Every finding on record at Casa Dorinda

Based on observation, interview and Policy and Procedure (P/P) the facility failed to ensure food safety requirements was followed and implemented whenFailed to discard leftover in the itchen's walk-in-refrigerator.Take temperature of cold foods for lunch meal service to maintain potentially hazardous food and Time/ Temperature Control for Safety PHF/TCS foods at safe temperatures.Ensure kitchen staff during food preparation for meals served to residents wear appropriate beard restraints. Ensure safe food storage when documenting temperatures on the temperature monitoring log exceed 41 degrees Fahrenheit (F) and went unnoticed due to incorrect guidelines listed on the log.1.During a concurrent observation and interview on 3/3/26 at 11:00 a.m. with Nutrition Service Manager (NSM), in the Skilled Nursing Facility (SNF) kitchen's walk-in-refrigerator, observed cooked white rice in a transparent container covered with a plastic wrap with a preparation date of 3/2/26 and cooked pasta in a transparent container, covered and labeled with a preparation date of 2/24/26. NSM stated the facility did not have a cool down log for the PHF leftover cooked rice and pasta. NSM stated the facility did not store leftover foods. NSM stated the leftover rice and pasta were left by one of the facility's Cook.During an interview on 3/03/26 at 3:00 p.m. with [NAME] (2), [NAME] 2 stated that he was the one who put the leftover cooked white rice and cooked pasta in the walk-in refrigerator and confirmed there was no cool down log for safe food handling. [NAME] 2 stated the leftover rice, and pasta should not have been stored in the refrigerator, and it should have been discarded.During a review of the facility's policy and procedures (P&P) titled, Leftovers Storage & Discarding Policy, revision date 11/14/25, the P&P indicated, Policy: In order to prevent food borne illness and improper cooling procedures. Facility maintains a policy of not keeping storage or reusing leftovers foods. Procedure.2. All cooked foods must be properly discarded at the conclusion of each meal period.During an interview on 3/5/26 at 10:35 a.m. with NSM, NSM acknowledged that leftover cooked rice, leftover pasta or any other leftovers should not be stored in the refrigerator.During an interview on 3/5/26 at 11:00 a.m. with Director of Dining Services (DDS), DDS acknowledged that leftover food should not be stored in the refrigerator. 2. During a concurrent observation and interview on 3/04/26 at 11:40 a.m. with the NSM, NSM measured the temperature of the cold tuna salad and stated it was 50 degrees F. NSM stated the tuna salad was intended to be served cold and should have been 41 degrees F or less. NSM stated that they were not checking prepared cold food temperatures for trayline service to ensure cold foods left the kitchen at 41 degrees F or less before serving it to the residents.A review of the facility's P&P titled Food Temperature Policy: Delivery to Med Cen, revised on 10/11/25 indicated, Purpose: This policy ensures that all Time/Temperature Control for Safety (TCS) foods delivered to a SNF are maintained at safe internal temperatures to prevent foodborne illness among vulnerable residents. The section titled Food Temperature Policy: Delivery to SNF.1. Internal Temperature Standards indicated that all food must be measured with a calibrated thermometer before being loaded for delivery and upon arrival. Cold foods must be maintained at 41 degrees F or lower.During an interview on 3/5/26 at 11:10 a.m. with DDS, DDS acknowledged that cold foods temperature should be checked before serving to the residents and the temperature should be maintained at 41 degrees F and lower.3. During a concurrent observation and interview on 3/5/26 at 9:57 a.m. with Dietary Aide 1 (DA1) in the SNF kitchen, DA 1 was observed with beard without a beard cover (facial hair restraint) while handling clean meal trays. DA 1 stated he should wear beard restraint when in the kitchen and preparing food for the residents. DA 1 stated there were no available beard restraints next to the hairnets when entering the SNF kitchen.During a concurrent observation and interview on 3/05/26 at 10:05 a.m. with the Trayline Aide (TA) in the SNF kitchen TA was observed with white beard without a beard cover during food preparation.During an interview on 3/5/26 at 10:15 a.m. with DDS, DDS acknowledged that beard restraint is not in their policy and should be. DDS stated he will add it in their policy. DDS stated that the Registered Dietitian (RD) is not involved in oversight of safe food handling and sanitation for the SNF or main kitchen foodservice operations. DDS stated it was either him and or his chef that conducted an audit of the foodservice operation for food safety and sanitation and an RD was not part of nor reviewed the audits to provide RD expertise on safe food handling, sanitation and related policies and procedures. During a review of the facility's P&P titled Hairnet/Hair Covering Policy revised on 4/1/25, the P&P stated Requires employee in all areas of Dining Service to wear effective hair restraints, such as hairnets, caps, or scarves, to prevent hair from falling into the food, contaminating clean equipment, or other sensitive areas, thereby ensuring hygiene and preventing contamination. This requirement stems from public health regulations, such as the FDA Food Code, and applies to anyone with hair that could fall into food or onto equipment, including bald individual and those with short hair.During a review of the U.S. Food and Drug Administration (FDA) Food Code (FDAFC), dated 2022, the FDAFC indicated, Food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food; clean equipment, utensils, and linens.During a review of the FDAFC Annex (FDAFCA), dated 2022, the FDAFCA indicated, Consumers are particularly sensitive to food contaminated by hair. Hair can be both a direct and indirect vehicle of contamination. 4. During a concurrent interview and record review on 3/03/26 at 1:02 p.m. with Licensed Nurse 1 (LN1) in the second-floor pantry area, LN1 stated that there was nothing wrong with the Pantry Refrigerator Monitoring Log for 2026. The refrigerator temperatures were documented as: March 1 - 44 degrees F. Pantry Refrigerator Monitoring 2026 reads as follows: Refrigerator should read between 36-46 degrees.During a record review of first floor Pantry Refrigerator Monitoring 2026 reads as follows: Refrigerator should read between 36-46 degrees.During an interview on 3/4/26 at 2:00 p.m. with Director of Nursing (DON), DON stated that monitoring temperature of the refrigerators was delegated to the night shift nursing staff and inaccurate temperature guidance on the log impeded the nurse from being able to identify when temperature was out of acceptable range to report the problem for prompt resolution for the health and safety of residents.During an interview on 3/5/26 at 10:30 a.m. with NSM, NSM acknowledged that the Pantry Refrigerator Monitoring guide was not accurate for the refrigerator temperature to read between 36 to 46 degrees Fahrenheit. NSM stated that refrigerator temperature should be 41 degrees F and below.During a review of the facility's P&P titled Refrigerator Temperature Log Policy, revised on 6/01/25, the P&P stated: This policy establishes the standards for monitoring, recording, and responding to refrigerator temperatures to ensure food safety and regulatory compliance. Section 2, Standard Operating Procedures: Required Ranges, indicated that refrigerator temperatures must be maintained between 33 degrees F and 41 degrees F.During an interview on 3/5/26 at 11:10 a.m. with DDS, DDS acknowledged that the refrigerators located in the first- and second floor pantries should maintain temperatures at or below 41 degrees Fahrenheit.

Based on interview and record review, the facility failed to provide care and all services are provided according to accepted standards of clinical practice for 5 of 12 sampled resident ( (Resident 40, 47 4, 1, and 34) when: Resident 40's nebulizer equipment (tubing and nasal canula) was not stored per facility policy.Resident 47 on oxygen had no signage posted indicating no smoking/oxygen in use.Ensure staff consistently used the unique identifiers to verify resident identity prior to medication administration These facility failures creates a potential for compromised resident outcomes and safety During an observation on 3/4/26 at 7:20 a.m., Licensed Nurse 3 (LN) 3, LN 3 was observed preparing medications for Resident 4. LN 3 entered the resident's room and administered five oral medications to the resident sitting in the chair. At no time did LN 3 ask the Resident to state their name and date of birth before administration. During an interview on 3/4/26 at 7:25 a.m., LN 3 verbalized they identified the resident by the name on the door and the picture in the MAR (medication administration record), further verbalizing, that's just what we do here. During an observation on 3/4/26 at 7:35 a.m., Licensed Nurse 1 (LN)1, LN 1 was observed preparing medications for Resident 1. LN 1 entered the resident's room and administered two oral medications. At no time did LN 1 ask the Resident to state their name and date of birth before administration. During an interview on 3/4/26 at 7:40 a.m., LN 1 verbalized they identified the resident by the name on the door and the picture in the MAR, further verbalizing, The resident has been here for a while and we know our residents. During an observation on 3/4/26 at 7:45 a.m., Licensed Nurse 2 (LN)2, LN 2 was observed preparing medications for Resident 34. LN 2 entered the resident's room and administered six oral medications. At no time did LN 2 ask the Resident to state their name and date of birth before administration. During an interview on 3/4/26 at 7:50 a.m., LN 2 verbalized they identified the resident by the picture in the MAR. During an interview on 3/4/26 at 9:45 a.m. with Director of Nursing (DON), DON verbalized our residents do not wear wristbands, we try to make this as home like as possible, when asked if residents should be identified by the name on the door, DON verbalized, probably not. During a review of the facilities policy and procedure (P&P) titled, Resident Identification Prior Medication/Treatments Administration, dated 12/4/2024, the P&P indicated, Staff will verify the resident's identity using at least two identifiers, which may include: Resident photograph in the eMAR, (Electronic medication administration record) Resident stating their full name and date of birth Review of [NAME] and [NAME], Tenth Edition, Fundamentals of Nursing, page 607-608 in the section titled, Medication Administration, indicated, To prevent medication errors, follow the seven rights of medication administration consistently every time you administer medications. Many medication errors can be linked in some ways to an inconsistency in adhering to these seven rights: The right medication The right dose The right patient The right route The right time The right documentation The right indication During review of Resident 40's admission Record (AR), dated February 21, 2026, the AR indicated Resident 40 was admitted to the facility with diagnoses of pneumonitis (inflammation of the lungs) and gastrostomy status (the presence of a surgically created, often permanent, opening in the stomach (stoma) used for long-term feeding or medication delivery). During an observation on 3/3/2026 at 12:37 p.m., Resident 40's nebulizer canula mask and tubing were observed on the nightstand, uncovered. During a subsequent observation on 3/4/26 at 8:00 a.m. the resident's nebulizer canula mask and tubing were observed on the nightstand and uncovered. During a review of Resident 40's Physician Order Report (POR), dated March 1, 2026, the POR indicated ipratropium-albuterol (inhaled medication used to relaxing muscles in the airways to improve breathing) solution for nebulization (a process that converts liquid medication into a fine mist (aerosol) for direct inhalation into the lungs and respiratory tract using a machine called a nebulizer) 0.5 mg (milligrams – a unit of mass or weight) – 3 mg (2.5 mg base)/ 3 mL (milliliters – a measure of volume), amount 1 vial inhalation every eight hours PRN (as needed). During a concurrent observation and interview on 3/4/2026 at 10:25 a.m. inside Resident 40's room with the Assistant Director of Nursing (ADON), ADON acknowledged the nebulizer equipment (tubing and nasal canula) were on the dresser and not properly stored per the facility's policy. During a review of the facility's policy and procedure (P&P) titled Use of Nebulizer, last revised on 2/28/26, the P&P indicates Equipment Care – Store clean/dry in labeled bag at bedside (name, room #). 2. During a review of Resident 47's admission Record (AR), dated March 1, 2026, the AR indicated, Resident 47 was admitted to the facility with diagnoses that include pleural effusion (commonly called water on the lungs, is the abnormal, excess accumulation of fluid in the thin, fluid-filled cavity between the lungs and chest wall), heart failure (heart muscle is too weak or stiff to pump enough oxygen-rich blood to meet the body's needs) and urinary tract infection (bacterial infection of the bladder, urethra, or kidneys). During an observation on 3/3/2026 at 3:27 p.m., Resident 47 was observed sitting in a recliner and on two liters (metric unit of capacity) of oxygen (O2) via nasal canula (a lightweight, flexible tube with two small prongs that rest in the nostrils to deliver supplemental oxygen) with no oxygen in use/no smoking sign posted outside or inside the resident's room. During a review of Resident 47's POR, dated March 1, 2026, the POR indicated Oxygen at 1-3 L/min (liters per minute) via NC (nasal canula) PRN per patient discretion. Further review of Resident 47's SNF (skilled nursing facility) Initial/Annual Examination dated 3/1/26, indicates Resident was admitted to the facility for completion of antimicrobial (substance that kills or inhibits the growth of microorganisms, including bacteria, viruses, fungi, and parasites) therapy and supplemental nasal oxygen . During a concurrent interview on 3/4/2026 at 10:55 a.m. with the ADON, the facility's policy on oxygen use was reviewed. ADON acknowledged oxygen in use/no smoking signage is required and it was not posted outside of Resident 47's room. During a review of the facility's P&P titled, Oxygen Administration, last revised on 1/30/26, the P&P indicated, Oxygen Safety: Oxygen in Use – No Smoking signage required.

Based on observation, interview, and facility Policy and Procedure (P/P), the facility failed to ensure the medical supply rotation policy was implemented when expired medications were found in the medication carts and medication roomsThis facility failure has the potential for medciation error. During an observation of medication room [ROOM NUMBER] on 3/4/26 at 10:10 a.m. located on the first floor behind nursing station, 1 container, Oxivir Tb Wipes, (ready-to-use, hospital-grade disinfectant) with expiration date of 12/28/2023 and 1 bottle of Biotene dry mouth oral rinse, with expiration date of 2/24/2026 was noted.During an interview on 3/4/26 at 10:20 a.m. with licensed nurse (LN1). LN 1 confirmed items were expired and indicated, they should have been removed from stock and disposed.During an observation of medication number 2 3/4/26 at 10:40 a.m. located on the second floor at nursing station, 10 Suppositories of Bisacodyl 10 mg (stimulant laxatives) with expiration date of 2/28/26 was noted.During an observation of medication room [ROOM NUMBER] on 3/4/26 at 10:45 a.m. located on the second floor behind nursing station 2 cartons Glucerna Therapeutic Nutrition ( specialized medical supplement with expiration date of 10/25 and three bottles of premier protein supplement with an expiration date of 2/14/26 was noted.Review of facility P/P titled Supply Rotation Policy date 3/29/17 indicated, . Medical supplies will be sufficiently stocked and maintained current. 3. Medical Supply room will be inspected weekly by Unit Managers and outdated items will be discarded.

Based on observation, interview, and record review the facility failed to ensure food were prepared by methods that conserve nutritive value, flavor, and appearance for five of twelve sampled residents (Resident 1,16, 23,25, and 34) when meals were not consistently served at an appetizing, palatable and preferable temperature as determined by the residents.This failure had the potential to cause weightloss.During a concurrent observation and interview on 3/3/26 at 12:20 p.m., with Nutrition Services Manager (NSM). NSM was observed using a calibrated thermometer to check the internal temperature of waffle fries from a test tray after the last lunch meal tray was served to residents and was noted to be 115 degrees Fahrenheit (F). NSM stated, the waffle fries were not at an acceptable temperature for service and acknowledged, facility has received complaints from residents regarding meals being served cold.During a concurrent observation, interview, and record review on 3/3/26 at 12:49 p.m. in the dining room during lunch. Resident 25 stated, The food has no flavor, and I cannot taste what I am eating and consumed less than 50% of the meal.During an interview on 3/3/26 at 12:55 p.m. in Resident 16's room, resident stated the food is not good and complained that the meals served often arrived cold.During an interview on 3/3/26 at 1:02 p.m. in Resident 1's room, resident stated lunch, and dinner are not good.During a review of the Resident Council Meeting (RCM) minutes dated 12/19/25, 1/19/26, and 2/13/26, residents documented concerns regarding food quality. The 12/19/25 minutes reflected a report that tray line food needed improvement and that the steak served was tough and tasteless. The 1/19/26 minutes reflected a report that the meat quality was poor and difficult to cut. The 2/13/26 minutes reflected a report that food continued to be served cold during various meals.During the confidential RCM on 3/4/26 at 11:10 a.m., Resident 34 indicated that the meat quality has not improved and that the food remains below the level expected at the facility. Resident 23 stated that the food seems institutional, the meat is too tough to chew, and a regular knife won't cut the meat.During an interview on 3/5/26 at 11:20 a.m. with Director of Dining Services (DDS), DDS acknowledged that cold food has been an ongoing issue in the facility. DDS further stated, We are aware that this has been brought up before and we are trying to improve the process.During a record review of the facility's policy and procedures (P&P) titled, Timely Meal Service, revised date 10/4/24, the P&P indicated Food will be delivered promptly to assure safe, palatable, and high-quality food served at the proper temperature. Procedure.6. Food will be served at preferred temperatures (hot food hot and cold foods cold) as discerned by the patients/residents and customary practice.A record review of the facility's policy and procedures (P&P) titled, Food Temperature Policy 1. Internal Temperature Standards All food must be measured with a calibrated thermometer before being loaded for delivery and upon arrival. Hot Foods: Must be maintained at 135F or higher. For optimal quality during transport . 4. Corrective Actions and Rejection Criteria Immediate Rejection: Any delivery arriving in the Danger Zone (between 41 F and 135 F) must be refused if the time out of control is unknown or exceeds safe limits.

Based on observation, interview and record review, the facility failed to ensure there is sufficient and qualified staff with the appropriate competencies and skills sets to carry out food and nutrition services when:1. The Nutritional Services Manager (NSM) was competent on the facility's refrigerated food storage guidelines for food safety.2. The NSM responsible for day-to-day food service for the residents at the Medical Center Skilled Nursing Facility (SNF) was qualified in accordance with federal and state regulations (Health and Safety Code (H&SC)1265.4(b) and Title 22 72035), as required per federal regulation.3. The Registered Dietitian (RD) provided frequently scheduled consultation to the NSM to include overseeing food safety and sanitation. Cross Refer F812This failure had the potential for food and nutrition services staff to be inadequately trained and supervised to carry out food and nutrition services.1. During a concurrent observation and interview on 03/03/26 at 10:47 a.m. with NSM inside the walk-in refrigerator of the SNF kitchen, uncooked chicken was observed in a stainless-steel container labeled with a preparation date of 03/03/26. During an interview with NSM, NSM stated that uncooked chicken could be stored in the refrigerator for three to four days. NSM also stated that they use the facility's Food Storage Guide (FSG), undated posted on the refrigerator door.During a concurrent interview and record review on 03/03/26 at 11:00 a.m. with NSM, NSM reviewed the FSG posted on the refrigerator door. NSM stated the uncooked chicken could be stored in the refrigerator for only one to two days.During a concurrent observation and interview on 03/05/26 at 9:21 a.m. with NSM inside the walk-in refrigerator of the SNF kitchen, 4 oz. (ounce) individual sized cartons of Mighty Shakes (a nutritional supplement to increase calories and protein) were labeled with a date of 02/25/26. NSM stated the kitchen staff placed the white sticker label of 2/25/26 when the MightyShakes were removed from the freezer and placed in the refrigerator. NSM stated they have three days to use the MightyShakes. NSM then pointed to a manufacturer date preprinted on each 4 oz. carton of MightyShake that indicated Use by Sep [September] 03 2026. NSM stated the MightyShakes could also be stored in the refrigerator, unopened, up to the manufacturer date of Sep 03, 2026.During a review of the manufacturer's specifications (MS) preprinted on each 4 oz. carton of MightyShake, the MS indicated, Store Frozen. Thaw at or below 40 degrees F [Fahrenheit]. Use thawed product within 14 days. Keep Refrigerated.During a concurrent observation and interview on 3/5/26 at 9:25 a.m. with NSM inside the walk-in refrigerator of the SNF kitchen, there was uncooked salmon and red [NAME] in a steel container labeled with a preparation date of 03/04/26. NSM stated the raw fish could be stored in the refrigerator for three to four days before being cooked. During a review of the facility's policy and procedures (P&P) titled, Food Storage Duration Policy, revision date 09/10/25, the P&P indicated, Purpose: To ensure the safety of our residents by using proper storage and techniques.Fresh Poultry/Fish recommended Maximum Storage of 1-2 days. 2. During a concurrent interview and record review on 03/05/26 at 10:30 a.m. with NSM in his office adjacent to the SNF kitchen, H&SC 1265.4 accessed on-line, current as 1/01/2025, was reviewed. NSM stated he had not met any of the education qualifying pathways to be a NSM (interchangeable with the state's terminology for a dietary services supervisor) as listed in H&SC 1265.4(b) which was required to supervise dietetic service operations. The state's Title 22 72035 indicated, Dietetic service supervisor means a person who has completed the training requirements specified in section 1265.4(b) of the Health and Safety Code. In addition, NSM reviewed the federal regulation, F801, and NSM stated he did not meet any of the qualifications listed in the regulation to be responsible for the daily management of the foodservice operation for the SNF kitchen. NSM stated he was currently in the role of full-time person responsible for the daily management of the foodservice operation for the SNF kitchen that distributes meals to the residents residing in the SNF.During an interview on 03/05/26 at 10:53 a.m. with Director of Dining Services (DDS), in the presence of NSM, DDS stated he was a Certified Dietary Manager (CDM) but was responsible for the entire Continuing Care Retirement Community (CCRC) food and nutrition services that entailed a main kitchen (in addition to the SNF kitchen) and other foodservice operations located on the campus. DDS stated he was not familiar with some of the specifics of the SNF kitchen such as whether the kitchen staff checked temperatures of the cold food prior to food leaving the kitchen to serve meals to residents (Cross Reference F812). DDS stated he was not full-time (defined as 35 hours per week) specifically to the role of daily management of the SNF kitchen foodservice operation as that was NSM's job responsibility. During a review of the facility's job description (JD) titled Nutritional Services Manager (NSM), dated 4/1/24 with a review date of 10/25/25, the NSM JD indicated, Training & experience required: 2. Certified Dietary Manager (CDM) Certificate or willingness to pursue and achieve a CDM as soon as possible.3. During an interview on 03/05/26 at 10:17 a.m. with NSM, NSM stated the facility's Registered Dietitian (RD) was contracted and was on site one time a week on Friday's. NCM stated they collaborate at times, when needed, to discuss plating of therapeutic diets during trayline, portion sizes per the planned menu and clinical nutrition care plans for residents. NSM stated the RD had not provided any in-services to kitchen staff since she has been contracted with the facility for about a year. NSM stated there was no formality, documentation, or set schedule to ensure NSM received frequently scheduled consultations from the RD to encompass the depth and breadth of the food and nutrition services, such as food safety, sanitation and in-services to lend RD expertise to oversight of the food and nutrition services operation.During an interview on 03/05/26 at 11:05 a.m. with DDS and Chef (1), DDS stated Chef 1 and I conduct food safety and sanitation audits for the main kitchen and SNF kitchen, usually monthly, and the RD is not part of this process. DDS confirmed the RD did not have a role in oversight of food safety and sanitation (Cross Reference F812). A review of the Registered Dietitian Consultant Agreement [RD contract], dated 4/18/25, the RD contract indicated, The Consultant shall provide the Facility with review of food safety and sanitation of the Food Service Department as needed, Duties and Obligations of Consultant.Scope of Services.the Consultant will provide in service education for dietary personnel and other facility personnel as needed.A review of Academy of Nutrition and Dietetics (AND) Nutrition Care Manual (NCM), dated 2025, the NCM indicated, High-risk groups should be aware of how long foods will keep in the refrigerator: Raw fish and seafood: 1 to 2 days, Raw chicken and turkey: 2 to 3 days.A review of FoodSafety.Gov (FSG), dated 9/19/2023, the FSG indicated, .for storing food in the refrigerator.short time limits.will help keep them from spoiling or becoming dangerous to eat.fresh [raw] poultry: chicken whole or chicken pieces 1 to 2 days, fish: 1 to 3 days (https://www.foodsafety.gov/food-safety-charts/cold-food-storage-charts). A review of the U.S. Food and Drug Administration Food Code (FDAFC), dated 2022, the FDAFC indicated, Highly susceptible population means persons who are more likely than other people in the general population to experience foodborne disease because they are: (1) Immunocompromised; preschool age children, or older adults; and (2) Obtaining food at a facility that provides services such.health care, or assisted living, such as a.nursing home.

Based on observation, interview, and record review the facility failed to ensure infection control practices were implemented when: Enhanced barrier precautions (EBP - Infection control measures the involves wearing personal protective equipment [PPE - protective gear such as gloves, gowns, masks, and eye protection] for specific high-contact tasks such as bathing, transfers, and wound care for at-risk residents to stop germ spread) were not implemented for three of three residents (Resident 3, Resident 4, Resident 40) with indwelling medical devices (instruments placed inside the body to assist with diagnostic, monitoring, or therapeutic functions) A nebulizer mask (a medical device worn over the nose and mouth to deliver liquid medication directly into the airways as a fine mist) used for breathing treatments for Resident 40 was not stored in a manner to maintain hygiene and prevent contaminationSoiled linen bags were found on the floor on two of two soiled linen rooms (SLR). These facility failures had the potential to result in cross-contamination (the transfer of harmful bacteria) that could impact residents' health and safety and cause preventable HAIs (Healthcare Associated Infections) for residents in an already compromised condition.1. During concurrent interviews and observations on 3/4/26, between 8:00 a.m. and 3:31 p.m., it was noted that Enhanced Barrier Precaution (EBP) signage was not posted and personal protective equipment (PPE) was not available at the point of care for the following residents: Resident 3, who was noted to have a peripherally inserted central catheter (PICC line) in the right arm Resident 4, who stated had a suprapubic catheter (a tube placed through the lower abdomen into the bladder for urine drainage) Resident 40, who reported having a feeding tube During a review of Resident 3's History and Physical (H&P) dated 1/31/26 indicates in part, .the patient is currently being treated for infectious endocarditis (a rare, life-threatening infection of the heart's inner lining or valves, usually caused by bacteria entering the bloodstream) with prolonged IV (intravenous – administered into a vein) antibiotics.has a PICC line. The Physician Order Report (POR), dated 1/16/26 indicates in part, Ceftriaxone (antibiotic used to treat severe bacterial infections) 2 grams IV. During a review of Resident 4's POR dated 11/13/25 indicates in part, Suprapubic catheter site care. Cleanse with NS (normal saline), pat dry, cover with 4x4 split sponge and secure with tape once a day. During a review or Resident 40's POR dated 11/4/25 indicates in part, Enteral feeding: tube site care: gently cleanse with NS around the stoma, apply a thin film of Boudreaux's paste (protective barrier ointment to treat and prevent skin irritation), around the stoma (a surgical connection between an internal organ and the skin) under the external bumper, apply split gauze on top of the past. During an observation on 3/4/26 at 9:10 a.m., a Licensed Nurse (LN 5) was observed changing Resident 40's bed linens without any PPE. During an interview on 3/4/2026 at 10:34 a.m. with Infection Prevention Nurse (IPN), IPN stated the facility did not implement EBP because it was a recommendation and not a requirement from the Centers for Medicare & Medicaid Services (CMS). IPN further stated the facility employs transmission-based precautions (TBP) for airborne, contact and droplet precautions and at the time of the interview there were no residents on TBP. During an interview on 03/04/2026 at 2:49 p.m., Licensed Nurse 4 (LN 4) confirmed that no residents were currently on transmission-based precautions (TBP). LN 4 explained that gloves were the only personal protective equipment (PPE) used when emptying urinary catheters. When asked again about PPE usage during care for residents with indwelling medical devices, LN 4 clarified that masks, face shields, or gowns are only used if a resident is on contact precautions. LN 4 added that gloves are not typically worn while changing bed linens unless the linens are contaminated or the resident is on contact precautions. LN 4 stated the training received at the facility was for universal and transmission-based precautions but was unfamiliar with enhanced barrier precautions (EBP). During an interview on 3/4/2026 at 2:56 p.m. with Licensed Nurse (LN 5), LN 5 reported unfamiliarity with Enhanced Barrier Precautions (EBP) and confirmed that training at the facility focused solely on Transmission-Based Precautions (TBP). LN 5 explained that when a resident is placed on TBP, nursing staff set up a cart outside the resident's room containing gowns, gloves, masks, a stethoscope, manual blood pressure cuff, thermometer, alcohol wipes, and disinfectant wipes. LN 5 clarified that the absence of carts outside resident rooms was due to no current residents being on TBP. LN 5 confirmed to changing Resident 40's bed linens without using any personal protective equipment (PPE), explaining that gloves are only required if linens are contaminated. Additionally, LN 5 stated that Resident 40 had no precautions in place. During an interview on 3/5/26 at 9:32 a.m. with Licensed Nurse (LN 2), LN 2 stated there were no residents on TBP. LN 2 acknowledged not knowing what enhanced barrier precautions are and explained that staff are trained to use universal precautions for all residents and TBP precautions are implemented for residents with airborne, droplet or contact precautions. LN 2 acknowledged only wearing gloves when providing foley catheter care or when administering tube feedings. During a follow-up interview on 3/5/26 at 9:57 a.m. with IPN, IPN acknowledged staff were not trained on EBP, only TBP to include airborne, droplet and contact precautions. During a concurrent interview and review on 3/5/26 at 2:50 p.m. with the Director of Nursing (DON) and the Administrator (ADM), guidance from the Centers for Medicare & Medicaid Services (CMS) reference number QSO-24-08-NH, dated March 20, 2024, was reviewed. This guidance indicates in part, CMS is issuing new guidance for State Survey Agencies and long-term care (LTC) facilities on the use of enhanced barrier precautions (EBP) to align with nationally accepted standards. EBP recommendations now include use of EBP for residents with chronic wounds or indwelling medical devices during high-contact resident care activities regardless of their multidrug-resistant organism status. Following the review of QSO-24-08-NH, both the DON and ADM stated that enhanced barrier precautions had not been implemented at the facility. They acknowledged, however, that EBP should have been in place for residents known to be colonized or infected with multi-drug-resistant organisms, as well as for those with indwelling medical devices who are at higher risk of acquiring such infections. 2. During review of Resident 40's admission Record (AR), dated February 21, 2026, the AR indicated Resident 40 was admitted to the facility with diagnoses of pneumonitis (inflammation of the lungs) and gastrostomy status (the presence of a surgically created, often permanent, opening in the stomach (stoma) used for long-term feeding or medication delivery). During an observation on 3/3/2026 at 12:37 p.m., Resident 40's nebulizer canula mask and tubing were observed on the nightstand, uncovered. During a subsequent observation on 3/4/26 at 8:00 a.m. the resident's nebulizer canula mask and tubing were observed on the nightstand and uncovered. During a review of Resident 40's POR dated March 1, 2026, the POR indicated ipratropium-albuterol (inhaled medication used to relaxing muscles in the airways to improve breathing) solution for nebulization (a process that converts liquid medication into a fine mist (aerosol) for direct inhalation into the lungs and respiratory tract using a machine called a nebulizer) 0.5 mg (milligrams – a unit of mass or weight) – 3 mg (2.5 mg base)/ 3 mL (milliliters – a measure of volume), amount 1 vial inhalation every eight hours PRN (as needed). During a concurrent observation and interview on 3/4/2026 at 10:25 a.m. inside Resident 40's room with the Assistant Director of Nursing (ADON), ADON acknowledged the nebulizer equipment (tubing and nasal canula) were on the dresser and not properly stored per the facility's policy. During a review of the facility's policy and procedure (P&P) titled Use of Nebulizer, last revised on 2/28/26, the P&P indicates Equipment Care – Store clean/dry in labeled bag at bedside (name, room #). During an observation on 3/4/2026 at 8:51 a.m. on the first floor SLR1, soiled linen inside a blue striped bag was found on the floor beside the soiled linen bin. During a concurrent observation and interview on 3/4/26 at 9:00 a.m. with the Assistant Director of Nursing (ADON) at the 2nd floor (SLR2), another blue striped bag was found on the floor beside the soiled linen bin. ADON stated the bag shouldn't be on the floor. During a concurrent observation and interview on 3/6/26 at 9:39 a.m.with Housekeeping (HK 1) on the first floor SLR1, HK1 noted the blue striped bag on the floor next to the bin. HK 1 stated, the bag should not be on the floor and picked it up and put it in the bin. HK1 indicated not knowing who placed the blue striped bag on the floor. During an interview on 3/6/26 at 9:45 a.m. with LN 4, LN 4 stated, the bags are supposed to be placed in the bins and that is how it is supposed to be, but some staff don't do it. During an interview on 3/4/26 at 3:29 p.m. with ADON in the facilities conference room, ADON stated, she called the linen company to inquire about the sign which requests the blue stiped bags to be outside of the bin. The company responded that the request may have come from the person who picks up and sorts the linen, but that is not a company policy. The company directed ADON to put blue striped bags in the bin with the other dirty bags. During a review of Medical Center Infection Control Program, undated, the assessment points indicated Soiled linens are not on the floor or furniture. During a review of the facility's policy and procedure titled, Bagging Soiled Linen, dated 12/20/24, indicated, Bag all soiled linen in yellow bags. Place bags in the green cart in the soiled linen room. During a review of the facility's Relias online education titled Common Infectious Conditions in LTC dated 2023, the educations indicated that training covers Standard, Contact, Enhanced Barrier, Droplet, and Airborne Precautions. Each precaution includes definitions, required personal protective equipment, and usage examples. During a review of the section titled Enhanced Barrier Precautions (EBP) outlines measures designed to prevent the transmission of multidrug-resistant organisms during patient care activities within long-term care facilities. EBP protocols are indicated for high-risk activities involving residents with wounds or indwelling devices, including resident transfers, bathing, dressing, personal hygiene, toileting, changing briefs, and changing linens. The guidelines specify that individuals with open wounds, urinary catheters, feeding tubes, central lines, tracheostomies, or ventilator tubing require the implementation of these precautions. During a review the facilities policy and procedure titled Transmission Based Precautions, stated no residents currently have a multi drug resistance organism. We do not use EBP goal is to create a homelike environment. PPE is available. 3. During an observation on 3/4/2026 at 8:51 a.m. in the first floor Soiled Linen Room (SLR1), soiled linen inside a blue striped bag was found on the floor and beside it was a blue soiled linen bin containing yellow and blue striped linen bags. During a concurrent observation and interview on 3/4/26 at 9:00 a.m. with the Assistant Director of Nursing/ Infection Preventionist (ADON/IPN) at the second floor SLR2, a second blue striped bag was found on the floor beside the soiled linen bin. ADON pointed at a sign on the wall with a picture of a blue striped linen bag stating, Please place these linen bags on floor requested by linen company. During an interview on 3/4/26 at 3:29 p.m., with ADON/IPN, linen company was called to inquire about the sign which requests the blue stiped bags to be outside of the bin. The company responded that the request may have come from the person who picks up and sorts the linen, but that is not a company policy. The company directed ADON/IPN to put the blue striped bags in the bin with the other dirty linen bags. The ADON/IPN did not comment on the contradiction of the usage of blue striped linen bags vs yellow bags and a blue soiled linen bin vs a green soiled linen bin as stated in the policy and procedure. During a review of the facility's policy and procedure titled, Bagging Soiled Linen, dated 12/20/24, indicated, Procedure: a. Bag all soiled linen in yellow bags. Place bags in the green cart in the soiled linen room. b. Medico will identify yellow bagged linen as being from skill nursing facilities or hospitals. c. Medico Linen will follow Federal guidelines on dilution rate when cleaning the linen.

Based on interview and record review, the facility failed to run reports 1700D (employee report), 1702D (individual daily staffing report) and 1702S (staffing summary report) to ensure payroll-based journal (PBJ) data (a system for facilities to submit staffing information on a regular and frequent basis, ensuring accuracy) was received by the Center for Medicare and Medicaid (CMS).This failure resulted in CMS not receiving registered nurse (RN) hours and licensed nursing coverage data for the month of September 2025.Findings:During a review of PBJ Staffing Data Report [NAME] (Certification and Survey Provider Enhanced Reports) Report 1705D, Quarter 4 2025 (September 1- September 30) run on 2/26/26 indicated, One Star Staffing Rating, No RN hours and failed to have Licensed Nursing Coverage 24 hours/day.During an interview on 3/3/26 at 11:08 a.m. with the Director of Nursing (DON), Administrator (ADM) and Assistant Director of Nursing. DON stated, she forgot to send the PBJ Report for September. During a review of the facilities Policy and Procedure (P&P) titled, The DON checks the data for accuracy and submits the data through the CMS portal.

Based on interview and record review, the facility failed to follow their policy and procedure and implement interventions of a fall care plan to ensure a bed alarm was turned on for one of three sampled residents (Resident 1) while Resident 1 was in bed.This facility failure resulted in Resident 1 getting out of bed, falling to the floor and sustaining an acute displaced right hip fracture (broken hip bone that moved so much a gap formed around the fracture).During a review of Resident 1's Face sheet, [undated], the Face sheet indicated, Resident 1 was admitted to the facility on [DATE] with the following diagnoses: Alzheimer's disease (brain disorder that causes memory loss, confusion, and other cognitive decline), unspecified dementia (loss of brain function), major depressive disorder (low mood, loss of interest or pleasure), recurrent mild muscle weakness, abnormalities of gait and mobility, essential hypertension (high blood pressure without a known cause), primary open-angle glaucoma (eye disease leading to gradual vision loss), fall on same level, presbycusis left ear (age-related hearing loss), history of falling.During an interview on 10/13/25 at 9:28 a.m. with the Director of Nursing (DON), the DON verbalized Resident 1 had an extended history of falls totaling 32 falls in five months when in assisted living, and has had nine falls since admission to the facility. The DON further verbalized Resident 1 had a witnessed fall on 9/27/25, and after that fall a bed alarm was placed. The DON stated, It was at change of shift. The nurse stated they believed the alarm was on, but the certified nursing assistant (CNA) that was involved couldn't recall if the bed alarm was set to on after changing (Resident 1) in bed. When CNAs change a resident, they turn it (bed alarm) off and whoever's attending to a resident at that moment is responsible for turning it on, and that would be either the CNA or the licensed nurse.During an interview on 10/13/25 at 10:50 a.m. with a Licensed Nurse (LN 1), LN 1 stated because (Resident 1) is falling, the resident has alarms. LN 1 further stated when you put the bed alarm on, it beeps and you can see with the light on the side of the bed that it's on, and the bed alarm needs to be turned on when you leave the resident.During an interview on 10/13/25 at 11:25 a.m. with the Assistant Director of Nursing (ADON), the ADON stated (Resident 1) is a fall risk and probably has fallen in the past and that's why we have alarms on. ADON verbalized was working when Resident 1 had the fall, name (LN 2) was the nurse on duty who did the assessment, and the fall was reported to me. ADON stated, I went in, and the resident was in bed, and we continued to assess him, and LN 2 communicated with the doctor about what happened and what symptoms he was showing. The doctor ordered a mobile x-ray. ADON verbalized then the resident started to grimace more, and didn't look like he was able to get comfortable. It was best to send him out for an evaluation. The ADON further stated, CNAs should be visually checking the alarms to make sure they are on if the resident is in bed or the tab alarm is on if they are in a chair, and it's CNAs and nurses who make sure alarms are on.During a concurrent interview and record review on 10/13/25 at 11:43 a.m. with the DON, Resident 1's Point of Care History, dated 9/28/25 was reviewed. The Point of Care History indicated, activate bed alarm when in bed and Tab alarm when in wheelchair for poor safety awareness [every shift] 9/28/25 5:21AM Done. 9/28/25 2:39PM Done. The DON verbalized the evening shift wasn't done because Resident 1 was sent out to the hospital about 3:40 p.m., and there's nothing to print. When asked if the checks for Resident 1's bed alarm were done on 9/28/2025 after the change of shift for the evening shift, the DON stated, No. The evening shift did not check that the bed alarm was on.It should be checked at the beginning of the shift and it wasn't.During an interview on 10/13/25 at 11:52 a.m. with a Certified Nursing Assistant (CNA1), CNA 1 stated, I was working on the day (Resident 1) fell. My shift ends at 3:30 p.m.That day when the resident fell, I can't remember if I set up the bed alarm or not .Me and the nurse were cleaning (Resident 1) in the bed .I can't remember if I set up the alarm .if we don't turn off the alarm it would be beeping because (the resident) moves back and forth, and when we were finished, I can't remember if we put the bed alarm back on or not .Every time we put the resident in bed, we have to turn the alarm on - whatever it is, the bed or floor alarm and if they are in the wheelchair.the bed alarm should have been turned back on. When asked when CNA 1 checks that residents' alarms are on, CNA 1 stated in the morning at start of the shift and when the resident is moved.During a concurrent interview and record review on 10/13/25 at 1:05 p.m. with the DON, the facility's Policy and Procedure (P&P) titled, Use of Resident Alarm devices, dated 12/19/24 was reviewed. The P&P indicated, To establish a consistent, safe, and person-centered approach to the use of resident alarm devices (tab alarms, chair/bed pad alarms, floor mat alarms, and siderail bed alarms) as part of individualized fall prevention strategies, while promoting resident dignity, autonomy, and compliance with federal and state regulations.2.1 Placement and set up Test alarm function before leaving the resident unattended.4.1 Nursing staff test each alarm at the start of every shift to ensure proper function. The DON stated, Yes, yes, I know, and further verbalized this facility P&P was not followed.During a telephone interview on 10/16/25 at 3:15 p.m. with LN 2, LN 2 stated I had heard (Resident 1) calling for help, and I was at the desk at the nurses' station and ran to his room. It was when he fell around 4:30 p.m. I did not go into his room before that.There were people in there with him until 3:30 p.m., because they were changing all the linens.I went in there, and he was on the floor, on the carpeted section, on his right side, and I didn't see the bed alarm on and there was no call light pressed. So there was nothing prior to that for me to be alarmed of, aside from him yelling for help. I looked at the bed to see if the alarm was on, and it wasn't. LN 2 verbalized bed alarms should be on when the resident is in bed, and you know a bed alarm is on when it's lit up green on the side panel of the bed. LN 2 further stated on initial assessment, he seemed shaken up, and there was no complaint of pain until later when we transferred him back to his bed, and that's when he said pain and hospital.During a review of Resident 1's Fall Risk Assessment, dated 7/21/25, the Fall Risk Assessment indicated, Mental Status/Level of Consciousness: Intermittent Confusion, Poor Recall, Judgement, Safety Awareness.Evaluation Fall Risk Score - Score of 10 or higher represents a high risk for falls. Total Fall Risk Score: 22.0000. Level: At Risk.Indicate Care Plan action taken. Continue Current Plan of Care.During a review of Resident 1's Care Plan History dated 07/1/2025 - 9/29/25, the Care Plan History indicated, Problem Start Date 10/31/2024.At Risk for falls. Goal Safety will be monitored and managed, Resident will remain free from injury. Approach Start Date 12/4/24 activate bed alarm when in bed and Tab alarm when in wheelchair for poor safety awareness. Special Instructions: for safety. Every Shift DAY, EVE, NIGHT.Discipline CNA, Licensed Nurse.During a review of Resident 1's Physician Order Report, dated 9/13/25 - 10/13/25, the Physician Order Report indicated, Start date 10/31/2024 activate bed alarm when in bed and Tab alarm when in wheelchair for poor safety awareness. Special instructions: for safety. Every Shift; DAY, EVE, NIGHT. Chartable task in POC.During a review of Resident 1's Resident Progress Notes, dated 9/28/25, the Progress Notes indicated, At 1630 (4:30 p.m.), resident yelling for help and RN on duty immediately ran to resident's room and found resident lying on his right side on carpet outside the entrance of his bathroom. Resident was incontinent of bladder, appears resident got out of bed. No call light and/or bed alarm sounded.During a review of Resident 1's Resident Progress Notes, dated 9/30/25, the Progress Notes indicated, Post Fall documentation; Two falls within a 48-hour period.RN noted that his bed alarm/call light not activated.Contributing factors for occurrence include: poor safety awareness and loss of balance/gait problems, toileting status, Improper use of safety alarms.During a review of Resident 1's hospital History & Physical, (H&P) dated 9/28/25, the H&P indicated, Reason for admission: Mechanical ground level fall with displaced acute right hip fracture.Plan: Proceed with surgery tomorrow for open reduction, internal fixation of his right hip fracture.

Based on interview and record review, the facility failed to run reports 1700D (employee report), 1702D (individual daily staffing report) and 1702S (staffing summary report) to ensure payroll-based journal (PBJ) data (a system for facilities to submit staffing information on a regular and frequent basis, ensuring accuracy) was received by the Center for Medicare and Medicaid (CMS). This failure resulted in CMS not receiving registered nurse (RN) hours and licensed nursing coverage data for the month of June 2024. Findings: During a review of PBJ Staffing Data Report CASPER (Certification And Survey Provider Enhanced Reports) Report 1705D, Quarter 3 2024 (April 1 - June 30) run 11/25/2024 indicated, One Star Staffing Rating, No RN hours, and failure to have licensed nursing coverage 24 hours/day. During an interview on 12/4/24 at 10:30 a.m. with the Director of Nursing (DON), DON verbalized they are responsible for sending staffing information to CMS, also verbalizing they were not aware of the reports to run to ensure CMS received data sent. During a review of the facility's policy and procedure (P&P) titled, PBJ Process dated 1/15/24, the P&P indicated, After the data is submitted the DON generates a report from CASPER to verify that the data has been submitted.

Based on observation, interview and record review, the facility failed to follow food safety requirements when: 1. Three (3) containers of prepared food were mislabeled as to date prepared of expiry date and is ante-dated (written date is one day after date of inspection) 2. One (1) of three (3) red buckets tested was below the recommended concentration of sanitizing solution. These failures has the potential for food borne illnesses affecting residents when safe refrigerated food are mislabelled, food has no use-by date, and sanitizing solutions are not safe when preparing foods. Findings: 1. During an observation on 12/02/24 at 11:36 a.m. at the kitchen freezer section, three stainless steel containers were identified. Two (2) containers with precut vegetables, and one (1) container with potatoes with spices, covered in clean [NAME] wrap and is labelled as 12/3/24. There is no evidence to indicate a date prepared or use by date. During an interview on 12/3/24 at 11:36 a.m. with Dietary Aide (DA1), DA verbalized that the staff who had previously worked on the weekend may have made a mistake and not checked on the date. DA 1 validates that there was no date prepared and use by date. During a review of Policy and Procedure (P&P) Titled: Storage of Food Supplies dated 11/04/24, the Storage of Food Supplies indicated in part . It is the policy of this facility to properly store dining service supplies in clean, appropriate containers at the proper temperature in the location and manner as prescribed by law . The following procedures are the responsibility of the dining services director: 11. Check foods in refrigerator to make sure they are properly covered. All prepared foods not in original containers must be covered, labelled, and dated. 13. Leftovers shall be tightly covered, stored appropriately and clearly labelled and dated. Leftovers shall be used within 72 hours and if not used within this time, will be properly discarded. 2. During a concurrent observation and interview on 12/03/24 at 10:13 a.m., testing of sanitizing solution used to clean surfaces of the kitchen in 3 Red Buckets were conducted with DA 2 with the following results: Bucket 1 400 ppm (unit of measure); Bucket 2 100 ppm; Bucket 3: 200 ppm. DA 2 states that the solution was changed early in the morning, cannot explain the discrepancy or difference in the test results. During an interview 12/03/24 at 2:30 p.m. with Sous Chef (SC), SC verbalized that the person in charge may have forgotten to change the solution or that the solution was diluted and that the sanitizing liquid may have lowered its potency. SC validates that disinfection process may be inadequate. During a review of P&P titled Red Sanitation Bucket Policy undated, the P&P indicated in part: Test solutions with test strips regularly to ensure they are maintaining the proper strength of sanitizer for food contact surfaces. There are three factors that influence the effectiveness of chemical sanitizers. 1. Concentration, recommended is from 200 ppm - 400 ppm.

Based on interview and record review, the facility failed to ensure a care plan for inappropriate behavior was updated to reflect episodes of inappropriate behaviors in one of four sampled residents ( Resident 9) per facility's policy and procedure. This failure had the potential for the Resident 9's inappropriate behaviors to have no effective interventions in place which can affect the resident's daily interactions with others and vice versa affecting the quality of life in the facility. Findings: During a review of Resident 9's, Admission Record (AR), dated 07/20/21, the AR indicated, Resident 9 had diagnoses including, Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills, and eventually the ability to carry out daily activities) with late onset and major depressive disorder. During a review of Resident 9's, Medication Administration Record (MAR), dated 01/01/24 - 12/04/24, the MAR indicated inappropriate behavior episodes occurred on the following dates: one episode 03/14/24, one episode 03/17/24, one episode 06/21/24, four episodes 06/23/24, one episode 06/29/24, one episode 07/20/24, two episodes 07/28/24, one episode 08/04/24, one episode 08/11/24, one emailing staff episode 08/12/24, one episode 08/20/24, one episode 10/09/24, one episode 11/13/24, one episode 11/16/24, two episodes 11/22/24. During a review of Resident 9's, Care Plan titled, Behavioral Symptoms indicated, problem start date of 08/08/2022 and long-term goal target date was 10/12/2024. The care plan further indicated no update was done or initiated after 08/08/2022 During a review of the facility's, policy and procedure (P&P) titled, Person Centered/Comprehensive Care Plans, dated 01/24/2017, the P&P indicated, Procedure: Care plans will be revised as changes in the resident's condition dictates. A review of the care plan will be completed no less than quarterly. During a review of the facility's policy and procedure (P&P) titled, IDT Care Plan Meeting, dated 11/2/2023, the P&P indicated, Procedure: IDT members will report on current status and discuss needed changes in the resident's care plan based upon assessments and observations. During a review of Resident 9's interdisciplinary reports (IDR), dated from 10/31/23 - 10/01/24, monitoring of the resident's inappropriate behavior was not addressed in the IDT quarterly meeting notes. A concurrent interview and record review was conducted on 12/04/24 2:34 PM and 12/5/24 at 10:52 AM with Minimum Data Set Nurse (MDSN), the MDSN stated, Monitoring behaviors is not as accurate as it should. MDSN confirmed Resident 9's care plan for monitoring inappropriate behavior target goal date was 10/12/24 and was not updated on 09/30/24 when the quarterly MDS was done.

Based on interview and record review, the facility failed to ensure the specific inappropriate behavior was documented for one of four sampled residents, (Resident 9) as stated in the careplan. This failure had the potential to inadequately identify what behavior needed to be monitored /planning of intervention to address the resident's inappropriate behavior. Findings: During a review of Resident 9's, Admission Record (AR), dated 07/20/21, the AR indicated, Resident 9 had diagnoses including, Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills, and eventually the ability to carry out daily activities) with late onset and major depressive disorder. During a review of Resident 9's, Care Plan, dated 10/01/24, the care plan indicated, Monitor and document episodes of inappropriate behavior directly/indirectly towards staff members. Special Instructions: Please be specific and document occurrence or quote in progress notes as well. Three Times A Day 02:00 PM, 10:00 PM, 06:00 AM. During a review Resident 9's, Medication Administration Record (MAR), dated 01/01/24 - 12/04/24, the MAR indicated inappropriate behavior episodes occurred on the following dates: one episode 03/14/24, one episode 03/17/24, one episode 06/21/24, four episodes 06/23/24, one episode 06/29/24, one episode 07/20/24, two episodes 07/28/24, one episode 08/04/24, one episode 08/11/24, one emailing staff episode 08/12/24, one episode 08/20/24, one episode 10/09/24, one episode 11/13/24, one episode 11/16/24, two episodes 11/22/24. During review of Resident 9's progress notes, dated 01/01/24 - 12/04/24, there was no specific documentation for the inappropriate behavior being monitored as instructed in the care plan/ special instructions. During an interview on 12/4/24 at 3:55 PM with Registered Nurse (RN3),RN3 acknowledged Resident 9 had incidents of inappropriate behavior on multiple occasions this year (2024). RN3 confirmed there were no progress notes detailing the specifics of the inappropriate behavior episodes.

Based on interview and record review, the facility failed to ensure a doctor's recommendation for a psychiatric consultation was followed up for implementation in one of four sampled residents (Resident # 9). This failure had the potential and risk for the resident's psychosocial health care needs to be unattended which can result in the deterioration of the physical, mental, and psychosocial well-being. Findings: Review of [NAME] and [NAME], seventh Edition, Mosby's Fundamentals of Nursing, page 336 in the section titled, Physician's Orders indicates, Nurses follow physician orders unless they believe the orders are in error or harm clients. Therefore, you need to assess all orders, and if you find one to be erroneous or harmful, clarification from the physician is necessary. During a review of Resident 9's, Admission Record (AR), dated 07/20/21, the AR indicated, diagnoses including, Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills, and eventually the ability to carry out daily activities) with late onset and major depressive disorder. During record review of Resident 9's social services notes (SSN), dated 10/13/22, the SSN indicated Resident requested to see a psychiatrist and upon clarification stated he sometimes feels depressed. During record review of Resident 9's physician notes, dated 10/17/2022 at 9:08 PM, the note indicated .OA Depression .Depression and feelings of De JaVu (a feeling of having already experienced the present situation). Psych consult. During record review of the nurses' notes, dated 10/17/22 at 10:41 PM, the note indicated, Seen by [attending physician] this pm, new orders received. Medical Doctor (MD) rec psych MD per resident's request for c/o Dejà [NAME]. During record review of Resident 9's medical record, no progress notes, consultation notes, or medical notes indicating Resident 9 was seen by a psychiatrist was located. During an interview on 12/04/24 at 03:24 PM with Registered Nurse (RN3) and Director of Nursing (DON), RN3 acknowledged Resident 9 requested a psychiatric consultation. RN3 said she forgot to order the psychiatric request (failed to put in an MD order). RN3 stated, I forgot to document it (referring to the resident requesting to see a psychiatrist).

Based on record review, observation, and interview, the facility failed to ensure the change of shift narcotics reconciliation count was properly counted and signed by two licensed nurses to ensure accuracy of the narcotic/controlled medications. This failure had the potential to result in an inaccurate count and drug diversion (the illegal distribution or abuse of controlled prescription drugs) of controlled medications. Findings: During a medication pass observation, on 12/3/24, at 7:53 a.m., in the East Wing, first floor of the facility, the narcotic count book/log (a book/log recording the systemic monitoring, counting, and documentation of controlled medications/substances every start and end of each shift) for the month of November, was observed to be missing several signatures from both the incoming and outgoing licensed nurses. During record review, the following were noted. On November 21, 2024, the incoming 3-11 shift nurse failed to sign at the start and at the end of the shift. On November 21, 2024, the incoming 11-7 shift nurse failed to sign at the start of the shift and at the end of the shift on November 22, 2024, at 7 a.m. On November 22, 2024, the incoming 3-11 shift nurse failed to sign at the start of the shift. On November 31, 2024, the incoming 3-11 shift nurse failed to sign at the start and at the end of the shift. On November 31, 2024, the incoming 11-7 shift nurse failed to sign at the start of the shift. During an interview with RN 2, at 8 a.m., in the East Wing hallway, RN 2 reviewed the document and concurred with the finding. RN 2 stated, Yes, there are missing signatures in the narcotic count book. During a review of the facility's policy and procedure titled, Narcotic Medication Control, dated 4/7/17 and revised 10/22/23, indicated in part, 2. Narcotics will be counted daily at shift change by two licensed nurses ., b. On coming shift will count the narcotics and sign Narcotic Count Log under Nurse On column ., c. Outgoing shift will call out number of remaining medication as indicated on the individual medication count log and sign Narcotic Count Sheet under Nurse Off) column.

Based on observation, interview, and record review, the facility failed to ensure biologicals were properly stored and labeled and the medications of discharged residents were properly stored, discarded , labeled per policy and procedure . This failure had the potential for biologicals, medications, medication items to be diverted. Findings: During a concurrent medication pass observation and interview, on 12/3/24, at 9:50 a.m., in the East Wing, first floor of the facility, with Registered nurse (RN 2), the following were noted in the 1 East medication cart (EMC). Five plastic containers of Polyethylene Glycol 3350 Powder for Solution (a laxative used to prevent constipation) had the respective room numbers written/labeled on the caps but were missing the open dates. One of the plastic bottles of Polyethylene Glycol 3350 Powder for Solution belonging to a discharged resident . RN 2 inspected the 5 plastic bottles of Polyethylene Glycol 3350 Powder for Solution and stated, The open dates were not labeled, and the bottle of the discharged resident should have been removed from the medication cart. During another concurrent observation and interview, on 12/3/24, at 10 a.m., at the first-floor nursing station medication room, with LVN 2, the following were noted. Three used insulin pens (a medication/hormone that lowers the level of glucose in the blood of diabetics) belonging to one discharged resident were in the medication refrigerator. The three insulin pens were NovoLOG Flex Pen 100 UNIT/1ML insulin pen, Insulin Glargine (LANTUS) 100 units/1 ml., and insulin aspart (NovoLOG) 100 units/1 ml. All three insulin pens were used but missing open dates. LVN 2 indicated the three insulin pens were for a resident who was transferred out/discharged to the hospital , and as to why it were still in the medication refrigerator at the nursing medication room , LN 2 had no response /explanation . During a review of the facility's policy and procedure titled, General Dose Preparation and Medication Administration, dated 12/1/07 and revised 4/30/24, indicated in part, 2.10 Facility staff should enter the date opened on the label of medications with shortened expiration dates (e.g., insulin, irrigation solutions, etc.). 2.10.1 Facility staff may enter the expiration date based on date opened on the label of medications with shortened expiration dates. No policy and procedure for medications brought from home or hospital or on discontinued medications was presented upon request .

Based on observation, interview, and record review, the facility failed to ensure proper handwashing was observed in between vital signs taking and medication pass by one of one nurse (RN 2). This failure had the potential to result in cross contamination and spread of infections to residents , compromising their wellbeing. Findings: During an observation on 12/3/24, at 9:18 a.m., with RN 2, in Unit 1 East, RN 2 was observed using a hand sanitizer on the wall, sanitized his hands and donned surgical gloves, before knocking and entering room [ROOM NUMBER]A with the vital sign machine on wheels. RN 2 failed to sanitize the vital signs machine which was observed previously used on another resident. RN 2 then proceeded to take the resident's vital signs. Subsequently, RN 2 completed the task of obtaining the residents vital signs and proceeded to wheel the vital signs machine out of the room. RN 2 once again, failed to sanitize the vital signs machine after use. RN 2 doffed and disposed of the surgical gloves, failed to hand sanitize and proceeded to prepare the residents medications. RN 2 took the prepared medications, re-entered room [ROOM NUMBER]A without hand sanitizing to administer the prepared medications. RN 2 exited the room and failed to hand sanitize before touching medication cart and proceeding to the next resident. During an observation on 12/3/24, at 9:45 a.m., RN 2 failed to observe hand hygiene etiquette before entering room [ROOM NUMBER]A to administer medications and after exiting room [ROOM NUMBER]A. The CDC (Centers for Disease Control and Prevention) article titled Clinical Safety: Hand Hygiene for Healthcare Workers, dated 2/27/24, indicated, CDC provides the following recommendations for hand hygiene in healthcare settings. 1) Immediately before touching a patient. 2) After touching a patient or patient's surroundings. 3) Immediately after glove removal. During a review of the facility's policy and procedure titled, Hand Hygiene, dated 2/27/17 and revised on 10/30/23, indicated in part, C. Decontaminate hands: 1. Before direct contact with residents .3. After contact with a residents intact skin. During a review of the facility's policy and procedure titled, General Dose Preparation and Medication Administration, dated 12/1/07 and revised 4/30/24, indicated in part, 1.1 Appropriate hand hygiene should be performed before and after direct resident contact.

Based on observation, record review, and interview, the facility failed to ensure one of four sampled residents (Resident 15) development of a foot drop was monitored and assessed for appropriate intervention to prevent further decline in range of motion. This failure resulted in reduced mobility of the foot with potential for contractures ( hardening and stiffening of muscle /bones). Findings: During an observation on 12/3/24, at 2:26 p.m., in room [ROOM NUMBER], Resident 15 was observed on bed, in a supine position (facing upwards) with feet on a pillow. The toes of both feet were noted to be flexed or extending, pointing towards the foot of the bed (outward) instead of upward (towards the ceiling). During a review of Resident 15's Physical Therapy Evaluation & Plan & Treatment, dated 2/11/22, under Musculoskeletal System Assessment, the AROM (Active Range of Motion) - (R) Ankle Dorsiflexion (upward or backward bending of a body part, often referring to a hand or foot) = WNL (Within Normal Limits); Plantar (sole of the foot/feet) Flexion (bending) = WNL. The AROM - (L) Ankle Dorsiflexion = WNL; Plantar Flexion = WNL. The Physical Therapy evaluation indicated Resident 15 had no extension or flexed feet on 2/11/22. ( admission /initial assessment). During a review of Resident 15's Annual MDS (Minimum Data Set [process that provides a comprehensive assessment of resident's functional capabilities and helps nursing home staff identify health problems]), dated 4/10/24, indicated Resident 15 did not receive any kind of therapies from the Rehabilitation Department (OT (Occupational Therapy)/PT (Physical Therapy)/ST (Speech Therapy). During a review of Resident 15's Quarterly MDS, dated [DATE], Section GG indicated Resident is dependent on staff for mobility while Section O indicated Resident 15 did not receive any kind of therapies from the Rehabilitation Department (OT/PT/ST). During an interview with the assistant director of nursing (ADON), on 12/3/24, at 2:59 p.m., in the ADON's office, regarding the observed foot drop of Resident 15, the ADON reviewed the electronic rehabilitation records dated 2/11/22 and concurred the noted footdrop was new. The ADON indicated, the footdrop cause might be attributed to how the resident was positioned. The ADON added , I will call the doctor to get an order to have rehab evaluate the resident. During an interview with the Director of Rehabilitation (ReD), on 12/5/24, at 10:18 a.m., in the rehab room, the ReD concurred with the finding regarding Resident 15's footdrop, and that it should be reported to rehab for assessment and timely intervention.

F656 Develop/Implement Comprehensive Care Plan S483.21(b) Comprehensive Care Plans S483.21(b)(1) Based on interview and record review, the facility failed to ensure Resident 1 ' s burn wound care plan included wound measurements and documentation requirements to monitor wound progression towards healing. This failure resulted in resident ' s burn wounds not being measured and documentation performed as required. Finding: During a concurrent review of Resident 1 ' s medical record and interview with the Director of Nursing (DON) on 10/15/24 at 2:00 p.m., the DON reported that on 10/5/24 a License Vocational Nurse (LVN) poured coffee into Resident 1 ' s mug. Resident 1 started sipping the coffee and then accidentally dropped the mug on his lap. Resident 1 sustained a third degree burn on both thighs. The DON reported weekly measurements and documentation of the wounds were performed. The burn wounds were only measured and documented on 10/6/24. The DON confirmed the record does not contain any other measurements and documentation of the resident ' s burn wounds. During a concurrent review of Resident 1 ' s burn wounds care plan and interview with the Assistant Director of Nursing (ADON) on 10/15/24 at 3:35 p.m., the care plan was asked where it indicates when the wounds need to be measured and/or documented weekly. The ADON reviewed the care plan thoroughly and stated I agree, this care plan does not say the wounds need to be measured and documented weekly . A review of the facility policy and procedure titled Documentation of Wounds and Skin Conditions, dated 10/26/23, indicated Resident skin conditions will be accurately assessed, treated, and documented until resolved. 6. Document weekly on the event until resolved.

F658 Services Provided Meet Professional Standards S483.21(b)(3) Comprehensive Care Plans The services provided or arranged by the facility, as outlined by the comprehensive care plan, must- (i) Meet professional standards of quality. Based on interview and record review, the facility failed to implement standards of practice when Resident 1 ' s burn wounds were not assessed and documented according to standards of practice and its policy. This failure resulted in resident ' s burn wounds only being assessed and documented only one time. Findings: According to the national institute of health NIH (2023) at https://www.nih.gov. The frequency of burn wound assessments depends on the stage of healing and the patient's needs. Initial assessment: Patients with burns should be seen the day after the injury to assess pain, adjust medication, and check dressing changes. Subsequent assessments: Patients are typically seen weekly until the wound heals. However, if there are concerns about pain control or wound care, the patient may need to be seen daily. A review of the facility policy and procedure titled Documentation of Wounds and Skin Conditions, dated 10/26/23, indicated Resident skin conditions will be accurately assessed, treated, and documented until resolved. 5. Open a Skin Integrity observation as indicated in the electronic health record EHR for each affected area that is expected to take 14 days or longer to resolve. Note: indicate the affected area in the short description. b. Skin integrity- non pressure ulcer for non-pressure skin problems. 6. Document weekly on the event until resolved. During a concurrent review of Resident 1 ' s medical record and interview with the Director of Nursing (DON) on 10/15/24 at 2:00 p.m., the DON reported that on 10/5/24 resident sustained a third degree burn on both thighs. The burn wounds were assessed and documented on 10/6/24. The DON confirmed the record does not contain any other documentation of the resident ' s burn wounds. The DON was asked how the facility assesses, monitors, and documents the progression of the burn wounds. The DON reported weekly documentation of the wounds are performed. The DON further explained their computer software system has an observation template to document and describe a wound initially, then, weekly thereafter or until wound is resolved. A copy of a blank Skin Integrity observation template was provided. Then, DON was asked if there was a completed observation documentation for Resident 1 ' s wounds. DON replied No, this resident does not have one (Skin Integrity observation documentation). No, we did not initiate the weekly observation for this resident and yes, we should have done it. The DON acknowledged Resident 1 ' s wounds will take longer than 14 days to resolve therefore they should have opened and document under the Skin Integrity observation/template documentation.

Based on observation, interview, and record review, the facility failed to ensure sanitary conditions were maintained in the food and nutrition services when: 1. The high temperature dish machine was not reaching proper wash, rinse and final rinse temperatures in order to effectively sanitize in accordance with the manufacturer's guidelines. 2. The three compartment sink used to wash pots and pans was not implemented in an effective manner to properly wash and sanitize the foodservice equipment. 3. The tube to dispense sanitizer was located in the hand washing sink. These failures had the potential to result in cross contamination and food borne illness in a highly susceptible resident population in which the majority of residents were on oral diets. Cross Reference F801 Findings: 1. During a concurrent observation and interview on 3/14/24 at 11:16 a.m. with dish washer (DW) 1 in the main kitchen, DW 1 was observed running breakfast dishes through the high temperature dish machine. DW 1 observed the wash temperature gauge affixed externally to the dish machine and DW 1 stated the wash water reached 110 degrees F (Fahrenheit), the rinse temperature gauge reached 130 degrees F, and the final rinse temperature gauge reached 158 degrees F. DW 1 was observed to continue to use the high temperature dish machine to wash the resident's dishes from the morning breakfast. During a concurrent observation and interview on 3/14/24 at 11:21 a.m., upon surveyor request, the Sous Chef (SC) observed the high temperature dish machine while in use. SC stated the final rinse temperature needed to reach 180 degrees F in order to have sanitized the dishes. SC observed the final rinse temperature was not reaching 180 degrees F. SC went to the side of the high temperature dish machine and stated the switch (located under a label titled Heater) was not turned on, the dish machine was off as indicated by a red light was not showing per SC. SC verified kitchen staff were almost done washing the dishes. During a concurrent interview and record review on 3/14/24 at 11:30 a.m. with SC,the facility's High Temp Dish Machine monitoring log that was completed for the AM Reading was reviewed. The AM Reading column, dated 3/14/24 indicated Sanitizer - 180 degrees F, Rinse - 154 degrees F, and Wash - 164 degrees F, with DW 1 initial's next to the logged data. SC was unable to explain how the temperatures were recorded as such when SC said the dish machine was found to be off. The directions located on the High Temp Dish Machine indicated, Sanitizer Temp > 180F, Rinse Temp > 160 F, Wash Temp > 150F. SC stated that he had a supervisory role over the dish machine area. SC stated DW 1 had not reported any problems to him related to the high temperature dish machine. During a concurrent observation and interview on 3/14/24 at 11:35 a.m., SC had DW 1 run another load of dishes through the high temperature dish machine, and SC stated the wash water temperature continued to show 110 degrees F, and the final rinse temperature was 200 degrees F. During a concurrent observation and interview on 3/14/24 at 11:49 a.m., SC ran another load of dishes through the high temperature dish machine and stated the wash water reached 110 degrees F, and the rinse water temperature gauge reached 150 degrees F, and the final rinse temperature was greater than 180 degrees F. SC stated the high temperature dish machine manufacturer's guidelines were not being met for the wash and rinse cycles. During a concurrent observation and interview on 3/14/24 at 1:06 p.m. with Director of Dining Services (DDS) and the Registered Dietitian (RD), DDS stated SC informed him the high temperature dish machine was not meeting manufacturer's guidelines after surveyor identified the problem and he (DDS) then contacted an outside service to assess the high temperature dish machine. At that time, the outside service was observed in the main kitchen working on the high temperature dish machine. DDS stated the outside service informed him the dish machine was not meeting temperatures in accordance with manufacturer directions and a heating element needed to be replaced. During a review of the facility's policy and procedure (P&P) titled, High Temp Machine Ware Washing, dated 6/21/21, the P&P indicated, Policy/Purpose: All flatware, serving dishes, and utensils are washed, rinsed, and sanitized after each use. The machine for ware washing will be checked prior to each meal period to ensure that it is functioning properly.Procedure.Temperatures should be at least: Wash - Temp 150 F, Rinse - Temp 160 F, Sanitizer - Temp 180F . During a review of the manufacturer's directions located on a data plate (DP) affixed to the high temperature dish machine, the DP indicated, Final Sanitizing Rinse Minimum Temperature: 180 degrees F, Pumped Rinse Tank Minimum Temperature: 160 degrees F, Wash Tank Minimum Temperature: 150 degrees F . During a review of the FDA (Food & Drug Administration) Food Code Annex (FDAFC), dated 2022, the FDAFC indicated, The data plate provides the operator with the fundamental information needed to ensure that the machine is effectively washing, rinsing, and sanitizing equipment and utensils. The warewashing machine has been tested , and the information on the data plate represents the parameters that ensure effective operation and sanitization and that need to be monitored. (FDA Food Code Annex 3, 4-204.113 Warewashing Machine, Data Plate Operating Specifications.) During a review of the FDAFC, dated 2022, the FDAFC indicated, To ensure properly cleaned and sanitized equipment and utensils, warewashing machines must be operated properly. The manufacturer affixes a data plate to the machine providing vital, detailed instructions about the proper operation of the machine including wash, rinse, and sanitizing cycle times and temperatures which must be achieved. (FDA Food Code Annex 3, 4-501.15 Warewashing Machines) 2. During an observation on 3/14/24 at 11:22 a.m. in main kitchen, a dish washer (DW) 2 was washing pots, pans, and large food storage containers at the 3 (three)-compartment sink, in which first compartment contained wash water, second compartment contained rinse water, and third compartment contained a sanitizing solution. During an observation on 3/14/24 at 11:29 a.m., in main kitchen, DW 2 removed a large food storage bin and large lid from the second compartment and placed into the third compartment (sanitizer). The large food storage bin and lid were partially immersed into the sanitizing solution, with the other half sticking up above the sanitizing solution. During a concurrent observation and interview on 3/14/24 at 11:47 a.m. with Sous Chef (SC) at the 3-compartment sink in the main kitchen, DW 2 was observed removing the large food storage bin and lid from the 3-compartment sink and placed on a rack to air dry. SC stated, It was not okay. SC verified the foodservice equipment was not completely sanitized as half of the equipment was not immersed into the sanitizer solution. SC verified once the foodservice equipment was placed on the rack to air dry the equipment would be available for use. During a review of the manufacturer's guidelines (MGs) located on the bottle of sanitizer that facility used in the third compartment of the 3-compartment sink, the MG's indicated, To sanitize food processing equipment, utensils, and other food contact articles. in a three compartment sink: 4. Sanitize by immersing articles with a use-solution.200-400 PPM.for at least 60 seconds. Articles too large for immersing must be visibly wetted by rinsing, spraying, or swabbing. During a concurrent observation and interview on 3/14/24 at 11:54 a.m., with SC, SC observed DW 2 place another load of foodservice equipment into the wash water compartment at the 3-compartment sink. SC checked the wash water temperature, located in the first compartment, utilizing a digital thermometer and SC stated, It's 100 degrees F. DW 2 checked the concentration of the sanitizer, located in the third compartment, with a sanitizer concentration testing strip, and DW 2 stated, It's 100 [PPM -parts per million]). It's been in use a while. Should be changed. SC and DW 2 stated the sanitizer concentration should be at 200 PPM in order to effectively sanitize. DW 2 stated the sanitizing solution located in the third compartment that tested at 100 PPM had been there since 6 a.m. During a concurrent interview and record review on 3/14/24 at 11:58 a.m. with SC, a log located near the 3-compartment sink titled Three Compartment Daily Sanitizer Log (3CSL) was reviewed. The 3CSL indicated, Chemical reading should be between 150-350 ppm. SC stated the facility had not required staff to check the wash water temperature at the 3-compartment sink to ensure it was an appropriate temperature while in use. During a review of the facility's policy and procedure (P&P) titled, 3 Comp Sink P&P, dated 7/23/2021, the P&P indicated, Follow the 5 steps for appropriate use of the 3 compartment sink, to ensure that all items are washed and sanitized appropriately. This will ensure the safety for all people dining on our food. Procedure: While there are only three sinks, there are five essential steps you need to complete when using your three compartment sink.2) Clean items in the first sink. Wash them in detergent solution at least 110 degrees F. replace the water when the suds are gone or the water is dirty.4) Sanitize them in the third sink. Soak in sanitizer solution. Soak time and temperature should be based on manufacturer's recommendation, with a minimum soak time of 60 seconds. The chemical levels must be checked with the test strip, every time the water is changed and solution is added. Currently our chemical levels should read between 200-400 ppm.5) Air dry all items. Place items upside down so they will drain. 3. During a concurrent observation and interview on 3/29/24 at 11:05 a.m. with lead diet aide (LDA) in the trayline kitchen (staff refer to that kitchen as trayline kitchen and/or medical [skilled nursing facility] kitchen), a long tube was curled up and laying on the sink bed of a designated hand washing sink. LDA stated the tube was used to dispense sanitizer solution and should not have been located in the hand washing sink. LDA pointed to the food production sink and stated the tube should be over in that area as it was used to dispense sanitizer for food contact surfaces. During a concurrent observation and interview on 3/29/24 at 11:38 a.m. with Executive Chef (EC) in the medical/trayline kitchen, EC observed the outlet portion of the long tube that was used to dispense sanitizer solution was located in the hand washing sink. EC verified the tube should not be in the hand washing sink as it was an infection control concern. During a review of the facility's policy and procedure (P&P) titled, Hand Washing, undated, the P&P indicated, Procedure: Use only hand sinks designated for that purpose. Do not wash hands in sinks in the production area. Dry hands with single use towels or a mechanical hot dryer.Turn off faucets using a paper towel in order to prevent recontamination of clean hands.

Based on observation, record review and interview, the facility failed to provide adequate supervision and assistance for one of two sampled residents (Resident 1) to prevent avoidable accident and injury. Resident 1, assessed by the facility as severely impaired cognition (mental process) requiring two or more-person assistance during transfers, was left alone and unsupervised in front of the beauty parlor with no staff nearby. A tab alarm (an alarming device that alerts the facility staff when the resident attempts to get up from the wheelchair unassisted) was not attached as ordered by the physician and as required in her plan of care. Resident 1 got up from her wheelchair and fell to the floor. As a result of this failure, Resident 1 fell on the floor and sustained left metacarpal (hand bone) fractures (break of bones), scraped her forehead and suffered pain. Findings: During an observation and concurrent interview of Resident 1, inside her room, on 5/14/19 at 11:30 a.m., Resident 1 was observed with a left hand splint wrapped with a dressing. Resident 1's interview was limited due to the resident's cognitive impairment. Resident 1 was awake and alert to name only. Resident was not able to follow simple commands, and her speech was minimal. During an observation of the second floor on 5/14/19 at 11:30 a.m., where Resident 1's room was located on the West side of the floor. The nursing station (where staff congregates) was located on the middle of the floor. The floor was divided into the West and the East side for residents care assignments. The beauty parlor was located on the East side of the floor, at the very end of the floor, no other rooms were nearby to the east side of the beauty parlor. No other residents' rooms were located in-front of the beauty parlor, only the exit stairwell. There was a long and far distance between the nursing station and the beauty parlor. When Resident 1 was left alone and unsupervised, in front of the beauty parlor (at the end of the floor), it would have been hard to hear from the nursing station when Resident 1 was calling for assistance. Review of Resident 1's face sheet indicated, [DIAGNOSES REDACTED]. Review of Resident 1's minimum data set (MDS - comprehensive resident assessment) assessment dated [DATE] indicated, Resident 1's BIMS score was 06. BIMS stands for Brief Interview for Mental Status. The BIMS test is used to get a quick snapshot of how well you are functioning cognitively. BIMS scores 13 to 15 means: intact cognition. 8 to 12 means: moderately impaired cognition. 0-7 means: severely impaired cognition. Resident 1 required extensive assistance with two persons with bed mobility and transfers. Resident 1 had reduced strength to legs, and was not able to ambulate independently. Resident 1 needed extensive assistance with two or more-person assistance during transfers from bed, chair, wheelchair, and standing position. Review of Resident 1's Fall Risk assessment dated [DATE] indicated, Resident 1 was at risk for falls related to several factors including: a. intermittent confusion, poor recall, judgment, safety awareness, b. balance problem while standing and walking requires use of assistive device- e.g. cane, walker, wheelchair c. impaired mobility, d. decline in cognitive skills, other dementia, e. history of falls f. decline in functional status g. joint pain due to [MEDICAL CONDITION], and f. use of narcotics for pain. Review of Resident 1's Falls Care Plan Report, dated 8/27/16, indicated risk of falling with several reasons including history of impulsivity and poor safety awareness. The planned interventions included the use of a Tab alarm while resident was on the wheelchair for safety. Review of Physician order [REDACTED]. Review of the Tab Alarm Instructions Manual provided by facility on 5/15/19, in the PATIENT SET-UP & USE part indicated to follow these procedures before each use: 1. Securely mount the pull string monitor to a wheelchair using the clip on the back of the monitor 2. Attach the garment clip to the patient's clothing near the back of their neck between their shoulders. 3. Adjust the string length (using the adjuster) based upon the amount of movement you wish the patient to have prior to setting off the alarm. 4. Test monitor and check battery before each use . 5. When magnet is detached from the monitor the alarm will sound. To silence alarm, replace magnet on metal disc on front of monitor. Review of Post Fall Observation Detailed Report, dated 5/1/19 at 2:56 p.m., created by licensed nurse (LN 1) caring for Resident 1, indicated, on 5/1/19 at 1:55 p.m., Resident 1 fell in the hallway while in a wheelchair, complained of pain 7/10 (pain scale on 1 to 10, zero represents no pain at all while 10 represents the worst imaginable pain) and the tab alarm was not in use at the time of the resident's fall. Review of Resident Progress Notes, dated 5/1/19 at 4:13 p.m., indicated Resident is post fall observation, unwitnessed .Resident left wrist is painful, and forehead scrapped. Administered [MEDICATION NAME] (narcotic pain medication for moderate to severe pain). A review of Radiology Patient Report, dated 5/3/19, indicated Resident 1 sustained 3rd thru 5th metacarpal (hand bone) fractures (breaks) on her left hand, as a result of the fall on 5/1/19. During an interview with certified nursing assistant (CNA 1) on 5/14/19 at 11:48 a.m., CNA 1 was the first person who responded to Resident 1's fall incident on 5/1/19. According to CNA 1, resident was found on the floor laying on her left side with her arm underneath. Resident was alone waiting outside the beauty parlor for her appointment. CNA 1 stated She (Resident1) can be impulsive and impatient at times. She (Resident1) probably got impatient waiting outside the beauty parlor, got up by herself and fell . She (Resident 1) is forgetful, most of the time. CNA 1 confirmed, No, there was no alarm sounding . During an interview with assistant director of nursing (ADON) on 5/14/19 at 11:56 a.m., ADON responded to Resident 1's fall incident on 5/1/19. ADON stated I hear (Beautician's name) yelling for help, (Resident's name) was on the floor with her head towards the wall. She (Resident 1) was moaning. With her cognitive impairment, she (Resident 1) thinks she can stand up. But, she can't. She (Resident 1) is impulsive. She (Resident 1) doesn't remember. ADON was asked, if the tab alarm was sounding, when she arrived at the scene. ADON reply I don't recall any alarm sounding. During an interview with security officer (SO) on 5/14/19 at 12:02 p.m. SO responded to Resident 1's fall incident on 5/1/19. According to SO, he received a radio call on the date resident fell . SO came to the hall outside the beauty parlor, saw resident (Resident 1) laying on her left side on the floor. SO was asked, if the tab alarm was sounding, when he arrived at the scene. SO indicated there was no alarm ringing when he arrived at the scene. During an interview with the director of nursing (DON) and concurrent review of Resident 1's clinical record on 5/14/19 at 12:30 p.m., the DON stated I don't think the tab alarm was on the resident (Resident 1) when she fell . During an interview with licensed nurse (LN 2) on 5/14/19 at 1:15 p.m. LN 2 responded to Resident 1's fall incident on 5/1/19. LN 2 stated I was told someone had fallen in the hall. It was (Resident's name). When I arrived, she (Resident 1) was laying on the floor, on her left side. She (Resident 1) was moaning. She (Resident 1) tries to get up by herself, all the time. She (Resident 1) forgets a lot that she can't. She (Resident 1) has fallen before. LN 2 was asked, if the tab alarm was sounding, when she arrived at the scene. LN 2 reply I did not hear any alarm sounding at all. During an interview with licensed nurse (LN 1) on 5/14/19 at 1:30 p.m., LN 1 was caring for Resident 1, on 5/1/19, the date of the fall. LN 1 stated I was with another resident when someone call me to let me know (Resident's name) had fallen while waiting alone at the beauty parlor. When I arrived, she (Resident 1) was laying on her left side with her arm twisted back. We got her back to her wheel chair. She (Resident 1) had pain on the left hand & wrist. LN 1 was asked, if the tab alarm was sounding, when she arrived at the scene. LN 1 reply The tab alarm was not sounding at all. The (tab) alarm was not on (attached to) her clothes. The (tab) alarm was connected to the chair. Not on (Resident's name) clothes. LN 1 was asked what she thought cause Resident 1's fall. LN 1 stated I think improper use of devices. LN 1 was asked to expound on that. LN 1 reply There was no tab alarm on (attached to) resident and no foot rest on her wheelchair. She (Resident 1) tried to get up by herself and fell . During a second interview with the director of nursing (DON) and concurrent review of Resident 1's clinical record on 5/14/19 at 3:58 p.m., DON stated I think the tab alarm was not on (attached to the resident), that's why no one heard it. When I interviewed staff regarding the fall incident. I spoke with everyone, no one said anything about the alarm (sounding) because the (tab) alarm was not on (attached to) the resident. This was one of the contributing factors to the fall. Surveyor said Are you saying the tab alarm was not on (attached to) the resident's clothes when she fell down while waiting alone outside of the beauty parlor. DON reply Yes, the tab alarm was not on the resident when she fell . I'm being honest with you. On 5/14/19 at 4:05 p.m. the facility's administrator (Admin) was present during DON's second interview. Admin stated . Yes, we know the alarm was not on the resident when she fell . During an interview with Certified Nursing Assistant (CNA 2) on 5/10/19 at 9:01 a.m., CNA 2 was caring for Resident 1, on the date of the fall, 5/1/19. According to CNA 2, Resident 1 was in the dining room for lunch from about 12:15 p.m., to 1:30 p.m. CNA 2 stated After 1:30 p.m. I took her (Resident 1) from the dining room to the bathroom. She (Resident 1) is a two person assist for transfers. I asked another CNA (CNA 3) to help me. She (Resident 1) used the toilet. We sat her in her wheel chair. At that time, another resident needed me, so another CNA (CNA 3) took her (Resident 1) to the beauty parlor. CNA 2 was asked, if she applied/attached the tab alarm on Resident 1's clothing when she (Resident 1) was sitting on her wheelchair. CNA 2 reply I didn't put (attached) the tab alarm on her (Resident 1) while she was sitting on her wheelchair, in the bathroom. During an interview with Certified Nursing Assistant (CNA 3) on 5/24/19 at 9:27 a.m., CNA 3 was the CNA who wheeled Resident 1 to the beauty parlor on 5/1/19. CNA 3 stated Yes, I wheeled her (Resident 1) to the beauty parlor. (CNA 2's name) told me she (Resident1) needed to go to the beauty parlor and since the beauty parlor is located in the East side where I was working. I said I could take her (Resident 1) on my way back to my work area. CNA 3 was asked, if he attached the tab alarm to Resident 1's clothes. CNA 3 reply I didn't know she (Resident 1) needed the tab alarm, so No, I didn't put (attached) on the tab alarm on her (Resident 1). CNA 3 confirmed leaving Resident 1 alone, unsupervised, and without the tab alarm attached to her clothing in front of the beauty parlor on 5/1/19.

Based on observation, interview and record review, the facility failed to provide adequate supervision for two of five sampled residents (Residents 1 and 2) and failed to ensure an assistance device was working properly for Resident 1. Resident 1 was known to propel himself throughout the first floor of the facility and wore a monitoring device that failed to activate alarms when he exited the facility. Resident 1 fell and sustained a fracture. Resident 2 fell after being left unattended despite a physician's orders [REDACTED]. Findings: 1. Record review on 9/7/11 revealed Resident 1 was admitted with [DIAGNOSES REDACTED]. Review of the " Social Services Quarterly Notes" dated 11/4/10 revealed Resident 1's cognition had declined since admission, including orientation and level of confusion. On 12/13/10, social services recommended that Resident 1's private companion hours double due to "increasing disorientation and care needs." The comprehensive assessment dated [DATE], revealed both short-term and long-term memory loss with severely impaired cognitive skills for daily decision-making. The assessment indicated Resident 1 required extensive assistance with most activities of daily living and primarily utilized a wheelchair for mobility. This was reinforced in an interview with the Director of Nursing (DON) on 9/7/11, at 11:50 a.m., "(Resident 1) would do his laps," repeatedly propelling himself in his wheelchair around the first floor "all day long." Review of a facility report dated 3/10/11, revealed on 3/9/11 at 5:45 p.m. Resident 1 was found on the ground next to his wheelchair outside the (west) side entrance of the facility. This report also noted a monitoring device as "pre incident precautions." The investigative report, dated 3/10/11, indicated Resident 1 sustained a left shoulder fracture after having exited the building and falling from the wheelchair. At the time of the incident, Resident 1 was wearing an monitoring device that did not alarm as intended when Resident 1 attempted to exit the facility. Review of the "Emergency Department Physician Report" dated 3/9/11 indicated Resident 1, as a result of the fall, sustained an upper arm/shoulder fracture. Review of the facility follow up report submitted by the director of security, dated 3/10/11, to Resident 1's fall incident revealed Resident 1's monitoring device did not activate when Resident 1 exited the facility. The report indicated, when a monitoring device was held "at knee level as if attached to a walker or wheelchair," the alarm did not activate. "We subsequently tested all doors in the medical center and found that if it (monitoring device) is at a lower level... the system does not always activate." Resident 1's monitoring device was located below knee level and attached to the wheelchair. During an interview on 9/7/11 at 9:10 a.m., the associate director of plant operations explained the monitoring device was a "Simplex" security system. During an interview on 9/14/11 at 2 p.m., the DON denied Resident 1 wandered or was "an eloper," " he just moved a lot and made his rounds", stating the monitoring device was on at the time of his fall as a "precaution only." During an interview on 9/14/11 at 2:30 p.m., a certified nurse assistant (CNA 1) explained Resident 1 liked to go outside but it was necessary for staff to accompany the resident. When Resident 1 would attempt to exit the facility alone, the alarm from his monitoring device would sound. CNA 1 stated Resident 1 did not like to wear his monitoring device. The CNA demonstrated that the monitoring device was therefore secured to the wheelchair where the wheel axle met the chair's central frame, slightly under the seat. During an interview on 11/2/11 at 10:10 a.m., the associate director of plant operations revealed there were no routine system or transmitter checks for the "Simplex" monitoring system prior to Resident 1's exit from the facility and fall on 3/9/11. On 11/3/11, review of the manufacture's manual titled " Simplex: Enhanced Wandering Patient/Infant Security System - Installation and Programming Instructions," revealed recommendations of weekly system testing with documentation and verification each shift change that all monitored residents are wearing transmitters. 2. Record review on 11/17/11 of Resident 2's nurses notes, dated 9/18/11, and doctor orders, dated 9/30/11, revealed Resident 2 fell while left unsupervised for 15 minutes despite physician orders [REDACTED]. Resident 2 was admitted with [DIAGNOSES REDACTED]. A history and physical dated 3/1/11 described Resident 2 as not having the capacity to understand and make decisions. Review of the comprehensive assessment dated [DATE] indicated Resident 2's recall, memory, and mood fluctuated and Resident 2 required limited assistance from one person for most activities of daily living. The fall risk assessment dated [DATE] revealed Resident 2 was a high risk for falls. Social service notes dated 8/31/11 described Resident 2 as depressed and having enough insight to be aware of his" loss of freedom, privacy and personal options." During an interview on 11/18/11 at 2 p.m., the director of nursing (DON) stated Resident 2 "finds nurses invasive and very irritating. He could express his needs and would give good reasons why he didn't need to wait for assistance." The DON explained Resident 2 would frequently remove alarm sensors and get up without asking for assistance from staff. Review of nurses notes dated 9/18/11 at 6:50 p.m. described an incident where Resident 2 was assisted to the floor by a certified nurse assistant while in the bathroom when Resident 2's legs "weakened." Review of the physician orders [REDACTED]." The order was written subsequent to the physician's first visit after the 9/18/11 fall. During an interview on 11/18/11 at 2 p.m., Resident 2's physician explained the reasoning behind the increased supervision order written on 9/30/11 stating, the resident was weakened and having seizures. "I just wanted to tighten up on things." On 11/18/11, review of nurses notes dated 10/5/11 at 6:45 p.m. (5 days after the physician order [REDACTED]." His nurse requested him to sit in a chair "for a few minutes" then left the room. After 15 minutes, the nurse returned to find Resident 2 "fell while walking to the bathroom by himself while CNA was busy showering another resident." There was no documented injury.

Based on observation, interview and record review, the facility failed to maintain accurate medical records for one of five sampled residents (Resident 2) when a physical therapy assessment was photocopied monthly and dates changed to indicate the assessment occurred on the current month. As a result, Resident 2's clinical record had not been maintained accurately with acceptable standards of practice. Findings: Record review on 11/17/11 revealed Resident 2 was admitted with [DIAGNOSES REDACTED]. Review of Resident 2's physical therapy notes revealed Resident 2 received physical therapy from 4/1/11 through 4/8/11 to improve safety and balance following a fall. Upon completion, Resident 2 was transitioned to the "maintenance program" (restorative nursing assistance) for gait balance training and therapeutic exercises. During an interview and concurrent record review on 11/18/11 at 2:55 p.m., a restorative nursing assistant (RNA 1) revealed restorative nursing assistance provided to Resident 2 was documented on the physical therapy notes. Review of Resident 2's physical therapy notes revealed a monthly calendar starting April 2011 through September 2011, missing October, and documentation of November through 11/8/11 with identified days Resident 2 received restorative nursing assistance. Each month's narrative progress notes, signed by the physical therapist, revealed the progress notes for each month had been photocopied from the month prior and the date changed. The notes included the RNA plan / guideline but also indicated Resident 2 "tolerates tx (treatment) well-needs some assist for gait." During an interview on 11/18/11 at 3 p.m., the director of nursing (DON) and the physical therapist confirmed the physical therapy notes "from months ago" were copied and placed in the record "for use as guidelines" and dated each month for documentation of the restorative nursing program plan and treatment. The DON indicated there had not been any attention paid to the narrative note on the photocopied form that was written by the physical therapist regarding how Resident 2 had tolerated the maintenance program and was not indicative of a current assessment.