observation on 4/21/2026 at 9:45 a.m. in Medication Cart Subacute Cart 2, LVN 4 was observed administering amlodipine (a medication used for high blood pressure,) cholecalciferol (a medication used as a dietary supplement to provide support to bones,) docusate (a medication used for constipation,) polyethylene glycol (a medication used for constipation,) levetiracetam (a medications used for epilepsy,) potassium chloride (a medication used for low blood potassium levels,) and acetaminophen (a medication used for pain) via gastrostomy tube ([G-tube] - a tube inserted through the belly that delivers nutrition and medications directly to the stomach) to Resident 87, and was observed not administering oyster shell calcium to Resident 87. During an interview on 4/21/2026 at 10 a.m., with LVN 4, LVN 4 stated LVN 4 did not administer oyster shell calcium earlier at 9:45 a.m. to Resident 87, as prescribed by Resident 87's physician, since oyster shell calcium was not available in Medication Cart subacute Cart 2 or in the facility. LVN 4 stated that medications should be readily available in the facility to ensure timely administration at the scheduled times and prevent missed doses. LVN 4 stated missing the administration of oyster shell calcium was an omission due to the medication not being available and was considered a medication error. LVN 4 stated oyster shell calcium was house supply (supply intended for facility resident use) medication used for bone strength and not administering can place Resident 87 at risk of osteoporosis (a condition with fragile bones and fractures.) During an interview on 4/21/2026 at 11:57 a.m., with the Director of Nursing (DON,) the DON stated per facility policies medications should be ordered seven (7) days in advance and be readily available in the facility for administration of doses at their scheduled times as prescribed. The DON stated that licensed nurses should follow medication administration guidelines and five (5) rights of medication administration to ensure physician orders were followed and medications were administered to residents as prescribed. The DON stated that LVN 2 failed to prepare and administer sevelamer to Resident 84, according to the physician orders, leading to an omission of the scheduled dose on 4/20/2026. The DON stated that not receiving a dose places Resident 84 at risk of having further increase in blood phosphate levels. The DON stated this was considered a medication error. During the same interview, the DON stated that LVN's were expected to re-order medications timely and follow-up on the refills to ensure medications were available to residents. The DON stated LVN 4 failed to administer oyster shell calcium to Resident 87 on 4/21/2026 at 9:45 a.m. since oyster shell calcium was not available in the facility. The DON stated this was considered a medication error. The DON stated that the DON was not notified that oyster shell calcium was unavailable for ordering as house supply, and that the facility failed to notify the physician to obtain an alternate order of calcium for Resident 87. During the same interview, the DON stated that LVN 2 failed to administer glipizide and menthol-methyl salicylate to Resident 201 on 4/20/2026 at 10:10 a.m. since glipizide and menthol-methyl salicylate were not available in the facility. The DON stated these were considered medication errors, and a significant error for not receiving glipizide. The DON stated menthol-methyl salicylate was prescribed for pain and glipizide was prescribed for high blood sugar levels by Resident 201's physician, and not administering both medications could potentially harm Resident 201 by not relieving the pain and increasing or decreasing the blood sugar levels. The DON stated the facility failed to follow policy and procedures for medication reordering and administration resulting in significant medication errors, unavailability and interruption of medication administration and continuity of care for Resident 84, 87 and 201, thereby increasing the risk of worsening pain, imbalance in blood mineral levels, uncontrolled blood sugar levels and potential hospitalization. During a review of Resident 84's admission Record (a document containing demographic and diagnostic information,) dated 4/20/2026 the admission Record indicated Resident 84 was originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnosis including kidney (pair of organs responsible for filtering waste materials out of the blood) disease and dependence on dialysis. During a review of Resident 84's Order Summary Report (a report listing the physician order for the resident,) dated 4/19/2026, the report indicated Resident 84 was prescribed sevelamer 800 milligram ([mg-unit of measure of mass]) one (1) tablet orally three (3) times a day for hyperphosphatemia, starting 3/30/2026. During a review of Resident 84's Medication Administration Record ([MAR] - a record of mediations administered to residents,) for April 2026, the MAR indicated Resident 84 was prescribed sevelamer 800 mg, one (1) tablet orally three (3) times a day for hyperphosphatemia, to give at 9 a.m. During a review of Resident 87's admission Record, dated 4/21/2026, the record indicated Resident 87 was originally admitted to the facility on [DATE] and re-admitted on [DATE] with a diagnosis including dysphagia (difficulty swallowing.) During a review of Resident 87's Order Summary Report, dated 4/20/2026, the report indicated Resident 87 was prescribed oyster shell calcium 500 MG one (1) tablet via G-tube once a day for supplement, starting 5/25/2024. During a review of Resident 87's MAR for April 2026, the MAR indicated Resident 87 was prescribed oyster shell calcium 500 MG one (1) tablet via G-Tube once a day for supplement, to give at 9 a.m. During a review of Resident 201's admission Record, dated 4/20/2026, the record indicated Resident 201 was originally admitted to the facility on [DATE] with a diagnosis including type two (2) diabetes mellitus (DM 2-a disorder characterized by difficulty in blood sugar control), and low back and right hip pain. During a review of Resident 201's Order Summary Report, dated 4/19/2026, the report indicated Resident 201 was prescribed glipizide 2.5 mg one (1) tablet orally once a day for DM Type 2, starting 1/13/2025, and menthol-methyl salicylate cream to left hand twice a day for left hand middle and ring finger pain, starting 4/9/2026. During a review of Resident MAR for April 2026, the MAR indicated Resident 201 was prescribed glipizide 2.5 mg one (1) tablet orally once a day for DM Type 2, to give at 9 a.m., and menthol-methyl salicylate cream to left hand twice a day for left hand middle and ring finger pain, to give at 9 a.m. and 5 p.m. During a review of the facility's Policy and Procedures (P&P,) titled Medication Administration -General Guidelines, last reviewed 11/25/2025, the P&P indicated: Medications are administered as prescribed in accordance with good nursing principles and practices. 2.Medications are administered in accordance with written orders of the attending physician. 10. Medications are administered within 60 minutes of scheduled time (1 hour before and 1 hour after). 1.The Individual who administers the medication dose records the administration on the resident's MAR after the medication is given. During a review of the facility's P&P titled Ordering and Receiving Medications from the dispensing Pharmacy, last reviewed 11/25/2025, the P&P indicated: Medications and related products are received from the dispensing pharmacy on a timely basis. 2.a. Reorder medications five days in advance of need to assure an adequate supply is on hand. During a review of the facility's P&P titled House-Supplied (Floor Stock) Medications, last reviewed 11/25/2025, the P&P indicated: The facility maintains a supply of commonly used over-the-counter medications considered as floor stock or house medications as permitted by state regulation. C. Floor stock medications are ordered from the provider/dispensing pharmacy or other provider according to facility policy. During a review of the facility's P&P titled Ordering of Supplies and Equipment, last reviewed 11/25/2025, the P&P indicated: 7. If supplies are not available, the facility will make reasonable efforts including but are not limited to: Contact available resources for the requested items Notify the physician and provide alternatives as indicated. During a review of the facility's P&P, titled Adverse consequences and Medication Errors, last reviewed 11/25/2025, the P&P indicated: 1. An 'adverse consequence' refers to an unwanted, uncomfortable or dangerous effect that a drug may have, such as a decline in mental or physical condition, or functional or psychosocial status. An adverse consequence may include: a. Adverse drug/medication reaction; b. Side effect; 2. The staff and practitioner strive to minimize adverse consequences by: a. Following relevant clinical guidelines and manufacturer's specifications for use, dose, administration, duration, and monitoring of the medication; 1. An adverse drug reaction (ADR) is a form of adverse consequences. It may be either a secondary effect of a medication that is usually undesirable and different from the therapeutic and helpful effects of the drug; or any response to a medication that is noxious and unintended. 1. A medication error is defined as the preparation or administration of drugs or biological which is not in accordance with physician's orders, manufacturer specifications, or accepted professional standards and principles of the professional(s) providing services. 2. Examples of medications errors include: a. Omission - a drug is ordered but not administered; b. Unauthorized drug- a drug is administered without a physician's order; 3. A significant medication-related error is defined as: b. Requiring hospitalization, or extending a hospitalization. f. Life threatening.

Findings: During an observation on 4/20/2026 at 10:10 a.m. in Medication Cart Station 3, Licensed Vocational Nurse (LVN) 2 was observed administering gabapentin (a medication used for neuropathy [nerve damage,]) and metformin (a medication used for high blood sugar level) orally to Resident 201. Resident 201 was observed swallowing the gabapentin and metformin tablets with a glass of water. LVN 2 was observed not administering glipizide (a medication used for high blood sugar levels) to Resident 201. During a concurrent interview and record review on 4/20/2026 at 2:25 p.m. with LVN 2, LVN 2 reviewed Resident 201's Medication Administration Record ([MAR] - a document of the medications administered to a resident that is part of the resident's permanent medical record]) for April 2026. LVN 2 stated that LVN 2 did not administer glipizide that day (4/20/2026) at 10:10 a.m. to Resident 201, as prescribed by Resident 201's physician, since glipizide was not available in Medication Cart Station 3 or in the facility. LVN 2 stated that medications should be ordered four (4) to seven (7) days in advance of last dose, and followed up as needed with pharmacy, to ensure timely availability of medications and prevent missing doses. LVN 2 stated missing administration of doses was considered a medication error. LVN 2 stated glipizide was a medication used to control blood sugar levels and not administering and/or missing a dose could harm Resident 201 by causing high or low blood sugar levels and unresponsiveness resulting in potential hospitalization. LVN 2 acknowledged the April 2026 MAR indicated Resident 201 was not administered glipizide between 4/16/2026 and 4/20/2026. LVN 2 stated facility failed to ensure glipizide was readily available in the facility at time of scheduled doses, resulting in omission of doses between 4/16/2026 and 4/20/2026 and medication errors for Resident 201. LVN 2 stated LVN 2 will follow up with pharmacy to expedite the refills and notify Resident 201's physician the morning dose was not administered and obtain additional orders as necessary. During a concurrent interview and document review on 4/21/2026 at 11:57 a.m., with the Director of Nursing (DON,) the DON reviewed Resident 201's April 2026 MAR. The DON stated per facility policies medications should be ordered seven (7) days in advance and be readily available in the facility for administration of doses at their scheduled times as prescribed. The DON stated LVN's are expected to re-order medications timely and follow-up on the refills to ensure medications were available to residents. The DON stated that LVN 2 failed to administer glipizide to Resident 201 on 4/20/2026 at 10:10 a.m. since glipizide was not available in the facility. The DON stated glipizide was prescribed for high blood sugar levels by Resident 201's physician, and not administering can potentially harm Resident 201 by increasing or decreasing the blood sugar levels. The DON acknowledged the April 2026 MAR indicated Resident 201 was not administered glipizide between 4/16/2026 and 4/20/2026. The DON stated not administering glipizide since 4/16/2026 were considered significant medication errors. The DON stated the facility failed to follow policy and procedures for medication reordering and administration resulting in significant medication errors, unavailability and interruption of medication administration and continuity of care for Resident 201, increasing the risk of uncontrolled blood sugar levels and potential hospitalization. During a concurrent document review and interview on 4/21/2026 at 12:17 p.m. with Registered Nurse (2,) RN 2 reviewed Resident 201's April 2026 MAR. RN 2 acknowledged the documentation on the MAR between 4/16/2026 and 4/20/2026 indicated that glipizide was not administered to Resident 201. RN 2 stated not administering glipizide daily to Resident 201 between 4/16/2026 and 4/20/2026 were considered significant medication errors. During a review of Resident 201's admission Record (a document containing demographic and diagnostic information,) dated 4/20/2026, the record indicated Resident 201 was originally admitted to the facility on [DATE] with a diagnosis including DM Type 2 and low back and right hip pain. During a review of Resident 201's Order Summary Report (a report listing the physician order for the resident,) dated 4/19/2026, the report indicated Resident 201 was prescribed glipizide 2.5 mg one (1) tablet orally once a day for DM Type 2, starting 1/13/2025, and menthol-methyl salicylate cream to left hand twice a day for left hand middle and ring finger pain, starting 4/9/2026. During a review of Resident MAR for April 2026, the MAR indicated: 1.Resident 201 was prescribed glipizide 2.5 mg one (1) tablet orally once a day for DM Type 2, to give at 9 a.m. 2. Glipizide 2.5 mg was documented as not administered daily by several licensed vocational nurses between 4/16/2026 and 4/20/2026. During a review of the facility's Policy and Procedures (P&P,) titled Medication Administration -General Guidelines, last reviewed 11/25/2025, the P&P indicated: Medications are administered as prescribed in accordance with good nursing principles and practices. Medications are administered in accordance with written orders of the attending physician. 2. Medications are administered within 60 minutes of scheduled time (1 hour before and 1 hour after). 10. During a review of the facility's P&P, titled Adverse consequences and Medication Errors, last reviewed 11/25/2025, the P&P indicated: 1. An 'adverse consequence' refers to an unwanted, uncomfortable or dangerous effect that a drug may have, such as a decline in mental or physical condition, or functional or psychosocial status. An adverse consequence may include: a. Adverse drug/medication reaction; b. Side effect; 2. The staff and practitioner strive to minimize adverse consequences by: a. Following relevant clinical guidelines and manufacturer's specifications for use, dose, administration, duration, and monitoring of the medication; 1. An adverse drug reaction (ADR) is a form of adverse consequences. It may be either a secondary effect of a medication that is usually undesirable and different from the therapeutic and helpful effects of the drug; or any response to a medication that is noxious and unintended. 1. A medication error is defined as the preparation or administration of drugs or biological which is not in accordance with physician's orders, manufacturer specifications, or accepted professional standards and principles of the professional(s) providing services. 2. Examples of medications errors include: a. Omission - a drug is ordered but not administered; b. Unauthorized drug- a drug is administered without a physician's order; 3. A significant medication-related error is defined as: b. Requiring hospitalization, or extending a hospitalization. f. Life threatening.

Based on observation, interview, and record review the facility failed to: 1.Remove and discard from use one (1) expired latanoprost (a medication used for glaucoma [a condition of increased pressure in the eyeball]) eye drop bottle for Resident 26, in accordance with manufacturers' requirements and facility policies, in one (1) of five (5) inspected medication carts (Medication Cart 2B). 2. Label one (1) levalbuterol (a medication used to treat and prevent shortness of breath) inhalation solution foil pouch (a package made of foil protecting the inhalation solution from light and degradation) with a date open for Resident 99, in accordance with the manufacturer's requirements in one (1) of five (5) Medication Carts (Medication Cart 1B.) These deficient practices increased the risk that Residents 26 and 99 could have received medications that had become ineffective or toxic due to improper storage or labeling, accidentally used due to improper labeling, possibly leading to health complications resulting in infections, hospitalization or death. Cross referenced to F880.Findings: During an observation on 4/20/2026 at 12:10 p.m., in Medication Cart 1B with Licensed Vocational Nurse (LVN) 14, the following medication was found either stored in a manner contrary to their respective manufacturer's requirements, not labeled with an open date as required by their respective manufacturer's specifications, or stored and labeled contrary to facility policies: One (1) open levalbuterol inhalation solution foil pouch for Resident 99, was found stored at room temperature and not labeled with a date indicating when the foil pouch was opened. According to the manufacturer's product storage and labeling, opened foil pouch of levalbuterol inhalation solutions should be stored between 68 to 77 degrees Fahrenheit and once the foil pouch is opened to be used within two (2) weeks. During a concurrent interview, LVN 14 stated the levalbuterol inhalation solution foil pouch for Resident 99 in Medication Cart station 1B was not labeled with a date indicating when the foil pouch was opened. LVN 14 stated that per facility policy multi-dose (containing more than one dose) products such as inhalation solutions should be labeled with the date when first opened to know when they expire. LVN 14 stated that expired medications have lost potency (strength) and will not be effective in treating residents' condition, in this case wheezing. LVN 14 stated according to the manufacturer guidelines, the inhalation solutions should be used within two (2) weeks of opening the pouch. LVN 14 stated LVN 14 was unaware when the pouch was opened therefore unaware when it would expire. LVN 14 stated failing to record the date of first use could lead to Resident 99 receiving potentially expired and ineffective levalbuterol. LVN 14 stated this could cause Resident 99 harm by not treating or preventing the wheezing (whistling sound during breathing when airways are narrowed, inflamed, or blocked making it difficult for air to move freely) and bronchospasm (a condition where airways are narrowed making breathing more difficult) requiring immediate treatment and potential transfer to the hospital. During an observation on 4/20/2026 at 12:50 p.m., in Medication Cart 2B, with Licensed Vocational Nurse (LVN) 12 the following medications were found either stored in a manner contrary to their respective manufacturer's requirements, and/or not removed/discarded from use: One (1) open latanoprost eye drop bottle for Resident 26 was found stored at room temperature and labeled with a date indicating use began on 3/1/2026, and pharmacy instructions printed on the bottle indicating to discard unused portion after 28 days. According to the manufacturer's product storage and labeling, opened latanoprost bottles may be stored at room temperature up to 77 degrees Fahrenheit and used or discarded within six (6) weeks of opening/use. During a concurrent interview, LVN 12 stated that the latanoprost eye drop bottle was not stored properly for Resident 26. LVN 12 stated multi-dose (containing more than one dose) medications, such as eye drop bottles, have a shorter expiration date once opened, than the one printed on the bottle by the manufacturer. LVN 12 stated the label on the bottle indicated the bottle was opened on 3/1/2026 and that to discard after 28 days. LVN 12 stated that eye drop medications used beyond the 28-day expiration date have lost potency (effectiveness,) maybe contaminated (contain bacteria) and will not be effective in treating the residents' glaucoma, in addition to causing eye infections because of loss of sterility (free from bacteria.) LVN 12 stated the latanoprost eye drop bottle was used between 3/1/2026 and 4/19/2026, placing Resident 26 at increased risk of experiencing adverse effects (unwanted, uncomfortable, or dangerous effects,) not effectively treating the glaucoma, causing further nerve damage, infections, and potential blindness. LVN 12 stated medications that are expired must be removed from the medication cart to prevent accidental use. LVN 12 stated the latanoprost bottle was expired and needed to be immediately removed from the medication cart and discarded to prevent further use and replaced with a new one from pharmacy. During a concurrent interview and record review on 4/21/2026 at 3:48 p.m., with the Director of Nursing (DON,) the DON stated eye drop bottles were considered multi-dose medications and opened latanoprost bottles had six (6) week expiration dates to ensure the medication was potent, sterile and not contaminated. The DON stated the latanoprost eye drop bottle for Resident 26 was opened on 3/1/2026 and expired on 4/12/2026 and was not removed from use from medication Cart 2B on 4/12/2026. The DON stated this failure led to the administration of expired and ineffective latanoprost to Resident 26 between 4/13/2026 and 4/19/2026, increasing the risk of not effectively treating the glaucoma, and leading to eye nerve damage, infections and possible blindness. The DON stated that severed licensed nurses failed to remove expired latanoprost for Resident 26 from Medication Cart 2B. During the same interview, the DON stated that breathing inhalation solutions stored in foil pouches should be labeled with a date when removed from pouch to know when the beyond use date is (a date identifying an expiration date after opening a multi-dose product,) otherwise unable to determine the expiration date. The DON stated once the pouch was opened, the inhalation solutions expire within two (2) weeks. The DON stated that expired inhalation treatments have lost effectiveness and when administered in error will not treat wheezing or bronchospasm further causing breathing difficulty for Resident 99 requiring immediate treatment and hospitalization. During a review of the facility's policy and procedures (P&P,) titled Storage of Medications, last reviewed 11/25/2025, the P&P indicated: Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. M. Outdated, contaminated, or deteriorated medications.are immediately removed from stock, disposed of according to procedures for medication disposal, and reordered from the pharmacy if a current order exist. During a review of the facility's P&P titled Procedures for All Medications, last reviewed 11/25/2025, the P&P indicated: E. When opening a multi-dose container, place the date on the container. During a review of the facility's P&P, titled Guide for Special Handling of Medications, last reviewed 11/25/2025, the P&P indicated: Ophthalmic preparations - discard 28 days after opening. Expiration date may vary per manufacturer's recommendations. Xopenex (brand name for levalbuterol) - discard 2 weeks after opening the foil pouch. During a review of manufacturer's guide Highlights of Prescribing Information for latanoprost dated January 2023, the guide indicated Protect from light. Store unopened bottle(s) under refrigeration at 36 to 46 F. Once a bottle is opened for use, it may be stored at room temperature up to 77 F for 6 weeks. During a review of manufacturer's guide Highlights of Prescribing Information for levalbuterol inhalation dated July 2019, the guide indicated 'Store Levalbuterol Inhalation Solution, USP in the protective foil pouch at 20 - 25 C (68 - 77 F). Once the foil pouch is opened, the vials should be used within 2 weeks.

Based on observations, interviews and record reviews, the facility failed to provide residents' meals at regular times scheduled in accordance with resident needs, preferences, and requests when lunch was served late on 4/22/2026.This deficient practice had the potential to result in hunger and frustration for 124 to 125 residents receiving meals from the kitchen, including Resident 76 and Resident 88. Findings:1. During a review of Resident 76's Face Sheet, the Face Sheet indicated the facility admitted Resident 76 on 4/18/2025 with diagnoses including, but not limited to, essential hypertension (HTN, high blood pressure), type two diabetes (increased of blood sugar due to insulin resistance), and dysphagia (difficulty swallowing).During a review of Resident 76's Minimum Data Sheet (MDS- a resident assessment tool) dated 10/21/2025, the MDS indicated Resident 76 understood others and make self-understood. The MDS indicated Resident 76 needed supervision or touching assistance (helper provides verbal cues and or touching or steadying and or contact guard assistance as resident completes the activity. Assistance may be provided throughout the activity or intermittently) when eating. During a review of Resident 76's Order Summary Report, dated 4/18/2026, the report indicated Resident 76 was ordered consistent carbohydrate (CCHO, same amount of carbohydrate each meal), no added salt (NAS, no salt packet on the tray), regular texture, thin consistency (no modification with texture and consistency).During a resident council meeting interview on 4/21/2026 at 11:03 a.m., Resident 76 stated the breakfast sausage was cold and pink inside and the food has been cold lately. Resident 76 stated that breakfast and lunch had been arriving late recently and they did not receive lunch until 2:00 p.m. today, and that the quality of food had been poor. During a review of Resident 88's Face Sheet, the Face Sheet indicated the facility admitted Resident 88 on 3/31/2026 with diagnoses including, but not limited to, essential HTN, hyperlipidemia (high fat in the blood), and congestive heart failure (progressive condition where the heart muscle cannot pump blood efficiently enough to meet body's needs).2. During a review of Resident 88's MDS dated [DATE], the MDS indicated Resident 88 understood others and make self-understood. The MDS indicated Resident 88 needed supervision or touching assistance when eating. During a review of Resident 88's Order Summary Report, dated 4/18/2026, the report indicated Resident 88 was ordered CCHO, NAS, regular texture, thin consistency, double protein, double non-starchy vegetables and no starches and grains.During a resident council meeting interview on 4/21/2026 at 11:03 a.m., Resident 88 stated lunch did not arrive until nearly 2:00 p.m. the other day. During an interview on 4/20/2026 at 8:53 a.m., with the Assistant Dietary Supervisor (ADS), the ADS stated the breakfast trayline (an area where foods were assembled form the steamtable [kitchen appliance that keeps food warm at a safe temperature for serving] to resident's plates) duration is one (1) hour During an observation on 4/20/2026 at 8:54 a.m. of the meal schedule posted in the hallway, observed a sign that indicating the following meal schedule: Breakfast 7:30 a.m. Lunch 12:30 p.m. Dinner 5:30 p.m.During an observation on 4/20/2026 at 9:14 a.m., of the breakfast trayline service, staff were observed to have finished the breakfast trayline.During an observation on 4/20/2026 at 12:48 p.m., dietary staff were observed starting the lunch trayline service.During an observation on 4/20/2026 at 12:58 p.m., of the lunch tray line service, staff were observed pushing the first cart containing food trays to the dining room. During an observation on 4/20/2026 at 2:08 p.m., of the trayline lunch service, staff were observed to have finished the lunch trayline.During an observation on 4/20/2026 at 2:10 p.m. staff were observed staff the last tray cart out of the kitchen, which arrived at Station 1 at 2:11 p.m.During an observation on 4/20/2026 at 2:14 p.m., of nursing staff passing food trays, nursing staff were observed serving the first tray to a resident at bedside.During an observation on 4/20/2026 at 2:18 p.m., of nursing staff passing food trays, nursing staff were observed serving the last tray in the cart to a resident at bedside. During an interview on 4/21/2026 at 2:48 p.m. with the Dietary Supervisor (DS), the DS stated the meal schedule for breakfast is at 7:30 a.m., lunch at 12:30 p.m., and dinner at 5:30 p.m.During an observation on 4/22/2026 at 7:33 a.m., of the breakfast trayline service, staff were observed starting the trayline service.During a concurrent observation and interview on 4/22/2026 at 7:56 a.m., of the breakfast service with [NAME] 2, observed staff pushed the first cart of food out of the kitchen. [NAME] 2 stated the breakfast trayline runs from 7:30 a.m. to 8:30 a.m.During an observation on 4/22/2026 at 9:04 a.m., staff were observed preparing the last breakfast tray.During an observation on 4/22/2026 at 9:06 a.m., observed the tray cart arrived at Station 3.During an observation on 4/22/2026 at 9:07 a.m., of the nursing staff's process for checking meal trays, a nursing staff was observed checking the trays against the diet type report to ensure accuracy of the meals.During an observation on 4/22/2026 at 9:10 a.m., of the nursing staff's process for checking meal trays, nursing staff were observed finishing the tray checks and passing the meal trays to residents in their rooms. During an observation on 4/22/2026 at 9:13 a.m., observed the nursing staff pass the last tray to a resident's room.During an interview on 4/22/2026 at 9:14 a.m., with the DS and Registered Dietitian (RD), the DS stated that the trayline was delayed today because there was a lot of food production for special requests from residents. The DS stated the residents were requesting extra omelet. The DS stated the first cart should come out at 7:30 a.m. but it came out ten (10) minutes late. The DS stated the trayline lasted for an hour and the delay was not reasonable, and the staff could do better. The DS further stated the meals should be served on time because residents expect it at a certain time. The RD stated it was important for meals to come on time to prevent resident dissatisfaction and to keep food temperatures palatable. During a review of the facility's policies and procedures P&P titled Meal Service, dated 11/25/2025, the P&P indicated, Resident meals will be served in a standard manner at regular hours with maximum if fourteen hours between the evening meal and breakfast the following day. Residents may also choose at the discretion of the Dietary Services Supervisor and Administrator individual mealtimes. An unavoidable variance of fifteen minutes will be considered acceptable. This is to facilitate routine and optimum resident nourishment.Time schedule: breakfast: 7:30-8:30 a.m.; lunch 12:30-1:30p.m., and dinner 5:30-6:30 p.m.

Based on observation, interview, and record review, the facility failed to prepare food in a form designed to meet individual needs when pureed capri blend vegetables looked flat and spread on the plate and puree spring fruit crip was watery and did not hold its shape. These failures had the potential to result in difficulty in swallowing, difficulty in eating, decrease in food and nutrient intake to 21 of 21 residents on puree diet (foods that are soft, pudding like consistency and hold its shape), resulting in unintended (not planned) weight loss and choking (when food gets stuck in your airway, blocking the flow of air to your lungs). Findings: During a review of the facility's cook spreadsheet (a sheet containing the kind and amount of food each diet would receive) titled, Winter Menus, dated 1/12/2026, the spreadsheet indicated residents on puree diet/International Dysphagia Initiative ([IDDSI] a framework for categorizing food textures and drink thickness) Level 4 would include the following foods on the tray: -Pureed baked hamburger 1/2 cup (c, a household measurement) -Pureed brown sauce 1 ounce (oz, a unit of measurement) -Pureed boiled potatoes 1/2 c -Pureed capri blend vegetables 1/3 c -Pureed wheat roll 1/4 c -Margarine 1 test -Pureed spring fruit crisp 1/4 c -Milk 4 oz During an observation on 4/20/2026 at 1:38 p.m., of puree food plated on the plate of residents, observed the pureed capri vegetables looked flat and spread out on the plate. Observed no spoon tilt test (a test used to assess the cohesiveness and stickiness of foods) or fork pressure test (a test used to assess the firmness and texture of food by applying pressure with the tines of the fork) was performed during trayline (an area where foods were assembled form the steamtable [kitchen appliance that keeps food warm at a safe temperature for serving] ) by the kitchen staff. During an observation on 4/20/2026 at 2:08 p.m., of the trayline, there were no observations of staff performing spoon tilt test or fork pressure test on pureed foods all during the trayline lunch service. During a concurrent observation and interview on 4/20/2026 at 2:36 p.m. of the puree tray with the Dietary Supervisor (DS), the DS stated the pureed capri blend vegetables did not hold its shape on the plate and the puree spring fruit crisp looked watery. The DS stated the pureed food should not look flat on the plate and watery as the residents could choke and aspirate (accidental breathing in of food and liquid into the airway and lungs) as a potential outcome of improper puree texture and consistency. During an interview on 4/22/2026 at 8:17 a.m., with the Registered Dietitian (RD), the RD stated they follow IDDSI standards with the diet and staff should perform spoon tilt test and fork pressure tests when they make the food and during trayline to make sure they serve the right texture for the residents with difficulty swallowing and eating eat safely. During a concurrent review and interview on 4/22/2026 at 8:27 a.m., of the puree tray picture taken at lunch time at 4/21/2026 with the RD, the RD stated based on the picture, the food held its shape on the plate for pureed tray however the pureed capri blend vegetables could have been in better shape because it was possible for the heat in trayline to make the food lose its structure. The RD stated the spring fruit crisp was holding a mount, but it was possible to be a little liquid-y because fruits have a lot of liquid naturally. The RD stated she would have the staff add some thickener and have them remake the puree vegetables and dessert. The RD stated that after reviewing the picture visually, the puree food in trays should not be served to the residents. The RD stated it was important to make sure they serve the residents the right texture so that they could eat safely, especially for residents with difficulty swallowing and chewing. During a review of the facility's Diet Manual titled, IDDSI Level 4L Regular Pureed Diet, dated 11/25/2025, the manual indicated, The pureed diet has been designed for resident who have difficulty chewing and/or swallowing. The texture of the pureed food items included in this diet should be smooth and free of lumps, hold their shape, while not being too firm or sticky, and should not weep. Detailed recipes and procedures for pureeing food may be found in Book 1, under the Food Safety/Miscellaneous section. During a review of the facility's recipe titled, Recipe: Pureed (IDDSI Level #4) Vegetables, dated 11/25/2025, the P&P indicated, 5. Finished puree items should be smooth and free of lumps, hold its shape, while not being too firm or sticky, and should not weep. During a review of the facility's recipe titled, Recipe: Pureed (IDDSI Level 4) Fruit, dated 11/25/2025, the recipe indicated, 3. The finished pureed items should be smooth and free of lumps, hold its shape, while not being too firm or sticky, and should not weep. During a review of the IDDSI guideline website titled IDDSI, dated 7/2019, the IDSSI guideline indicated, Level 4 Pureed is usually eaten with spoon, falls off spoon in a single spoonful when tilted and continues to hold shape on the plate, no lumps, not sticky, and liquid must not separate from solid. Food testing method: Spoon tilt test and fork drip test.

Based on observation, interview, and record review, the facility failed to prepare food by methods that conserved appearance, flavor and temperature when: 1.Cold foods were not served cold and capri blend vegetables were squashed and brownish green in color for lunch meal on 4/20/2026.2. Foods not served at palatable temperatures for breakfast time on 4/22/2026.These failures had potential to result in 103 of 125 facility residents including Resident 76, Resident 130, and Resident 169 at risk of unplanned weight loss, a consequence of poor food intake, getting food from the kitchen. Findings: During a review of Resident 76's Face Sheet, the Face Sheet indicated the facility admitted Resident 76 on 4/18/2025 with diagnosis including, but not limited to, essential hypertension (HTN, high blood pressure), type two diabetes (increased of blood sugar due to insulin resistance), and dysphagia (difficulty swallowing). During a review of Resident 76's Minimum Data Sheet (MDS- a resident assessment tool) dated 10/21/2025, the MDS indicated Resident 76 understood others and make self-understood. The MDS indicated Resident 76 needed supervision or touching assistance (helper provides verbal cues and or touching or steadying and or contact guard assistance as resident completes the activity. Assistance may be provided throughout the activity or intermittently) when eating. During a review of Resident 76's Order Summary Report, dated 4/18/2026, the report indicated Resident 76 was ordered consistent carbohydrate (same amount of carbohydrate each meal), no added salt (NAS, no salt packet on the tray), regular texture, thin consistency (no modification with texture and consistency). During a resident council meeting interview on 4/21/2026 at 11:03 a.m., Resident 76 stated the breakfast sausage was cold and pink inside and the food has been cold lately. Resident 76 stated the breakfast, and lunch has been coming out later lately and they did not receive lunch until 2:00 p.m. today. Resident 76 stated the food quality has been low. During a review of Resident 130's Face Sheet, the Face Sheet indicated the facility admitted Resident 130 on 3/26/2010 with diagnoses including, but not limited to, essential HTN, type 2 diabetes, and hyperlipidemia (high fats in the blood). During a review of Resident 130's MDS dated [DATE], the MDS indicated Resident 130 understood others and make self-understood. The MDS indicated Resident 130 needed set up and clean up assistance (helper sets up and cleans up, resident completes activity. Helper assists only prior to or following the activity) when eating. During a review of Resident 130's Order Summary Report, dated 3/25/2026, the report indicated Resident 130 was ordered CCHO, soft-bite size level 6 (foods that are tender, moist that does not require chewing before swallowing. Foods must be cut into small pieces no larger than 1.5 centimeters x 1.5 centimeters), thin consistency, okay to have regular bread, bread-like products and baked goods. During a resident council meeting interview on 4/21/2026 at 11:03 a.m., Resident 130 stated foods were served cold at different times. During a review of the facility's menu spreadsheet (a sheet containing the kind and amount of food each diet would receive) titled Winter Menus, dated 4/20/2026, the spreadsheet indicated residents on regular and therapeutic diets would include the following foods on the tray: -Baked hamburger three (3) ounces (oz, a unit of measurement) -Brown sauce 1 oz -Diced Fried Potatoes 1/2 cup (c, a household measurement) -Capri blend vegetables 1/2 c -Wheat roll 1 pc -Margarine 1 teaspoon -Spring Fruit crisp 3x2 1/2 inch -Milk 4 oz During an observation on 4/20/2026 at 1:10 a.m., observed fruit cup, pudding and spring fruit were out on trayline (an area where foods were assembled from the steamtable to resident's plate), with no ice. During a concurrent observation and interview on 4/20/2026 at 1:26 p.m., of the trayline with the Dietary Supervisor (DS), observed the following temperature of the cold foods: -Pudding 59.7 F -Fruit cup 54.8 F -Spring fruit crisp 67 F The DS stated, these are not cold items. The DS stated since the cold foods have been out of the refrigerator and not on ice, foods would not be served cold the residents affecting the quality of food. The DS stated cold food must be served cold and it should be 40 F and below. The DS stated residents would not be satisfied and happy and would not eat the food if the cold foods were not served cold. The DS stated the residents could potentially lose weight from not eating the food. During a concurrent test tray (a process of tasting, temping, and evaluating the quality of food) observation and interview on 4/20/2026 at 2:18 p.m., with the DS, observed the DS take the temperature of the following foods with the resulting temperatures: -Milk 48 F -Spring fruit crisp 70 F The DS stated the temperature of cold foods needs to improve as residents would not eat the food if it were not in palatable temperatures. The DS stated the capri blend vegetables looked mushed and brownish green in color because it was overcooked. The DS stated the presentation of the vegetables and the way it was cooked needs improvement as residents could lose weight and would not get the vitamins and nutrients that they need from over cooking the vegetables. The DS stated the vegetables needed to be colorful, green or light green and not overcooked to prevent losing vitamins from cooking. During a review of Resident 169's Face Sheet, the Face Sheet indicated the facility initially admitted Resident 169 on 4/19/2024 and readmitted on [DATE] with diagnoses including, but not limited to, Parkinson's disease (progressive brain disorder that causes nerve cells to breakdown, resulting to loss of dopamine [a chemical needed for smooth, coordinated muscle movement), Vitamin B12 deficiency anemia (a condition where the body lacks enough healthy red blood cells due to storage of vitamin B12 [vitamin necessary to produce red blood cells that carry oxygen]), major depressive disorder (a mental health condition characterized by a persistent feeling of deep sadness, emptiness, or loss of interest in activities for at least two weeks). During a review of Resident 169's MDS dated [DATE], the MDS indicated Resident 169 understood others and make self-understood. The MDS indicated Resident 169 needed set up and clean up assistance when eating. During a review of Resident 169's Order Summary Report, dated 9/5/2025, the report indicated Resident 169 was ordered regular diet, regular texture (diet with no restriction), thin consistency, large portion to increase calorie needs (adding extra food on a standard tray) During a resident council meeting interview on 4/21/2026 at 11:03 a.m., Resident 169 stated most of the time breakfasts were served cold. During a review of the facility's menu spreadsheet titled Winter Menus, dated 4/22/2026, the spreadsheet indicated residents on regular and therapeutic diets would include the following foods on the tray: -Blended juice 4 oz -Oatmeal 3/4 c -Breakfast meat 1 oz -Waffles (4-5 inches), 1 piece -Strawberry topping 1/4 c -Warm syrup and margarine 1 tsp -Parsley sprig -Milk 8 oz During concurrent test tray and interview on 4/22/2026 at 9:14 a.m., of regular diet with the DS and the Registered Dietitian (RD), observed the DS take the temperature of the following foods using the facility thermometer with the following readings: -Sausage 88 F -Waffles 95 F -Oatmeal 130 F -Whole milk 45 F The DS stated the food could be hotter and they have a delayed trayline today because of additional requests from the residents making the food not hot. The RD stated it was important to have the meals on time to prevent resident's dissatisfaction and to keep the temperature in palatable temperatures. During a review of the facility's policies and procedures (P&P) titled, Food Preparation Policy, dated 11/25/2026, the P&P indicated, Food is to be prepared in such a manner as to maximize flavor, appearance, and nutritional value.All foods will be prepared by methods that preserve nutritive value, flavor, and appearance, and will be attractively served at a proper temperature and in a form to meet individual needs of the resident.11. Hold food for the shortest time possible before service. Do not hold food for more than 2 hours. Hot food must be more than or equal to 140 F and cold food less than or equal to 40 F. During a review of the facility's P&P titled, Food Preparation of Vegetables and Fruits, dated 11/25/2025, the P&P indicated, Fruits and vegetables will be prepared to conserve the nutritive value, enhance flavor, and appearance and to prevent foodborne illnesses.3) [NAME] vegetables in small amount of water and for the shortest time possible. Avoid overcooking and long holding. 4) Prepare vegetables as close to the meal as possible.

Based on observation, interview, and record review, the facility failed to dispose garbage and refuse properly when: 1.A garbage container by the preparation area was not completely closed or covered when not actively in use. 2.The dumpster (a movable waste container designed to be brought and taken away by special collection vehicle, or to a bin that a specially designed garbage truck lifts) surroundings had sticky black spills. These failures had potential to attract birds, flies, insects, pests and possibly spread infection to 125 of 125 facility residents. Findings: During an observation on 4/20/2026 at 8:49 a.m., of the trash can containing food scraps, paper and plastic trash, it was observed that the trash can was not actively being used and it was not covered. During a concurrent observation and interview on 4/20/2026 at 9:10 a.m., with the Dietary Supervisor (DS), the trash can by the preparation area was observed to uncovered. The DS stated that the trash should be kept closed with a lid to prevent cross-contamination. The DS stated none of the staff were using the trash can and that it should be covered because it could attract flies that may contaminate residents' food, potentially causing foodborne illness. During a review of the facility's policies and procedures (P&P) titled Waste Control and Disposal, dated 11/25/2025, the P&P indicated, (2) trash bins should be covered at all times. During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated, 5-501.113 Covering Receptacles and waste handling units for refuse, recyclables, and returnable shall be kept covered: (A) Inside food establishment if the receptacles and units: (1) Contain food residue and are not in continuous use; or (2) After they are filled; and 174 (B) With tight-fitting lids or doors if kept outside the food establishment. During an observation on 4/22/2026 at 10:14 a.m., with the DS, dark liquid spills were observed on the ground surrounding the dumpster. The DS stated there were dark liquid spills present but did not know what the substance was and stated it could be anything. The DS stated the maintenance department only used brooms to maintain and clean the area. The DS further stated it was important for the dumpster grounds to remain free from spills because spills could attract pests that could enter the facility and potentially spread infection to residents. During an interview on 4/22/2026 at 10:21 a.m. with the Maintenance Supervisor (MS) and the DS, the MS stated they only use brooms to maintain the cleanliness of the area surrounding the dumpster. However, the DS stated his expectation was for the surrounding dumpster area to remain clean and free of spills and trash. The MS stated the surrounding area should be kept to prevent flies, mice, and rats from entering the facility, as these pests could potentially spread diseases. During a review of the facility's P&P titled Waste Control and Disposal, dated 11/25/2025, the P&P indicated, 6. Outside garbage bin should be kept close at all times and surrounding area must be kept clean. During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated, 5-501.116 Cleaning Receptacles. Proper storage and disposal of garbage and refused are necessary to minimize the development of odors, prevent such waste from becoming an attractant and harborage of breeding places for insects and rodents, and prevent the soiling of food preparation and food service areas. Improperly handled garbage creates nuisance conditions, makes housekeeping difficult, and may be possible source of contamination of food, equipment, and utensils. Outside receptacles must be constructed with tight-fitting lids or covers to prevent the scattering of the garbage or refuse by birds, the breeding of flies, or the entry of rodents. Proper equipment and supplies must be made available to accomplish thorough and proper cleaning of garbage storage areas and receptacles so that unsanitary conditions can be eliminated.

Based on interview and record review, facility failed to ensure one of three sampled residents (Resident 1) was free from unnecessary physical restraint. The facility sent Resident 1 unaccompanied to an outside treatment center three time a week using a transportation van. The transportation driver tied Resident 1 down to his wheelchair with a blanket during trip to control Resident 1's behavior of refusing to sit down. This deficient practice resulted in the resident being subject to further use of restraints to control Resident 1's behavior and causing the resident undetermined psychological trauma, mental anguish, and fear that a resident with impaired cognition may not express outward (reasonable person standard). On 10/ Resident 1 got an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings: A review of Resident 1's Admission Record indicated the facility admitted the resident a [AGE] year-old male, on 6/1/2021 and readmitted him on 10/6/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Fast heart rate, rapid breathing, sweating, and feeling tired may occur), [CONDITION(S)] disorder (is a brain disorder that causes changes in a person's mood, energy, and ability to function), general muscle weakness, heart failure (disease condition where heart muscle is unable to pump blood adequately) and pneumonia (infection of one or both lungs). A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 9/14/2021, indicated Resident 1 had moderately impaired cognition (is when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday). Resident 1 needed extensive assistant with most activity of daily living (ADLs - such as bed mobility, transfer, dressing, personal hygiene, and toilet use). Resident 1 used a walker and wheelchair as mobility devices. Resident 1 was incontinent of bladder and bowel functions (inability of the body to control the evacuative functions of urination or defecation). A review of Resident 1's Care Plan developed on 9/25/2021 for the resident's problem of Non-Compliance with Care by Refusing Medication, included in the interventions providing explanation or rationale of care for better compliance, informing the resident of possible alternatives, consequences / needs, and notifying the resident of any risks / consequence of non-compliance. A review of the Physician's Orders for Resident 1, on re-admission 10/6/2021, indicated for the resident to have hemodialysis treatment at a [CONDITION(S)] center three times a week on Tuesdays, Thursdays, and Saturdays at 8:10 a.m. Pick up by transportation van at 7:30 a.m. A review of a Grievance Report form dated 10/7/2021, completed by Social Services 1 (SS 1) and signed by the Administrator, indicated Resident 1 came back on 10/7/2021 from the [CONDITION(S)] center with a blanket tied around his body/waist. The transportation company confirmed the driver had to tie Resident 1 with a blanket because Resident 1 was refusing to sit down and was combative. SW documented a sitter (companion) would be provided to Resident 1 for future appointments including [CONDITION(S)] treatment to ensure his safety. A review of the Physician's Order for Resident 1 dated 10/7/2021, indicated to give the resident [MEDICATION(S)] (anti-anxiety medication) 0.5 milligram (mg) one tablet by mouth two times a day for inability to cope with ADLs causing anger. A review of Resident 1's Care Plan developed on 10/7/2021 for the resident's problem of Non-Compliance Behavior to Prescribed Medical Treatment - Refusing Hemodialysis, included in the interventions providing explanation or rationale of therapy / care for better compliance and discussing benefits of compliance with and risks of non-compliance. A review of Resident 1's History and Physical exam completed by the attending physician on 10/08/2021, indicated Resident 1 did not have the capacity to understand and make decisions. A review of Resident 1's Care Plan developed on 10/12/2021 for the resident having periods of anxiety manifested by inability to cope with ADL's causing anger, included in the interventions keeping Resident 1 away from stressful situations. A review of Resident 1's Licensed Nurse Record dated 10/12/2021 timed at 4:06 a.m., signed by Licensed Vocational Nurse 2 (LVN 2), indicated Resident 1 left at 7 a.m., with the transportation driver. A review of Resident 1's Care Plan developed on 10/12/2021, for the resident having periods of anxiety manifested by inability to cope with ADL's causing anger included in the interventions keeping Resident 1 away from stressful situations. A review of Resident 1's Change of Condition (COC) documentation, dated 10/12/2021, indicated the resident had generalized rash and blisters, identified at the [CONDITION(S)] center and present upon the resident's return to the facility. Resident went to General Acute Care Hospital 1 (GACH 1) for evaluation of possible allergic reaction. A review of Resident 1's Admission Notes dated 10/17/2021, indicated the resident returned from GACH 1. A review of Resident 1's Change of Condition (COC) documentation, dated 10/12/2021, indicated the resident had generalized rash and blisters, identified at the [CONDITION(S)] center and present upon the resident's return to the facility. Resident went to General Acute Care Hospital 1 (GACH 1) for evaluation of possible allergic reaction. A review of Resident 1's Admission Notes dated 10/17/2021, indicated the resident returned from GACH 1. A review of Resident 1's COC documentation, dated 11/01/2021 timed at 1:55 p.m., indicated the Administrator received a report on 10/07/2021 about Resident 1 been tied down while transported to the hemodialysis center. At 2:20 p.m., Resident 1's body assessment noted no injury. A review of Resident 1's Situation-Background-Assessment-Recommendation (SBAR - communication form used to facilitate prompt and appropriate communication about a resident's condition) dated 11/1/2021, indicated at 2:20 p.m., the Ombudsman (advocate for the rights of long-term care facilities residents) called the Administrator about Resident 1 being tied down while transporting him from and to the [CONDITION(S)] center. Resident 1 got aggressive, screamed, and spat at a staff when he was being interviewed by a staff about the incident. Resident 1 was re-assessed for body injury about the incident, facility noted no injury on Resident 1. On 10/20/2021 at 10:05 a.m., during an interview, Hemodialysis Staff 1 (HDS 1) stated on 10/09/2021 and 10/12/2021 Resident 1 was dropped off at the [CONDITION(S)] center tied up to his wheelchair because according to the driver, Resident 1 was combative and would not sit down. HDS 1 stated the facility did not send a companion (sitter) with Resident 1 to hemodialysis. On 10/20/2021, at 1:30 p.m., during an interview with Resident 1, in his room, he was sitting at the edge of the bed. Resident 1 stated he went to hemodialysis with transportation, and he was always tied in the transportation car and the driver was rough with him. On 11/16/2021 at 9:30 p.m. during a telephone interview, LVN 2 stated before 10/12/2021, Resident 1 went to hemodialysis without a staff accompanying him (sitter) but alone with the transportation driver. LVN 2 stated tying a resident was an allegation of abuse and should be reported and investigated immediately. A change of condition should have been done and check the resident for any injuries. LVN 2 stated Resident 1's physician should have been notified as soon as the facility was made aware of the abuse. On 11/16/2021 at 9:47 a.m., during an interview with SS 1 and a concurrent review of the Grievance Report form dated 10/07/2021, SS 1 stated Resident 1 returned from hemodialysis on that day (10/07/2021) with a blanket tied around his waist. SS 1 stated the transportation company was called and was told Resident 1 was tied with a blanket because he was refusing to sit down. The facility's corrective action was to provide a sitter for future appointments including hemodialysis transfer to ensure safety of the resident. SS 1 stated the investigation was documented in the grievance report, informed the Administrator, who signed the report. On 11/16/2021 at 10:37 a.m., during an interview, Nursing Aide 1 (NA 1) stated being assigned since 11/2/2021 to accompany Resident 1 to appointments including hemodialysis. NA 1 did not accompany Resident 1 on 10/9/2021 and 10/12/2021. NA 1 stated Resident 1 went to the [CONDITION(S)] center alone (no staff accompanying him) with the transportation driver until 11/2/2021. On 11/16/2021 at 1:26 p.m., during an interview, CNA 3 stated on 10/12/2021 Resident 1 left the facility at 7 a.m. for hemodialysis and was picked up by the driver from the transportation company. CNA 3 stated Resident 1 went alone with the driver. There was no staff accompanying the resident. On 11/17/2021 at 1 p.m., during an interview, LVN 3 stated Resident 1's physician was supposed to be notified following an abuse incident. LVN 3 stated tying down a resident was abuse and residents should not be restrained in any form. Resident 1 could be traumatized and depressed. LVN 3 stated the facility was responsible for protecting Resident 1 from abuse. On 11/17/2021 at 2:37 p.m., during an interview, Director of Nursing (DON) after reviewing Resident 1's clinical record, confirmed the licensed nurses did not notify Resident 1's physician about abuse incident in a timely manner. DON stated there was no physician's order for the use of [MEDICAL RECORD OR PHYSICIAN ORDER] . DON stated after the grievance on 10/7/2021, the decision was to provide a sitter when going to hemodialysis appointment. DON confirmed Resident 1 left for [CONDITION(S)] on 10/09/2021 and 10/12/2021 without a sitter. DON stated sitter should have been provided to prevent the driver from tying the resident. DON stated physical restraint can cause skin breakdown, emotional trauma, and behavioral issues. DON stated the facility was responsible for protecting residents from any form of abuse. On 11/17/2021 at 3:59 p.m., during an interview, the Administrator confirmed he was the facility's Abuse Coordinator and learned about the abuse allegation during the stand-up meeting on 10/7/2021. Administrator stated Resident 1 was supposed to be provided with a sitter to [CONDITION(S)] to protect him from further abuse. The Administrator stated he should have called the transportation company on 10/7/2021 and not waited for 25 days. The Administrator called the transportation company on 11/1/2021 to conduct his own investigation and prevent loss of dignity and physical harm. On 1/23/2022 at 2:35 p.m., during an interview, Registered Nurse 3 (RN 3) stated on 10/7/2021 a [CONDITION(S)] center staff called to inform her Resident 1 had been combative during the hemodialysis. RN 3 stated she called the physician and obtained an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . RN 3 stated Resident 1 was not on [MEDICATION(S)] on readmission on 10/6/2021 but exhibited behavior issues on 10/7/2021 upon return from hemodialysis. A review of facility's contract agreement with the [CONDITION(S)] services dated 11/4/2004, indicated the facility had the responsibility for arranging suitable transportation of the patient including the qualified personnel to accompany the patient. The facility shall be responsible for ensuring that the patient is medically stable to undergo such transportation and shall be responsible for the patient during the transfer. A review of facility's policy and procedures titled, Physical Restraint last reviewed on 11/23/2021, indicated physical restraint are any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot move easily and which restrict the freedom of movement or normal access to the use of one's body. The licensed nurse shall be responsible for obtaining an order from the attending physician, which included: 1. Specific type of restraint 2. Purpose of restraint 3. Time and place of application 4. Approaches to prevent decreased functioning when applicable 5. Informed consent obtained from resident or from surrogate decision-maker.

Based on interview, and record review, the facility failed to follow its policy and procedures on resident abuse for one of three sampled residents (Resident 1). On 10/7/2021, the facility was made aware the transportation driver was tying Resident 1 up in the wheelchair during the transportation from and to the [CONDITION(S)] center but continued to allow the transportation of Resident 1 without a staff accompanying the resident for at least three additional days. Facility did not report to the necessary agencies and did not conduct a thorough investigation of the incident. This deficient practice resulted in the resident being subject to further mistreatment by the transportation driver using restraints to control Resident 1's behavior. Findings: A review of Resident 1's Admission Record indicated the facility admitted the resident a [AGE] year-old male, on 6/1/2021 and readmitted him on 10/6/2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Fast heart rate, rapid breathing, sweating, and feeling tired may occur), [CONDITION(S)] disorder (is a brain disorder that causes changes in a person's mood, energy, and ability to function), general muscle weakness, heart failure (disease condition where heart muscle is unable to pump blood adequately) and pneumonia (infection of one or both lungs). A review of Resident 1's Care Plan developed on 6/18/2021, indicated Resident 1 and/or responsible party were made aware the facility had stabled systems to prevent abuse. Resident 1 shall not be subject to abuse by anyone, including but not limited to facility staff, other residents, consultants or volunteers, staff of other agencies, family members of legal counsel. The interventions included - Inform Resident 1 and/or responsible party of the facility policy for reporting abuse (concern form) to be completed by Resident 1, their appointed representative or staff members of the facility. Abuse included unreasonable confinement. A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 9/14/2021, indicated Resident 1 had moderately impaired cognition (is when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday). Resident 1 needed extensive assistant with most activity of daily living (ADLs - such as bed mobility, transfer, dressing, personal hygiene, and toilet use). Resident 1 used a walker and wheelchair as mobility devices. Resident 1 was incontinent of bladder and bowel functions (inability of the body to control the evacuative functions of urination or defecation). A review of Resident 1's Care Plan developed on 9/25/2021 for the resident's problem of Non-Compliance with Care by Refusing Medication, included in the interventions providing explanation or rationale of care for better compliance, informing the resident of possible alternatives, consequences / needs, and notifying the resident of any risks / consequence of non-compliance. A review of the Physician's Orders for Resident 1, on re-admission 10/6/2021, indicated to have hemodialysis treatment at a [CONDITION(S)] center three times a week on Tuesdays, Thursdays, and Saturdays at 8:10 a.m. Pick up by transportation van at 7:30 a.m. A review of a Grievance Report form dated 10/7/2021, completed by Social Services 1 (SS 1) and signed by the Administrator, indicated Resident 1 came back from the [CONDITION(S)] center with a blanket tied around his body/waist. The transportation company confirmed the driver had to tie Resident 1 with a blanket because Resident 1 was refusing to sit down and was combative. SS 1 documented a sitter (companion) would be provided to Resident 1 for future appointments including [CONDITION(S)] treatment to ensure his safety. A review of the Physician's Orders for Resident 1, dated 10/7/2021, indicated to administer the resident [MEDICATION(S)] 0.5 milligrams (mg) one tablet by mouth twice a day for inability to cope with ADLs causing anger. A review of Resident 1's Care Plan developed on 10/7/2021 for the resident's problem of Non-Compliance Behavior to Prescribed Medical Treatment - Refusing Hemodialysis, included in the interventions providing explanation or rationale of therapy / care for better compliance and discussing benefits of compliance with and risks of non-compliance. A review of Resident 1's History and Physical exam completed by the attending physician on 10/8/2021, indicated Resident 1 did not have the capacity to understand and make decisions. A review of Resident 1's Care Plan developed on 10/12/2021 for the resident having periods of anxiety manifested by inability to cope with ADL's causing anger, included in the interventions keeping Resident 1 away from stressful situations. A review of Resident 1's Licensed Nurse Record dated 10/12/2021 timed at 4:06 a.m., signed by Licensed Vocational Nurse 2 (LVN 2), indicated Resident 1 left at 7 a.m., with the transportation driver. A review of Resident 1's Care Plan developed on 10/12/2021, for the resident having periods of anxiety manifested by inability to cope with ADL's causing anger included in the interventions keeping Resident 1 away from stressful situations. A review of Resident 1's Change of Condition (COC) documentation, dated 10/12/2021, indicated the resident had generalized rash and blisters, identified at the [CONDITION(S)] center and present upon the resident's return to the facility. Resident went to General Acute Care Hospital 1 (GACH 1) for evaluation of possible allergic reaction. A review of Resident 1's Admission Notes dated 10/17/2021, indicated the resident returned from GACH 1. A review of Resident 1's Change of Condition (COC) documentation, dated 11/1/2021 timed at 1:55 p.m., indicated the Administrator received a report on 10/7/2021 about Resident 1 been tied down while transported to the hemodialysis center. At 2:20 p.m., Resident 1's body assessment noted no injury. This body assessment was done 11/1/2021, 25 days after the report dated 10/7/2021. A review of Resident 1's Situation-Background-Assessment-Recommendation (SBAR - communication form used to facilitate prompt and appropriate communication about a resident's condition) dated 11/1/2021, indicated at 2:20 p.m., the Ombudsman (advocate for the rights of long-term care facilities residents) called the Administrator about Resident 1 being tied down while transporting him from and to the [CONDITION(S)] center. Resident 1 got aggressive, screamed, and spat at a staff when he was being interviewed by a staff about the incident. Resident 1 was re-assessed for body injury about the incident, facility noted no injury on Resident 1. Facility notified Resident 1's physician, the State Survey Agency (SSA) and law enforcement. On 10/20/2021 at 10:05 a.m., during an interview, Hemodialysis Staff 1 (HDS 1) stated on 10/9/2021 and 10/12/2021 Resident 1 was dropped off at the [CONDITION(S)] center tied up to his wheelchair because according to the driver, Resident 1 was combative and would not sit down. HDS 1 stated the facility did not send a companion (sitter) with Resident 1 to hemodialysis. On 11/16/2021 at 9:47 a.m., during an interview with SS 1 and a concurrent review of the Grievance Report form dated 10/7/2021, SS 1 stated Resident 1 returned from hemodialysis on that day (10/7/2021) with a blanket tied around his waist. SS 1 stated the transportation company was called and was told Resident 1 was tied with a blanket because he was refusing to sit down. The facility's corrective action was to provide a sitter for future appointments including hemodialysis transfer to ensure safety of the resident. SS 1 stated the investigation was documented in the grievance report, informed the Administrator, who signed the report. On 11/16/2021 at 10:37 a.m., during an interview, Nursing Aide 1 (NA 1) stated being assigned since 11/2/2021 to accompany Resident 1 to appointments including hemodialysis. NA 1 did not accompany Resident 1 on 10/9/2021 and 10/12/2021. NA 1 stated Resident 1 went to the [CONDITION(S)] center alone (no staff accompanying him) with the transportation driver until 11/2/2021. On 11/17/2021 at 12:26 p.m., during an interview, SS 1 confirmed writing a Grievance Report on Resident 1's abuse allegation, SS 1 stated the abuse coordinator was the Administrator and he would report the abuse to the necessary agencies. SS 1 stated the driver's action constituted abuse of Resident 1. On 11/17/2021 at 2:37 p.m., during an interview, Director of Nursing (DON) after reviewing Resident 1's clinical record, confirmed the licensed nurses did not notify Resident 1's physician about abuse incident in a timely manner. DON stated there was no physician's order for the use of [MEDICAL RECORD OR PHYSICIAN ORDER] . DON stated after the grievance on 10/7/2021, the decision was to provide a sitter when going to hemodialysis appointment. DON confirmed Resident 1 left for [CONDITION(S)] on 10/9/2021 and 10/12/2021 without a sitter. DON stated sitter should have been provided to prevent the driver from tying the resident. DON stated physical restraint can cause skin breakdown, emotional trauma, and behavioral issues. DON stated the facility was responsible for protecting residents from any form of abuse. On 11/17/2021 at 3:59 p.m., during an interview, the Administrator confirmed he was the facility's Abuse Coordinator and learned about the abuse allegation during the stand-up meeting on 10/7/2021. Administrator stated Resident 1 was supposed to be provided with a sitter to [CONDITION(S)] to protect him from further abuse. On 1/23/2022 at 2:35 p.m., during an interview, Registered Nurse 3 (RN 3) stated on 10/7/2021 a [CONDITION(S)] center staff called to inform her Resident 1 had been combative during the hemodialysis. RN 3 stated she called the physician and obtained an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . RN 3 stated Resident 1 was not on [MEDICATION(S)] on readmission on 10/06/2021 but exhibited behavior issues on 10/7/2021 upon return from hemodialysis. A review of facility's undated policy and procedures titled, Abuse & Mistreatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Administrator shall be responsible for reporting of all alleged and substantiated violations to the state agency and all other agencies as required. Facility shall report the incident by notifying the California Department of Public Health (CDPH or SSA) within two hours of the knowledge of such incident. Facility shall make reasonable efforts to protect residents from harm during an investigation process, when incidents involving the health, welfare, to safety of residents are reported, involved resident(s) shall be removed from the environment that threatens resident's health, welfare, or safety. Facility shall ensure complete and thorough investigation is conducted for all allegations of abuse.

Based on observation, interview, and record review, the facility failed to implement infection control program to prevent the spread infections for 177 residents and the staff, by: 1. Not monitoring the cockroach population in the kitchen 2. Not having an effective pest control service. 3. Not keeping clean and in good repair in the employee lounge, hallways, and rehabilitation room. 4. Not keeping clean and in good repair the interior of the ice machine, in the employee lounge to prevent the growth of microorganisms and biofilm (a thin, slimy film of bacteria that adheres to a surface) and not keeping clean the ice scooper and its container for the ice machine located in the employee lounge. This deficient practice caused an increased risk for vector-borne diseases (disease that result from an infection transmitted to human by insects including cockroaches) such as diarrhea, vomiting, and fever for the total of 177 residents in the facility. A review of article from (www.orkin.com) Cockroaches are nocturnal insects. They prefer to live and feed in the dark, a cockroach seen during the day is a possible sign of infestation. Cockroaches tend to prefer dark, moist places to hide and breed and can be found behind refrigerators, sinks, and stoves, as well as under floor drains and inside of motors and major appliances. In addition, the pest cockroaches can be carriers of various diseases because they are commonly found near waste deposits. Cockroaches often taint food with E.coli (Escherichia coli -can cause diarrhea, urinary tract infections, respiratory illness, and other illnesses) and Salmonella (type of bacteria that cause food-related illness); also exposure to cockroach waste and dead roaches over time can trigger allergies and asthma. On December 3, 2020 at 4:23 p.m., an Immediate jeopardy (IJ-a situation in which the provider's non-compliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment or death of a resident) was declared. The facility administrator (ADM), Director of nursing (DON), and Facility Regional Director (RDO) was notified of the immediate jeopardy situation. On December 17, 2020 at 12:54 p.m., the IJ was removed in the presence of the Administrator and DON after the facility submitted an acceptable plan of action (POA), removed and eliminated pest harborage and infestation from facility kitchen and the surveyor verified the POA was implemented including: 1. The facility increased the use of pest control service which applied deep treatment to the entire kitchen on 12/3/2020 at 9 p.m., 12/6/2020 and 12/11/2020 at 5:30 p.m. 2. Maintenance supervisor to check and seal all holes, penetration, creases on the walls and floors. 3. New systems established for Maintenance Supervisor, Infection Preventionist, kitchen staff for daily inspecting, monitoring and reporting for pests in the kitchen. 44. In-services performed with all kitchen and nursing staff. Findings: 1. On December 3, 2020, at 2:30 p.m., the Los Angeles County Environmental Health Department Inspector (EHS 1) (performs inspections of various licensed health care facilities and properties to determine conformance with applicable state laws and County ordinance code sections) informed the California Department of Public Health (CDPH) about the closure of the facility's kitchen due to active infestation of live cockroaches in the facility's kitchen. A review of EHS 1 report dated December 3, 2020 indicated EHS 1 observed two live nymph German cockroaches below the drain board at ware washing corner area, eight live adult German cockroaches at the wall ceiling juncture above ware wash unit, three dead cockroaches on the shelving below the drain board at same area, wight live German cockroaches just below the pass out window (where food is passed through to the adjacent dining room or served to the adjacent dining room), left of the food preparation sink, two live nymph cockroaches at same area, left of the food preparation sink, and cockroach fecal spotting at the right corner of the pass out window, left of food preparation sink. During an observation of the kitchen on December 3, 2020, at 4:40 p.m., the kitchen was closed with the notice of closure from LAC EHD posted on the kitchen door with a date December 3, 2020, timed at 2:20 p.m. During the same observation, the kitchen was inspected for the presence of cockroaches. There was one live nymph cockroach (baby cockroach) on the food preparation sink area (where fruits and vegetables are washed and prepared for residents), one live nymph cockroach on the floor in the dry storage area, one dead juvenile cockroach on the floor in the middle of the kitchen, one live adult cockroach on the wall in the dishwashing area, and one live nymph crawling on the resident food tray in the dishwashing room. There were cracks on the wall and ceiling in the dishwashing area, there were cracks in between the tiles on the floor (the grout was broken), there was dirt accumulated in the spaces between the food preparation sink and the pass out window, and there was a big plywood around the hand washing sink that could harborage pests. A review of article from the Department of Public Health, County of Los Angeles titled, Effective Management of Cockroach Infestation (retrieved December 4, 2020 at publichealth.lacounty.gov >Vector Management) indicated cockroaches may become pests in any structure that has food preparation or storage areas. They contaminate food and eating utensils, occasionally damage fabric and paper products, leave stains on surfaces, and produce unpleasant odors when present in high enough numbers. When cockroaches that live outdoors encounter human excrement in sewers or with pet droppings, they have the potential to transmit bacteria that cause food poisoning. During a concurrent interview on December 3, 2020 at 4:40 p.m., with DFSD, she stated that she has been working in the facility since 2019, does quarterly audits that include pest control and has never seen any cockroaches in the kitchen. DFSD stated if staff see cockroaches, they should let her know but there was no communication log for pests. DFSD stated the Pest Control technician comes once a month to spray the kitchen. On December 3, 2020, at 4:50 p.m., during an interview, the Dietary Assistant (DA) he had seen cockroaches in the kitchen floor and counters in the early morning. DA said when he sees a cockroach, he kills them. DA stated he will call the pest control technician when he sees cockroach but did not remember when he called the pest control technician. On December 3, 2020, at 5 p.m., during an interview, the Dishwasher (DW) stated that he sees cockroaches in the kitchen. When asked if he told the DFSD about the cockroaches, DW did not answer. On December 3, 2020 at 5:10 p.m., during an interview, the ADM stated she did not know there were cockroaches in the kitchen and the Pest Control Technician (PT) comes once a month and PT is an employee of the corporation. On December 3, 2020, at 5:20 p.m., during an interview, MHS stated that he oversees the housekeeping department who informs him of any pest-related issues in the facility but not in the kitchen. MHS stated kitchen staff is responsible for cleaning the kitchen and report any pest spotting. On December 3, 2020 at 5:38 p.m., during a concurrent interview with DON and Infection Control Preventionist (IPN), the IPN stated she makes rounds around the facility, involving the kitchen, to identify infection control issues including pest infestation. Both DON and IPN stated it was important to maintain the kitchen free of pests because of potential for harm to resident food. On December 5, 2020, at 10:30 a.m., during a telephone interview, ADM stated EHS 1 was at the facility and found more roaches and the kitchen remained closed. A review of EHS 1 report dated December 5, 2020, indicated, one live cockroach crawling on top of a stove in the kitchen, three live cockroaches harboring between a piece of wood and the side of the hand-washing sink in the kitchen, six live cockroaches in the utensil washroom (two located between the automatic dish washing machine drain board back splash and the wall, three located on top of the automatic dish washing machine drain board and one located crawling on the wall above the drain board), in addition, two egg casings and one nymph cockroach were observed on top of the dish washing machine drain board. On December 8, 2020, at 9:30 a.m., during a telephone interview, ADM stated she had found more roach activity in the kitchen and facility was working to seal more holes and cracks on the walls and floor tiles. On December 10, 2020, at 9:30 a.m., during a kitchen observation with EHS 1, there was one live adult roach in the dishwashing area, one live nymph on the floor in the dishwashing area, one live nymph above the ice machine, one live juvenile cockroach on the walking refrigerator and one live nymph cockroach in the dry storage area. EHS 1 and stated the kitchen will remain closed. On December 10, 2020, at 10 a.m., during an interview, RD 1 stated he started working at the facility on December 1, 2020 and during his first audit of the kitchen on the same date of hire, he did not find any pests. A review of the facility's document completed by an RD (no name), located in the kitchen and titled, Dietary Quality Control Survey dated October 2020 indicated, there were dead bugs on the floor near storeroom and all other food storage areas. The document did not include follow up or actions taken. On December 17, 2020, at 10:30 a.m., during an interview, the ADM stated on December 16, 2020, during an inspection of the kitchen, EHS 1 found one live roach in the kitchen and the inspector would return on December 17, 2020. On December 17, 2020, at 11:48 a.m. during an observation of the kitchen, there were no roached found or any other pest infestation. All the walls and floor crack had been repaired and sealed and the kitchen and the equipment were deep cleaned. On December 17, 2020, at 12:06 p.m., EHS 2 advised the facility to reopen the kitchen. A review of the job description for Infection Control Preventionist (IPN) dated November 28, 2016 indicated, Essential Duties and Responsibilities: Perform daily rounds in the facility to assess and identify infection control related issues and problems. Conduct staff in service education/training, when needed, to abate known problems. A review of facility policy tilted Housekeeping-Pest Control not dated, indicated, The administrator arranged for a pest control company to visit and inspect the facility at least once a month, ensuring that: Immediate action is taken to rid the facility or its grounds of any environmental pest as noted in the inspection report. After exterminating or spraying for insects, as the situation warrants, the facility is once again inspected by the pest control company to ensure that all environmental pests were removed from the premises. The company representative issues an additional report to the administrator, verifying that all environmental pests were removed. 2. On December 3, 2020 at 5:10 p.m., during an interview, the ADM stated she did not know there were cockroaches in the kitchen and the Pest Control Technician (PT) comes once a month and PT is an employee of the corporation. On December 5, 2020 at 11:57 a.m., during a telephone interview, PT stated she goes to the facility for about 20 minutes to one hour every month and was aware of the roach infestation and planned on making weekly visits but was not able. A review of the facility's Pest Management Sanitation Report for the past six months indicated: -On May 6, 2020, pest infestation noted in marked location: Outside- Cockroaches (Large) -On June 16, 2020, pest infestation noted in marked location: Outside- Cockroaches (Large) -On July 7, 2020, pest infestation noted in marked location: Dish washer area- Cockroaches -On August 8, 2020, the invoice indicated: Roaches; initial treatment; inside treatment: kitchen area. -On October 8, 2020, pest infestation noted in marked location: Outside- Cockroaches (Large) -On November 3, 2020, pest infestation noted in marked location: Outside- Cockroaches (Large), Kitchen- C[DIAGNOSES REDACTED] A review of facility policy tilted Housekeeping-Pest Control not dated, indicated, The administrator arranged for a pest control company to visit and inspect the facility at least once a month, ensuring that: Immediate action is taken to rid the facility or its grounds of any environmental pest as noted in the inspection report. After exterminating or spraying for insects, as the situation warrants, the facility is once again inspected by the pest control company to ensure that all environmental pests were removed from the premises. The company representative issues an additional report to the administrator, verifying that all environmental pests were removed. 3. On December 8, 2020, at 2:03 p.m., during an observation of the employee lounge, with the ADM, there was one dead cockroach between a crevice behind a refrigeration unit. There were crevices between wooden boards mounted on the floor, trash and debris accumulation under and around equipment, encrusted debris on the vending machine and inside a cabinet, and a hole on the wall around an electrical cover plate. ADM confirmed observations and stated the area needs to be cleaned and crevices needed to be sealed. On December 8, 2020, at 2;188 p.m., during a concurrent observation and interview with the ADM, there was a gap greater than .25 inch between the exterior double doors directing to a hallway that led to a kitchen door. ADM stated she will have the door fixed. On December 10, 2020, at 10:20 a.m., during an observation of the employee lounge with the ADM, there was one dead cockroach between a crevice behind a refrigeration unit. During a concurrent interview, the ADM stated staff will clean the employee lounge after they are done with the kitchen. On December 11, 2020, at 11:27 a.m., during a concurrent interview and observation on 12/11/2020, at 11:27 a.m., there was one dead cockroach on the floor along a hallway that led to a kitchen door. ADM confirmed the observation and stated the loose baseboards along the hallway would be replaced. On December 11, 2020, at 11:30 a.m., during an observation of the employee lounge with ADM, there was one live cockroach crawling on the floor and one dead cockroach inside a cabinet. ADM confirmed the observation and stated staff would clean the lounge after they finish with the kitchen and will have pest control treat the employee lounge as well. On December 16, 2020, at 11:20 a.m., during an observation of the employee lounge with ADM, there were crevices on the wall shelving, opening on the wooden floor base, missing baseboards, and missing floor tiles. ADM confirmed the observations. On December 16, 2020, at 11:30 a.m., during an observation with ADM, there were crevices around the baseboards along the hallway leading to a kitchen door. A review of the facility's policy and procedure titled, Housekeeping Pest Control, revised on September 22, 2020, indicated, The Administrator arranges for a pest control company to visit and inspect the facility at least once a month ensuring that the company representative inspects the facility for pest, submits a written report to the Administrator on the findings of his inspection, inspection report is filed and retained for a minimum of one year, immediate action is taken to rid of the facility or its ground of any environmental pest as noted in the inspection report, after exterminating or spraying that the facility is once again inspected by pest control company to ensure that all environmental pests were removed from the premises, the company representative issues an additional report to the Administrator, verifying that all environmental pests were removed, and All housekeepers should report to the Housekeeping Supervisor any signs of rodents or insects, including ants, in the facility. The Housekeeping Supervisor takes immediate action to remove the pests in the facility. If necessary, he or she calls the extermination company for assistance. A review of the 2017 U.S. Food and Drug Administration Food Code indicated that the premises (the physical facility, its contents, and surrounding land or property under the control of the permit holder) shall be maintained free of insects, rodents, and other pests. The presence of insects, rodents, and other pests shall be controlled to eliminate their presence on the premises by: routinely inspecting incoming shipments of food and supplies; routinely inspecting the premises for evidence of pests; using pest control according to law, manufacturer's use directions, conditions of certification and other additional conditions; and eliminating harborage conditions. The document further indicated, Insects and other pests are capable of transmitting disease to humans by contaminating food and food-contact surfaces. Effective measures must be taken to eliminate their presence in food establishments. 4. On December 8, 2020, at 2:11 p.m., during an observation with ADM of the ice machine located at the employee lounge, and concurrent interview, ADM stated ice from the ice machine was served to residents. The interior of ice machine had slime formation and encrusted debris. ADM verified that water was dripping on the back side of the ice machine through slime and onto the ice, and the encrusted debris inside the ice machine. ADM stated that maintenance staff were in-charge of cleaning the ice machine. The ice scooper and its container were on top of the ice machine. When asked how often the scooper and the container were sanitized or changed, ADM stated maintenance was supposed to clean and sanitize them every day but will have the dietary staff do it. ADM stated there was no documentation the cleaning was done. During an interview on 12/8/2020, at 2:25 p.m., the Maintenance/Housekeeping Supervisor (MHS) stated the ice machine was cleaned and sanitized on a monthly basis and the last time it was cleaned was on 11/28/2020. Upon inspection of the ice machine, the MHS stated that both, the interior and the exterior of the ice machine were dirty. MHS added that housekeeping was in-charge of maintaining the exterior clean. A review of the facility's policy and procedure titled Ice Machine Cleaning (reviewed and approved on 9/22/2020) indicated that The ice machine (bin) will be cleaned and sanitized once a month. Maintenance staff will clean and sanitize the motor (evaporator) every 3 to 6 months, depending on manufacture's recommendation. The ice scoop and container will be cleaned and sanitized daily. A review of the 2017 U.S. Food and Drug Administration Food Code, indicated equipment contacting food that is not Time/Temperature control for safety food: such as enclosed components of ice makers shall be cleaned at a frequency specified by manufacturer or if manufacturer specifications are absent then at a frequency necessary to preclude accumulation of soil or mold. The document further indicated that ice makers and ice bins must be cleaned on a routine basis to prevent the development of slime, mold, or soil residues that may contribute to an accumulation of microorganisms. If the manufacturer does not provide cleaning specifications for food-contact surfaces of equipment that are not readily visible, the person in charge should develop a cleaning regimen that is based on the soil that may accumulate in those items of equipment.

Based on observation, interview, and record review, the facility failed to implement infection control measures for 177 of 177 residents residing in the facility when the facility failed to: 1. Monitor the cockroach population by maintaining a consistent and effective pest control service in the employee lounge, hallways, and rehabilitation room. 2. Ensure employee lounge was kept in a sanitary manner. 3. Maintain the interior of the ice machine in the employee lounge in a sanitary manner and ensure proper sanitation is followed to prevent the growth of microorganisms and biofilm (a thin, slimy film of bacteria that adheres to a surface.) 4. Ensure the ice scooper and ice scooper container in the employee lounge were cleaned and sanitized daily. This deficient practice has the potential for the development and the spread of infection. Findings: A. During an observation and concurrent interview on 12/5/2020 at 11:04 a.m., with the Administrator (ADM) and Maintenance Supervisor (MS), in the rehabilitation area, ADM and MS confirmed and observed 1 dead adult German adult behind the rehabilitation refrigerator. During an interview with the ADM on 12/8/2020, at 11:35 a.m., she stated that All About Pest, a pest control company, sprayed the kitchen area and employee lounge Thursday night, on 12/3/2020. Pest control company came back on Sunday, 12/6/2020 and provided service on surrounding areas which includes the rehabilitation room, laundry area and business office. During an observation and concurrent interview with the ADM on 12/8/2020, at 1:36 p.m., there was a loose base board cover creating crevices on the wall at the training kitchen inside the rehabilitation room. There was one dead cockroach on the floor outside the facility across from the rehabilitation room. ADM confirmed observations. ADM stated that she will have the crevices sealed. The ADM explained that back in August, All About Pest sprayed the exterior of the facility. Another Pest Technician (PT) comes and does the monthly service for pest control and target pests includes rodents and insects inside and outside of the facility. ADM added that the PT's services involved placing baits inside the kitchen and exterior surrounding areas. When asked if their pest control program was effective, ADM answered, it was not effective. B.During an observation of the employee lounge with the ADM on 12/8/2020, between 2:03 p.m. and 2:11 p.m., there was one dead cockroach between a crevice behind a refrigeration unit. There were crevices between wooden boards mounted on the floor, trash and debris accumulation under and around equipment, encrusted debris on the vending machine and inside a cabinet, and a hole on the wall around an electrical cover plate. ADM confirmed observations. During a concurrent interview with the ADM, she stated that the area needs to be cleaned and crevices needs to be sealed. During a concurrent observation and interview with the ADM on 12/8/2020, at 2:18 p.m., there was a gap greater than .25 inch between the exterior double doors directing to a hallway that leads to a kitchen door. ADM stated that she will have the door fixed. During an observation of the employee lounge with the ADM on 12/10/2020, at 10:20 a.m., there was one dead cockroach between a crevice behind a refrigeration unit. ADM confirmed observation. During a concurrent interview, the ADM stated that they will clean the employee lounge after they are done with the kitchen. During a concurrent interview and observation on 12/11/2020, at 11:27 a.m., there was one dead cockroach on the floor along a hallway that leads to a kitchen door. ADM confirmed observation. ADM stated that loose baseboards along the hallway will be replaced. During an observation of the employee lounge on 12/11/2020, between 11:30 a.m. and 11:58 a.m., there was one live cockroach crawling on the floor and one dead cockroach inside a cabinet. ADM confirmed observations. During a concurrent interview, the ADM stated that as soon as kitchen is done, they will clean and deep clean the employee lounge. ADM added that she will have pest control treat the employee lounge as well. During an observation of the employee lounge on 12/16/2020, at 11:20 a.m., there were crevices on the wall shelving, opening on the wooden floor base, missing baseboards, and missing floor tiles. ADM confirmed observations. During a concurrent interview, ADM stated that they had removed the lockers, vending machines, sink, cabinet and platform used under the vending machine. They are in process of fixing the floor and sealing gaps around the baseboards and wooden floor base. ADM added that they will also seal around the wall shelving and conduct inch by inch inspection of the employee lounge. During a concurrent observation and interview on 12/16/2020, at 11:30 a.m., there were crevices around the baseboards along the hallway leading to a kitchen door. ADM stated sealing around baseboards and repair of walls along the hallway were still in progress. The ones that were loose and curved were straightened and sealed. ADM added that All About Pest will be back at the end of the week and will spray the exterior of building, kitchen, and will check the employee lounge. A review of the facility's policy and procedure titled Housekeeping Pest Control (reviewed and approved on 9/22/2020), indicated that The Administrator arranges for a pest control company to visit and inspect the facility at least once a month ensuring that the company representative inspects the facility for pest, submits a written report to the Administrator on the findings of his inspection, inspection report is filed and retained for a minimum of one year, immediate action is taken to rid of the facility or its ground of any environmental pest as noted in the inspection report, after exterminating or spraying that the facility is once again inspected by pest control company to ensure that all environmental pests were removed from the premises, the company representative issues an additional report to the Administrator, verifying that all environmental pests were removed, and All housekeepers should report to the Housekeeping Supervisor any signs of rodents or insects, including ants, in the facility. The Housekeeping Supervisor takes immediate action to remove the pests in the facility. If necessary, he or she calls the extermination company for assistance. A review of the 2017 U.S. Food and Drug Administration Food Code indicated that the premises (the physical facility, its contents, and surrounding land or property under the control of the permit holder) shall be maintained free of insects, rodents, and other pests. The presence of insects, rodents, and other pests shall be controlled to eliminate their presence on the premises by: routinely inspecting incoming shipments of food and supplies; routinely inspecting the premises for evidence of pests; using pest control according to law, manufacturer's use directions, conditions of certification and other additional conditions; and eliminating harborage conditions. The document further indicated that Insects and other pests are capable of transmitting disease to humans by contaminating food and food-contact surfaces. Effective measures must be taken to eliminate their presence in food establishments. C. During a concurrent interview and observation on 12/8/2020, at 2:11 p.m., the ADM stated that ice from the ice machine inside the employee lounge were given to residents for consumption. Observed interior of ice machine had slime formation and encrusted debris. ADM verified that water was dripping on the back side of the ice machine through slime and onto the ice. ADM also verified encrusted debris inside the ice machine. ADM stated that maintenance staff were in-charge of cleaning the ice machine. ADM added that she will have the ice machine emptied out, cleaned and will discontinue providing contaminated ice to residents. During an interview on 12/8/2020, at 2:25 p.m., the Maintenance/Housekeeping Supervisor (MHS) stated that the ice machine is cleaned and sanitized on a monthly basis and the last time it was cleaned was on 11/28/2020. Upon inspection, the MHS stated that both interior and exterior of the ice machine were dirty. MHS added that housekeeping was in-charge of maintaining the exterior clean. During an interview on 12/8/2020, between 2:25 p.m. and 2:58 p.m., the ADM stated that both ice scooper and container were supposed to be cleaned and sanitizer every day. However, it was not being done and there were no logs kept. ADM added that she will have dietary in charge of cleaning and sanitizing of scooper and container, will create a log, and will provide store bought ice for resident consumption. A review of the facility's policy and procedure titled Ice Machine Cleaning (reviewed and approved on 9/22/2020) indicated that The ice machine (bin) will be cleaned and sanitized once a month. Maintenance staff will clean and sanitize the motor (evaporator) every 3 to 6 months, depending on manufacture's recommendation. The ice scoop and container will be cleaned and sanitized daily. A review of the 2017 U.S. Food and Drug Administration Food Code, indicated equipment contacting food that is not Time/Temperature control for safety food: such as enclosed components of ice makers shall be cleaned at a frequency specified by manufacturer or if manufacturer specifications are absent then at a frequency necessary to preclude accumulation of soil or mold. The document further indicated that ice makers and ice bins must be cleaned on a routine basis to prevent the development of slime, mold, or soil residues that may contribute to an accumulation of microorganisms. If the manufacturer does not provide cleaning specifications for food-contact surfaces of equipment that are not readily visible, the person in charge should develop a cleaning regimen that is based on the soil that may accumulate in those particular items of equipment.

Based on observation, interview, and record review, the facility failed to ensure food was stored in accordance with professional standards for food service safety when the facility failed to eradicate cockroach (small insects that cause spread of bacterial infection) population and eliminate harborage conditions in the kitchen. The facility's kitchen environment had cracks in the walls, broken grout between the floor tiles, plywood pieces that holds the sink in place, which provided both food and safe places for harborage of pests and the warm kitchen conditions necessary to encourage the cockroaches to thrive. In addition, lack of an effective reporting and communicating system regarding the presence of cockroaches in the kitchen delayed proper treatment to control harborage. These deficient practices provided unsanitary food preparation and storage area and had the potential to cross-contaminate food that could cause food borne illness in 131 of 177 residents who received food from the kitchen. A review of article from (www.orkin.com) Cockroaches are nocturnal insects. They prefer to live and feed in the dark, a cockroach seen during the day is a possible sign of infestation. Cockroaches tend to prefer dark, moist places to hide and breed and can be found behind refrigerators, sinks, and stoves, as well as under floor drains and inside of motors and major appliances. In addition, the pest cockroaches can be carriers of various diseases because they are commonly found near waste deposits. Cockroaches often taint food with E.coli (Escherichia coli -can cause diarrhea, urinary tract infections, respiratory illness, and other illnesses) and Salmonella (type of bacteria that cause food-related illness); also exposure to cockroach waste and dead roaches over time can trigger allergies and asthma. Immediate jeopardy (IJ-a situation in which the provider's non-compliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment or death of a resident) was declared on December 3, 2020 at 4:23 p.m. The facility administrator (ADM), Director of nursing (DON), and Facility Regional Director (RDO) was notified of the immediate jeopardy situation. The Facility administrator (ADM), (DON), Dietary Supervisor (DFSD) and Maintenance supervisor (MHS) were informed of the cracks on the walls in the ware washing area, cracks on the walls under fruit and vegetable preparation area and plywood around the handwashing sink. The facility was also informed of lack of a consistent communication between kitchen staff, dietary supervisor and maintenance department regarding presence of roaches in the kitchen and lack of aggressive action to control the harborage of cockroaches. On December 17, 2020 at 12:54 p.m., the IJ was removed in the presence of the Administrator and DON after the facility submitted an acceptable plan of action (POA), removed and eliminated pest harborage and infestation from facility kitchen and the surveyor verified the POA was implemented as follows: 1. The kitchen was closed all meals will be prepared by permitted food facilities including all special textured meals (mechanical soft diet and pureed diet.) 2. All food items in the kitchen, open and closed were immediately discarded Supervised by Dietary supervisor. 3. The kitchen and all kitchen equipment were deep cleaned. These items will be monitored and continue deep cleaning under the supervision of the Dietary Supervisor. 4. The facility increased the use of pest control service which applied deep treatment to the entire kitchen on 12/3/2020 at 9 p.m., 12/6/2020 and 12/11/2020 at 5:30 p.m. 5. All meals will be checked for proper consistency, thickness, and diet order by the licensed nurses and Registered Dietitian (RD). 6. Another facility will provide temperatures of all food prior to leaving the facility. The temperature of foods will also be taken upon arrival to facility. 7. All food inspected for proper handling upon arrival by the Registered Dietitian. 8. The RD and the cook, will all monitor the food temps. 9. Maintenance supervisor to check and seal all holes, penetration, creases on the walls and floors. 10. New systems established for Maintenance supervisor daily inspecting, monitoring and reporting for pests in the facility kitchen. 11. New systems established for Infection Prevention nurse to make rounds in kitchen for monitoring and reporting pest control and sanitation issues. 12. New system established for kitchen staff for daily monitoring and reporting for pest in the kitchen. 13. In-services performed with all kitchen and nursing staff. Additional in-service will be conducted. Findings: On December 3, 2020, at 2:30 p.m., the Los Angeles County Environmental Health Department Inspector (EHS 1) (performs inspections of various licensed health care facilities and properties to determine conformance with applicable state laws and County ordinance code sections) informed the California Department of Public Health (CDPH) about the closure of the facility's kitchen due to active infestation of live cockroaches in the facility's kitchen. A review of EHS 1 report dated December 3, 2020 indicated EHS 1 observed two live nymph German cockroaches below the drain board at ware washing corner area, eight live adult German cockroaches at the wall ceiling juncture above ware wash unit, three dead cockroaches on the shelving below the drain board at same area, wight live German cockroaches just below the pass out window (where food is passed through to the adjacent dining room or served to the adjacent dining room), left of the food preparation sink, two live nymph cockroaches at same area, left of the food preparation sink, and cockroach fecal spotting at the right corner of the pass out window, left of food preparation sink. During an observation of the kitchen on December 3, 2020, at 4:40 p.m., the kitchen was closed with the notice of closure from LAC EHD posted on the kitchen door with a date December 3, 2020, timed at 2:20 p.m. During the same observation, the kitchen was inspected for the presence of cockroaches. There was one live nymph cockroach (baby cockroach) on the food preparation sink area (where fruits and vegetables are washed and prepared for residents), one live nymph cockroach on the floor in the dry storage area, one dead juvenile cockroach on the floor in the middle of the kitchen, one live adult cockroach on the wall in the dishwashing area, and one live nymph crawling on the resident food tray in the dishwashing room. There were cracks on the wall and ceiling in the dishwashing area, there were cracks in between the tiles on the floor (the grout was broken), there was dirt accumulated in the spaces between the food preparation sink and the pass out window, and there was a big plywood around the hand washing sink that could harborage pests. A review of article from the Department of Public Health, County of Los Angeles titled, Effective Management of Cockroach Infestation (retrieved December 4, 2020 at publichealth.lacounty.gov >Vector Management) indicated cockroaches may become pests in any structure that has food preparation or storage areas. They contaminate food and eating utensils, occasionally damage fabric and paper products, leave stains on surfaces, and produce unpleasant odors when present in high enough numbers. When cockroaches that live outdoors encounter human excrement in sewers or with pet droppings, they have the potential to transmit bacteria that cause food poisoning. During a concurrent interview on December 3, 2020 at 4:40 p.m., with DFSD, she stated that she has been working in the facility since 2019, does quarterly audits that include pest control and has never seen any cockroaches in the kitchen. DFSD stated if staff see cockroaches, they should let her know but there was no communication log for pests. DFSD stated the Pest Control technician comes once a month to spray the kitchen. On December 3, 2020, at 4:50 p.m., during an interview, the Dietary Assistant (DA) he had seen cockroaches in the kitchen floor and counters in the early morning. DA said when he sees a cockroach, he kills them. DA stated he will call the pest control technician when he sees cockroach but did not remember when he called the pest control technician. On December 3, 2020, at 5 p.m., during an interview, the Dishwasher (DW) stated that he sees cockroaches in the kitchen. When asked if he told the DFSD about the cockroaches, DW did not answer. On December 3, 2020 at 5:10 p.m., during an interview, the ADM stated she did not know there were cockroaches in the kitchen and the Pest Control Technician (PT) comes once a month and PT is an employee of the corporation. On December 3, 2020, at 5:20 p.m., during an interview, MHS stated that he oversees the housekeeping department who informs him of any pest-related issues in the facility but not in the kitchen. MHS stated kitchen staff is responsible for cleaning the kitchen and report any pest spotting. On December 3, 2020 at 5:38 p.m., during a concurrent interview with DON and Infection Control Preventionist (IPN), the IPN stated she makes rounds around the facility, involving the kitchen, to identify infection control issues including pest infestation. Both DON and IPN stated it was important to maintain the kitchen free of pests because of potential for harm to resident food. During an observation for dinner service on December 3, 2020, at 5:55 p.m. coffee was prepared in the kitchen. Dietary staff was serving coffee in individual cups for residents. During a concurrent interview, DFSD stated she did not realize they should not serve coffee. She agreed the kitchen had been closed and that everything in kitchen was potentially contaminated. On December 4, 2020, at 11:50 a.m., during an interview, RD 2 stated residents would continue to receive food from another facility and permitted food establishments. RD 2 stated no food or beverage should be used from the kitchen because of the cockroach infestation. On December 5, 2020, at 10:30 a.m., during a telephone interview, ADM stated EHS 1 was at the facility and found more roaches and the kitchen remained closed. A review of EHS 1 report dated December 5, 2020, indicated, one live cockroach crawling on top of a stove in the kitchen, three live cockroaches harboring between a piece of wood and the side of the hand-washing sink in the kitchen, six live cockroaches in the utensil washroom (two located between the automatic dish washing machine drain board back splash and the wall, three located on top of the automatic dish washing machine drain board and one located crawling on the wall above the drain board), in addition, two egg casings and one nymph cockroach were observed on top of the dish washing machine drain board. On December 8, 2020, at 9:30 a.m., during a telephone interview, ADM stated she had found more roach activity in the kitchen and facility was working to seal more holes and cracks on the walls and floor tiles. On December 10, 2020, at 9:30 a.m., during a kitchen observation with EHS 1, there was one live adult roach in the dishwashing area, one live nymph on the floor in the dishwashing area, one live nymph above the ice machine, one live juvenile cockroach on the walking refrigerator and one live nymph cockroach in the dry storage area. EHS 1 and stated the kitchen will remain closed. On December 10, 2020, at 10 a.m., during an interview, RD 1 stated he started working at the facility on December 1, 2020 and during his first audit of the kitchen on the same date of hire, he did not find any pests. A review of the facility's document completed by an RD (no name), located in the kitchen and titled, Dietary Quality Control Survey dated October 2020 indicated, there were dead bugs on the floor near storeroom and all other food storage areas. The document did not include follow up or actions taken. A review of the facility document titled, Pest Management Sanitation Report dated October 8, 2020 indicated, pest activity was found and treated as needed: kitchen, laundry, employee lounge, etc. The pest report did not include additional recommendations or follow up. A review of the facility document titled Pest Management Sanitation Report dated November 25, 2020 indicated, pest activity was found. The document did not indicate the type or location of the infestation. The document indicated, retreated the kitchen as needed On December 17, 2020, at 10:30 a.m., during an interview, the ADM stated on December 16, 2020, during an inspection of the kitchen, EHS 1 found one live roach in the kitchen and the inspector would return on December 17, 2020. On December 17, 2020, at 11:48 a.m. during an observation of the kitchen, there were no roached found or any other pest infestation. All the walls and floor crack had been repaired and sealed and the kitchen and the equipment were deep cleaned. On December 17, 2020, at 12:06 p.m., EHS 2 advised the facility to reopen the kitchen. A review of the job description for Dietary Supervisor revised January 12, 2017 indicated, Essential Duties and responsibilities include: Inspects and evaluates the department regularly to ensure compliance with all state and federal regulations. Plans and coordinates standards and procedures of food storage, preparation, and service; equipment and department sanitation; and employee safety. Inspects and evaluates the department regularly to ensure compliance with all state and federal regulations, resolving deficiencies as identified. A review of the job description for Registered Dietitian revised 2019 indicated, Responsibilities: Monitors and recommends food service standards for sanitation, safety, and infection control. Reports to the administrator and Dietary Service Supervisor findings and concerns regarding dietary department and the nutritional care of residents. Submits reports on charting completed, problems addressed, survey concerns and recommendation for quality of care. A review of the job description for Infection Control Preventionist (IPN) dated November 28, 2016 indicated, Essential Duties and Responsibilities: Perform daily rounds in the facility to assess and identify infection control related issues and problems. Conduct staff in service education/training, when needed, to abate known problems. A review of facility policy tilted Housekeeping-Pest Control not dated, indicated, The administrator arranged for a pest control company to visit and inspect the facility at least once a month, ensuring that: Immediate action is taken to rid the facility or its grounds of any environmental pest as noted in the inspection report. After exterminating or spraying for insects, as the situation warrants, the facility is once again inspected by the pest control company to ensure that all environmental pests were removed from the premises. The company representative issues an additional report to the administrator, verifying that all environmental pests were removed. A review of facility policy titled Storage of Canned and Dry Goods (revised 2019) indicated, Food and Supplies will be stored properly and in a safe manner. The storage area will be clean, dry, well ventilated always. Storage area will be cleaned regularly and checked for any evidence of pests. A review of facility policy titled Infection Control (no date) indicated, This facility has established and will maintain an infection control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection. A review of the 2017 U.S. Food and Drug Administration Food Code 6-202.15 indicated, insects and rodents are vectors of disease-causing microorganisms which may be transmitted to humans by contamination of food and food contact surfaces. Food establishment shall be protected against the entry of insects and rodents by filling or closing holes and other gaps along floors, walls and ceilings; closed, tight fitting windows and solid self-closing tight fitting doors. A review of the 2017 U.S. Food and Drug Administration Food Code 4-402.11 indicated, the inability to adequately or effectively clean areas under equipment could create a situation that may attract insects and rodents and accumulate pathogenic microorganisms that are transmissible through food. Effective measures must be taken to eliminate their presence in food establishments. Ensure that fixed equipment is installed in a way that: allows accessibility for cleaning on all sides, above, and underneath the units or minimizes the need for cleaning due to closely abutted surfaces; ensures that equipment that is subject to moisture is sealed; prevents the harborage of insects and rodents and provides accessibility for the monitoring of pests.