Every finding on record at Catalina Island Health

Based on interview and record review, the facility failed to submit complete and verifiable Payroll-Based Journal ([PBJ] a mandatory, auditable data system used by the Centers for Medicare & Medicaid Services {CMS}) staffing data to CMS for quarter 2 of 2026 (1/1/2026, through 3/31/2026).The facility's failure to submit required staffing information had the potential to affect CMS oversight of nursing staffing levels and the facility's ability to demonstrate compliance with federal staffing reporting requirements, which could impact the care and services provided to residents.Findings:During a review of the facility's PBJ staffing data report dated 06/05/2026, the PBJ staffing data report indicated no staffing data had been submitted to CMS for quarter 2 of 2026 (1/1/2026, through 3/31/2026).During an interview on 06/10/2026, at 8:48 a.m., with the Director of Nursing (DON), the DON stated many of the facility's nursing staff were agency/travel personnel. The DON stated the facility needed to integrate traveler staffing information into the payroll system and upload the information to CMS. The DON stated the facility failed to submit the required PBJ data because the payroll interface was not connected to CMS and that no one had informed her that the systems were not linked. The DON acknowledged she was unaware the staffing reports had not been submitted to CMS as required. The DON stated the facility would work with department heads and responsible staff to ensure staffing information was accurately compiled and submitted on a quarterly basis to prevent future delays.During a review of the facility's policy and procedure (P&P) titled Reporting Direct Care Staffing Information (Payroll-Based Journal) dated 06/05/2023, the P&P indicated Direct care staffing information Is reported electronically to Centers for Medicare & Medicaid Services (CMS) through the payroll- based journal system (PBJ). Staffing information is collected daily and reported for each fiscal quarter no later than 45 days after the end of the reporting quarter.

Based on observation, interview, and record review, the facility failed to store food in a safe and sanitary manner. The facility had four residents receiving an oral diet. The facility failed to:1.Ensure open bags of frozen french fries and frozen ravioli were labeled with open dates.2.Ensure open containers of hot sauce, ground white pepper, dash original seasoning, chili powder, cayenne pepper, corn tortillas, white bread, dry pasta, cheese and garlic croutons, vanilla wafers, and shortbread cookies were labeled with open dates.3.Ensure an open container of liquid whole eggs and a clear plastic tub of peaches stored in the refrigerator were labeled with open dates.These failures had the potential to place residents at risk for developing foodborne illnesses (illnesses resulting from eating contaminated or spoiled foods) and could reduce the quality of food served in the facility.Findings:During a concurrent initial kitchen observation and interview on 6/09/2026 at 9:10 a.m. with the Dietary Supervisor (DS), multiple open food items in the dry storage area, refrigerator, and freezer were observed without open dates. The DS stated he had planned to work with his staff and implement a new system to ensure open dates were placed on food containers once they were opened.During an interview on 6/10/2026 at 10:05 a.m. with Dietary Aide (DA) 1, DA 1 stated any time a food item was opened, an open date needed to be placed on the container to help ensure the food remained fresh when served to residents. DA 1 stated residents' could develop a foodborne illness if they were served spoiled food.During an interview on 6/10/2026 at 10:19 a.m. with the Dietary Supervisor (DS), DS stated any time a food item was opened, it had to be labeled with an open date to ensure the food remained safe to serve. He stated the open date functioned as the quality date for the item. The DS stated improper storage of food items could decrease the flavor and quality of the food. He stated residents with compromised immune systems (weakened defense to infection) could develop a foodborne illness if they were served food that was not fresh.During an interview on 6/11/2026 at 7:21 a.m. with the Director of Nursing (DON), the DON stated open dates were placed on food items to ensure the food was served fresh. The DON stated there was a potential for foodborne illness if a food item did not have an open date after it was opened.During a review of facility's policy and procedure(P&P) titled, Food labeling & Dating of Kitchen Items, the P&P indicated This policy establishes requirements for labeling and dating of all food items stored, prepared or used within the dietary department to ensure food safety, prevent food borne illness, reduce waste, and maintain compliance with federal, state and accreditation standards. The P&P indicated all food items stored or prepared in the kitchen, including refrigerated, frozen and dry storage items, must be properly labeled and dated at the time of preparation, opening or storage.

Based on interviews and record review, the facility's Quality Assessment and Assurance (QAA-ongoing, facility-wide management process used to monitor clinical and administrative services, to ensure resident care meets established standards) Committee failed to provide effective oversight and monitoring to ensure sustained compliance with the facility's Plan of Correction (POC) for deficiencies cited during the previous recertification survey. Specifically, the QAA Committee failed to identify, monitor, and implement corrective actions to prevent the recurrence of deficiencies related to Payroll-Based Journal (PBJ- a mandatory, auditable data system used by the Centers for Medicare & Medicaid Services [CMS]) reporting, nurse aide performance reviews, and food labeling and storage practices.This deficient practice resulted in repeat deficiencies in the same areas during the current recertification survey.Findings:During a review of the facility's Statement of Deficiencies from the 2025 recertification survey revealed citations related to PBJ reporting, nurse aide performance reviews, and food labeling and storage practices.During a concurrent interview and record review on 06/11/ 2026, at 8:51 a.m., with the Director of Nursing (DON), the DON stated the facility had received deficiencies in PBJ reporting, nurse aide performance reviews, and food labeling and storage during the previous recertification survey in 2025. The DON stated she was not employed at the facility during the prior survey but acknowledged the deficiencies had recurred. The DON stated the facility would continue efforts to address these issues and prevent repeat deficiencies in the future.During a review of the facility's policy and procedure (P&P) titled Quality Assurance and Performance improvement (QAPI) revised 03/2020, the P&P indicated The QAPI is implemented and maintained to address identified priorities, and is based on data, resident and staff input and other information that measures performance and focuses on problems and opportunities that reflect processes, functions and services provided to the residents.

Based on interviews and record review, the facility failed to ensure Certified Nurse Assistants (CNAs) completed a minimum of 12 hours of annual in-service education for CNA 1, CNA 2, and CNA 3.This failure to provide the required annual in-service training has the potential to affect the CNAs' knowledge, skills, and competence in providing safe and effective care to residents.Findings:During a review of employee training records conducted on 06/10/2026 at 11:28 a.m., with the Director of Human Resources (DHR) and License Vocational Nurse (LVN 1), the records indicated CNA 1, CNA 2, and CNA 3 had not completed the required 12 hours of annual in-service training for the review period.During a concurrent interview and record review on 06/10/2026 at 1:12 p.m., with the Director of Nursing (DON) reviewed the training records for CNA 1, CNA 2, and CNA 3. The DON stated CNA 1, CNA 2, and CNA 3 had not completed the required 12 hours of annual in service education. The DON stated annual in service training was required to ensure staff maintained competency and provided safe, quality care to residents. She acknowledged the facility failed to ensure compliance with the annual training requirement. She stated although she assisted with CNA in services, most of her in service responsibilities focused on licensed nursing staff. The DON stated the missed training was due to staffing changes but reported she would work to ensure all required in service hours were completed.

Based on observation, interview, and record review, the facility failed to ensure medications and biologicals (group of medications) were properly labeled and stored in the medication storage rooms. The facility failed to:1.Ensure three open packages of house supply albuterol sulfate inhalation solution (breathing treatment), not assigned to a specific resident, were labeled with an open date while stored in a cupboard.2.Ensure the medication room refrigerator functioned properly, as ice buildup was observed on the back wall of the refrigerator and multiple boxes of insulin (used to control blood sugar) and tetanus vaccines (used to protect against bacterial infections) were stored in a pool of standing water inside the refrigerator.These failures had the potential to result in decreased medication potency, ineffective treatment, and adverse health outcomes for residents who rely on properly stored medications and biologicals.Findings:During an observation on 6/09/2026 at 3:23 p.m. in the medication storage room, observed three open packages of albuterol sulfate inhalation solution did not have open dates on the packaging.During an observation on 6/09/2026 at 3:23 p.m. in the medication storage room, the medication refrigerator was observed with melting ice buildup on the back wall, and multiple boxes of insulin and tetanus vaccines were stored in a pool of standing water inside the refrigerator.During an interview on 6/09/2026 at 3:28 p.m. with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated the three packages of albuterol sulfate solution did not have open dates and confirmed they should have been labeled with open dates. LVN 1 stated she was not sure what was wrong with the refrigerator. She stated there should not be ice buildup or standing water inside the refrigerator.During an interview on 6/10/2026 at 9:30 a.m. with LVN 1, LVN 1 she stated albuterol sulfate needed an open date because the medication could deteriorate, lose its potency, and become ineffective. LVN 1 stated the issue with the medication refrigerator was related to the coils and the temperature had not been properly regulated. She stated the temperature must be regulated to maintain the integrity of the medications. LVN 1 stated residents could experience adverse reactions due to the possibility of bacteria growing in improperly stored medications.During an interview on 6/11/2026 at 7:41 a.m. with the Director of Nursing (DON), the DON stated open dates were required to ensure medications were not used past a specific date, as medications could lose their potency and may not be as effective. The DON stated the refrigerator needed to be functioning properly to maintain the stability of the medications and to prevent any adverse reactions for the residents.During a review of facility's policy and procedure (P&P) titled, Medication labeling and Storage, (undated), the P&P indicated, The facility stores all medications and biologicals in locked compartments under proper temperature humidity and light controls. The P&P indicated medication, and biologicals are stored in the packaging, container or other dispensing systems in which they are received. The P&P indicated medications in bulk containers contains labels withv medication name, strength, quality, accessory instructions, lot number and expiration date.During a review of facility's policy and procedure (P&P) titled, Medication refrigeration Equipment Failure and Medication Protection, (undated), the P&P indicated, Medications shall be stored within the manufacturer- recommended temperature ranges at all times. The P&P indicated any refrigerator or freezer malfunction, temperature excursion, water intrusion, ice buildup, power interruption, or other condition that may compromise medications integrity shall be treated as a potential medication storage event. The P&P indicated medication stored in a refrigerator or freezer that experiences a malfunction shall immediately evaluated usability. The P&P indicated equipment failure may include but not limited to ice buildup affecting operation, water accumulation inside the unit.

Based on interview and record review, the facility failed to ensure annual performance evaluations were conducted for three sampled staff members Certified Nursing Assistant (CNA 1, CNA 2, CNA 3) and one Licensed Vocational Nurse (LVN 2).This deficient practice had the potential to affect the facility's ability to assess staff performance, identify training needs, and ensure staff competency in providing quality care to residents.Findings:During a concurrent interview and record review on 6/10/2026 at 11:28 a.m., with the Director of Human Resources (DHR), personnel files were reviewed for the following employees:CNA 1 - Hire date: 8/21/2017CNA 2 - Hire date: 12/4/1997CNA 3 - Hire date: 7/2023 and rehired 05/01/2025LVN 2 - Hire date: 4/20/2024Personnel records indicated all four employees lacked documented annual performance evaluations for calendar years 2024 and 2025.The DHR stated she had been in her position for approximately two months and had recently realized the importance of ensuring employee performance evaluations were completed annually.During an interview on 06/10/2026 at 1:12 pm with the Director of Nursing (DON), the DON stated she took her position at the end of 2025. The DON stated she had been working on staff training, in-services, and competency assessments; however, there was no established system left in place from prior leadership to ensure annual performance evaluations were completed. The DON stated annual performance evaluations were important for resident safety, staff development, identifying performance goals, and improving employee performance.During an interview on 06/10/2026, at 4:55 p.m., with CNA 1, CNA 1 stated annual performance evaluations were important because resident needs, equipment, and care practices change over time. CNA 1 stated annual evaluations help ensure resident safety and quality of care. CNA 1 stated she could not recall when her last annual performance evaluation or competency assessment was completed but acknowledged the importance of maintaining and tracking performance reviews.During a follow-up interview on 06/11/2026, at 09:01 a.m., with LVN 1, LVN 1 stated that annual competency assessments and performance evaluations were important to measure staff performance and identify areas for improvement. LVN 1 stated a performance evaluation may have been completed by the Director of Nursing in either 2023 or 2024 but was unable to recall the exact date. LVN 1 stated the importance of conducting annual evaluations to ensure staff competency and ongoing professional development.During a review of facility's policy and procedure(P&P) titled, Performance Evaluation (undated), the P&P indicated The facility endeavors to review each employee performance on an annual basis. The performance evaluations are intended to make you aware of your progress, areas for improvement and objectives or goals for future work performance.

Based on observation, interview and record review the facility failed to ensure the Ombudsman (an advocate for residents of nursing homes, board and care centers, and assisted living facilities) was notified for one of four sampled residents (Resident 4) who was hospitalized on [DATE].This failure violated the rights of Resident 4 by not notifying the Ombudsman to ensure Resident 4's discharge was safe and appropriate.Findings:During a review of Resident 4's admission Record, the admission Record indicated, Resident 4 was admitted to the facility on [DATE] and readmitted on [DATE]. Resident 4 had a diagnosis including hypertension (high blood pressure), myocardial infarction (heart attack) and angina (chest pain).During a review of Resident 4's History and Physical (H&P), dated 5/17/26, the H&P indicated, Resident 4 did have the capacity to understand and make decisions.During a review of Resident 4's Minimum Data Set ( MDS-resident assessment tool) dated 6/9/26, the MDS indicated, Resident 4's cognition (ability to think, understand, learn, and remember) was intact. The MDS indicated, Resident 4 was independent ( no assistance from helper), with activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily).During a review of Resident 4's Discharge Progress Note dated 5/16/26, the Discharge Progress Note indicated, Resident 4 was discharged and admitted to the general acute care hospital (GACH) on 5/16/26 for mastoiditis (infection of the bone behind the ear).During a concurrent interview and record review on 6/11/2026 at 12:05 p.m. with Registered Nurse 1 (RN 1), RN 1 stated she could not find the Ombudsman notification for Resident 1 who was transferred to the GACH on 5/16/26 for mastoiditis. RN 1 stated the Ombudsman should have been notified that the resident was no longer in the care of the facility to ensure the discharge was appropriate. RN 1 stated the Ombudsman served as the advocate for the residents.During an interview on 6/11/2026 at 7:21 a.m. with the Director of Nursing (DON), the DON stated the Ombudsman should have been notified as soon as Resident 4 was transferred to the GACH and no longer in the care of the facility to ensure the discharge was appropriate to meet the needs of the resident.During a review of the facility's policy and procedure (P&P) titled Resident Rights and Responsibilities (undated), the P&P indicated, When a resident requires a transfer or a discharge is initiated by the facility, a written notice must be provided to the resident/representative, and a copy must be sent to the Ombudsman at the same time. This notice is not required if the resident initiates discharge.

Based on interview and record review the facility failed to submit Payroll Based Journal (PBJ- auditable and verifiable staffing data from nursing facilities) staffing data to the Centers for Medicare & Medicaid Services (CMS). This failure had the potential to affect the care and services of the residents. Findings: During a review of the facility's PBJ staffing data report dated 5/2/2025, the PBJ indicated that no data had been reported for the month October 1 through December 31. During an interview on 5/8/25 at 8:51 a.m., with the Director of Nursing (DON), the DON stated the facility updated their firewall ( a physical structure or network security system designed to prevent the spread of unauthorized access) year 2024. The DON stated that it might be the reason why staffing data was not transmitted to CMS. The DON stated she will work on finding the data. During a review of the facility's policy and procedure (P&P) titled Reporting Direct Care Staffing Information (Payroll-Based Journal) dated 11/26/2022 indicated Direct care staffing information is reported electronically to Centers for Medicare & Medicaid Services (CMS) through the payroll- based journal system (PBJ). Staffing information is collected daily and reported for each fiscal quarter no later than 45 days after the end of the reporting quarter. 49889

Based on interview and record review, the facility failed to ensure two of two sampled residents (Resident 1 and Resident 2) were free of unnecessary medicines by failing to: 1. Monitor adverse effects of Aspirin( medicine used to reduce pain, fever and help prevent blood clots by thinning out the blood) for Resident 1. 2.Ensure behavior monitoring was done for the use of Lexapro ( medication used to treat depression) for Resident 2. These failures had the potential to result in Resident 1 and Resident 2 developing an adverse reaction ( unwanted and undesirable effects ) to the medications unrecognized and not identified by staff. Findings: 1. During a review of Resident 1's Admission Record, the Admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including dementia (a progressive state of decline in mental abilities), anemia (a condition where the body does not have enough healthy red blood cells) chronic atrial fibrillation( irregular heartbeat where the top chambers of the heart beat too fast which can cause blood not to flow properly), and hyperlipidemia( a condition in which there are high levels of fat particles in the blood). During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool) dated 4/12/2025, the MDS indicated Resident 1 had moderately impaired cognitive skills ( signifies a noticeable decline including memory loss, language difficulties, decision making that affects daily life). The MDS indicated Resident 1 was independent with bed mobility, standing, transferring to and from a bed to a chair. During a review of Resident 1's Physician Order Summary Report, the Physician Order Summary Report dated 3/20/2025 indicated an order of Aspirin 81 milligrams (mgs- unit of measurement) by mouth in the evening for Afib. During a concurrent interview and record review on 5/7/2025, at 4:07 p.m. with Registered Nurse (RN1), reviewed Resident 1's Physician Order Summary Report and Medication Administration Record. RN 1 stated there was no physician order to monitor for side effects ( any effect of a medicine that is in addition to its intended effect which can be harmful or unpleasant) of ASA. RN 1 stated aspirin can increase the risk for bleeding and could lead to gastrointestinal bleeding ( bleeding anywhere in the upper or lower digestive system ). RN1 stated Resident could develop an adverse effect like bleeding and could lead to increased risk for hospitalization if the resident was not being monitored for side effects of ASA. During an interview on 5/8/2025, at 7:57 a.m. with the Director of Nursing (DON), the DON stated Resident 1 should be monitored for any signs and symptoms of bleeding because of the ASA. The DON stated Resident 1 could be at risk of increased hospitalization or getting sick because ASA could cause bleeding. The DON stated the facility should ensure Resident 1 would not have any harm from using the ASA by adequate monitoring of resident's response to the medicine and its possible side effects. 49889 2. During a review of Resident 2's Admission Record, the Admission Record indicated Resident 2 was admitted to the facility on [DATE] with a diagnosis including post-traumatic stress disorder (PTSD-mental health condition that's caused by an extremely stressful or terrifying event), anxiety ( persistent and excessive worry that interferes with daily activities) disorder and dementia (a progressive state of decline in mental abilities). During a review of Resident 2's MDS dated [DATE], the MDS indicated Resident 2 had mild cognitive impairment. The MDS indicated Resident 2 was independent (resident completes activity by themselves) with activities of daily Living (ADLs- activities such as bathing, dressing and toileting a person performs daily). The MDS also indicated Resident 2 had an active diagnosis of PTSD, and anxiety. The MDS also indicated Resident 2 was taking an antipsychotic (medication used to treat psychotic disorders) and an antidepressant (medication used to treat depression). During a concurrent interview and record review on 5/7/25 at 2:37 pm with Registered Nurse 1 (RN), reviewed Resident 2's Physician Order Summary dated 5/7/25. The Physician Order Summary indicated Resident 2 was taking Lexapro 20 mg give one tablet by mouth one time a day to decrease angry outbursts related to generalized anxiety, monitor for angry outbursts. RN 1 stated she used to monitor Resident 2 for angry outbursts and was not sure why it was not being monitored any more. RN 1 stated they should have been monitoring Resident 2's behaviors to ensure that Resident 2 was not receiving any unnecessary medications. During an interview on 5/8/25 at 7:08 a.m. with the Director of Nursing (DON), the DON stated when Resident 2's physician wrote the order for Lexapro, Resident 2's physician did not add monitoring for angry outburst in the supplemental documentation section . The DON stated that Resident 2 was at risk for unnecessary medications when not monitoring the behavior that the medication was prescribed for. During a review of facility's policy and procedure(P&P) titled, Prevention of Unnecessary and Duplicate Medications, reviewed 1/17/2024, the P&P indicated a medication is considered unnecessary if the resident experiences inadequate monitoring for adverse consequences or effectiveness. The P&P indicated the nursing staff will monitor and document in the resident's chart for medications 'therapeutic response and potential adverse consequences such as side effects, interactions or signs of toxicity( the degree to which a substance can harm or cause damage to humans).

Based on observation, interview and record review, the facility failed to store food in a safe and sanitary manner by failing to: 1.Ensure an open bags of frozen tater tots, frozen dumplings and frozen mixed vegetables were labeled with an open date, use by date and were stored in sealed plastic bags or containers in the freezer. 2.Ensure three rolls of bacon wrapped in a foil and wax paper were labeled by use date and open date in the refrigerator. This failure had the potential to put residents at risk for developing food borne illnesses (illness cause by food contaminated with bacteria, viruses, parasites, or toxins ) and to decrease the quality of food served in the facility. Findings: During a concurrent observation and interview on 5/6/2025, at 9:05 a.m. with [NAME] (CK1), observed an open bags of frozen tater tots, frozen mixed vegetables with ice crystals inside the original plastic bag , and frozen dumplings not labeled with an open date and by use by date. CK 1 stated the kitchen staff should label open food items with an open date and use by date. During an observation and interview on 5/6/2025, at 8:55 a.m. with CK 1 and Food Service Worker (FSW 1), three rolls of bacon wrapped in foil and wax paper were not labeled with open date and by use date in the refrigerator. CK 1 and FSW 1 confirmed the rolls of wrapped bacon were not dated when it was open and by use date. During a telephone interview on 5/7/2025, at 10:48 a.m. with Certified Dietary Manager (CDM), CDM stated open bags of leftovers from the freezer and refrigerator should be stored in a sealed bag with an open date and use by date so the kitchen staff would know how long they could use the open bags of frozen and refrigerated food items. CDM stated this practice will ensure food safety and prevention of food borne illnesses among residents and staff. During an interview on 5/8/2025, at 6:58 a.m. with the Director of Nursing (DON), the DON stated labeling open bags of food items in the freezer or refrigerator with open date and use by date could ensure freshness of the food being served and prevent spoilage of food which could lead to sickness among the residents when consumed. During a review of facility's policy and procedure (P&P) titled, Food Receiving and Storage, dated 5/31/2022, the P&P indicated All foods stored in the refrigerator or freezer are covered, labeled dated with use by date. The P&P indicated refrigerated foods are labeled, dated and monitored so they are used by their use-by date, frozen or discarded.

Based on interview and record review the facility failed to ensure annual skills competencies (a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics in performing that an individual need to perform work roles or occupational functions successfully) were completed for four facility staff (Certified Nursing Assists (CNA) CNA 1, CNA 2, Licensed Vocational Nurse (LVN), LVN 1 and Registered Nurse (RN), RN 3). This deficient practice had the potential for the facility not to be able to assess the skills necessary to provide nursing services to assure resident safety and to ensure facility staff will be performed within the acceptable standards of practice. Findings: During a concurrent interview and record review on 5/7/2025 at 1:33 p.m. with Human Resources (HR) reviewed CNA 1, CNA 2, LVN 1 and RN 3's employee files. HR stated that CNA1 was hired on 12/4/1997, CNA 2 was hired on 6/12/2017, LVN 1 was hired on 2/4/2024 and RN 3 was hired on 11/15/2022. HR stated no annual skills competency for 2024 or 2025 were found for CNA1, CNA 2, LVN 1 and RN 3. HR stated that skills competencies should be done annually to ensure staff are competent in performing their job. HR stated that there was a safety risk for the residents when staff were not competent in their jobs. During an interview on 5/8/20205 at 8:51 a.m. with the Director of Nursing (DON), the DON stated skills competencies should be completed annually and that they were used to ensure that staff members' skills were up to date. The DON stated there could be a possible safety concern for the residents when skills competencies were not assessed with the staff. During a review of facility's policy and procedure (P&P) titled, Staffing Competency and Sufficient Staffing dated 11/26/2017. The P&P indicated, facility provides sufficient numbers of nursing staff with the appropriate skills and competency necessary to provide nursing and related care and services for all residents in accordance with resident care plans and the facility assessment . All nursing staff must meet the specific competency requirements of their respective licensure and certification requirements defined by state law.

Based on interview and record review the facility failed to ensure annual performance evaluations were conducted for two sampled facility staff (Certified Nursing Assistants (CNA), CNA 1 and CNA 2). This failure had the potential to negatively affect the care of the residents. Findings: During a concurrent interview and record review on 5/7/2025 at 1:33 p.m. with Human Resources (HR) we reviewed CNA1 and CNA 2's employee files. HR stated that CNA1 was hired on 12/4/1997 and CNA 2 was hired on 6/12/2017 and both CNA 1 and CNA 2 did not have an annual performance evaluation for 2024. HR stated that performance evaluations should be done annually to create a baseline for their performance. HR stated the performance evaluation was used to help determine the strengths and weaknesses of the employee. During an interview on 5/8/25 at 8:51am with the Director of Nursing (DON), the DON stated performance evaluations should be conducted annually and that they were used to acknowledge the staff's strengths and to help improve any weaknesses. The DON stated there could be a possible safety concern for the residents when performance evaluation was not done. During a review of facility's policy and procedure(P&P) titled, Performance Evaluation (undated). The P&P indicated the facility endeavors to review each employee's performance on an annual basis. The performance evaluations are intended to make you aware of your progress, areas for improvement and objectives or goals for future work performance.

Based on interview and record review, the facility failed to initiate and implement a comprehensive care plan for one of two sampled residents (Resident 1) by failing to: 1.Develop an individualized and person-centered plan of care to address the use of aspirin (ASA- medicine used to reduce pain, fever and help prevent blood clots by thinning out the blood). 2.Implement interventions to monitor signs and symptoms of bleeding related to the use of ASA. This failure had the potential to put Resident 1 at risk of side effects (an often harmful and unwanted effect of a drug that occurs along with the basic desired effect) of ASA not being identified and can cause a delay of care or treatment. Findings: During a review of Resident 1's Admission Record, the Admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and was readmitted on [DATE] with diagnosis that included dementia (a progressive state of decline in mental abilities), anemia (a condition where the body does not have enough healthy red blood cells) chronic atrial fibrillation( irregular heartbeat where the top chambers of the heart beat too fast which can cause blood not to flow properly), and hyperlipidemia( a condition in which there are high levels of fat particles in the blood). During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool) dated 4/12/2025, the MDS indicated Resident 1 had moderately impaired cognitive (ability to think, understand, learn, and remember) skills and was independent with bed mobility, standing, transferring to and from a bed to a chair. During a review of Resident 1's Physician Order Summary Report, the Physician Order Summary Report dated 3/20/2025 indicated a physician order of Aspirin 81 milligrams (mgs- unit of measurement) by mouth in the evening for A fib. During a concurrent interview and record review on 5/7/2025, at 4:07 p.m. with Registered Nurse (RN1), reviewed Resident 1's Physician Order Summary Report and Care Plan. RN1 stated Resident 1 had no Care plan for the use of ASA and no monitoring for its side effects such as bleeding, bruising, tarry, black stool (black or tar like stool caused by blood in the upper gastrointestinal tract which is potential sign of bleeding in the esophagus, or stomach) or bleeding gums. RN 1 stated ASA could cause increase bleeding, and the resident should be monitored for any signs and symptoms of bleeding. RN 1 stated the licensed nurses were responsible in developing a care plan to meet the needs of each resident. RN 1 stated Resident 1 could be at risk to develop adverse effects (undesirable or unintended consequences that result from a medication or treatment) from the use of ASA and could increase his risk of being hospitalized without being monitored for signs and symptoms of bleeding. During an interview on 5/8/2025, at 7:07 a.m. with the Director of Nursing (DON), the DON stated Resident 1 should have a care plan addressing the use of ASA to ensure no harm will occur from the use of ASA. The DON stated developing a care plan will ensure residents' safety and will meet Resident 1's goals and needs. The DON stated not developing a care plan and not monitoring the side effects of ASA could lead to the possibility of Resident 1 needing medical attention and could increase the risk of hospitalization . During a review of facility's policy and procedure (P&P) titled Care Plans, Comprehensive Person-Centered, dated 5/28/2024, the P&P indicated The facility will develop and implement for each resident a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs. The P&P indicated assessments of residents are ongoing and care plan reflects the currently recognized standards of practice for problem areas and conditions.

Based on interview and record review, the facility's Quality Assessment and Assurance Committee (QAA) failed to ensure effective oversight of the facility and implementation of the facility's plan of correction (POC) of the deficient practices identified during the previous recertification survey. This deficient practice resulted in the facility, to have repeat deficiencies in the area of comprehensive resident centered care plans, pharmacy services and food labeling and storage. Findings: During a review of the facility's Statement of Deficiencies for the 2024 Recertification survey. The recertification survey indicated the following repeat deficiencies in comprehensive resident's centered care plans, pharmacy services and food labeling and storage. During a concurrent interview and record review on 5/8/25 at 8:51a.m., with the Director of Nursing (DON), the DON stated that the facility did have deficiencies in comprehensive resident centered care plans, pharmacy services and food labeling and storage from the previous recertification survey in 2024. The DON stated she tried to keep up and more monitoring needs to be done. During a review of the facility's policy and procedure (P&P) titled Quality Assurance and Performance improvement (QAPI) dated 5/31/2024, the P&P indicated The QAPI is implemented and maintained to address identified priorities, and is based on data, resident and staff input and other information that measures performance and focuses on problems and opportunities that reflect processes, functions and services provided to the residents.

Based on observation, interview and record review, the facility failed to observe infection control practices for one of two sampled residents (Resident 1) by failing to: 1.To practice hand hygiene( practice of cleaning your hands to prevent the spread of germs, viruses, and bacteria) after removal of used gloves during medication administration for Resident 1. This failure had the potential to cause cross contamination( physical movement or transfer of harmful bacteria from one person, object or place to another) and could put residents and staff at risk for the spread of infection. Findings: During a review of Resident 1's Admission Record, the Admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and was readmitted on [DATE] with diagnosis including dementia (a progressive state of decline in mental abilities), anemia (a condition where the body does not have enough healthy red blood cells) chronic atrial fibrillation( irregular heartbeat where the top chambers of the heart beat too fast which can cause blood not to flow properly), and hyperlipidemia( a condition in which there are high levels of fat particles in the blood). During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool) dated 4/12/2025, the MDS indicated Resident 1 had moderately impaired cognitive skills ( signifies a noticeable decline including memory loss, language difficulties, decision making that affects daily life) and was independent with bed mobility, standing, transferring to and from a bed to a chair. During a medication administration observation on 5/7/2025, at 7:33 a.m. with Registered Nurse (RN 1), RN 1 picked up her cell phone to answer a call with her hand wearing a glove. Observed RN 1 removed her gloves after the phone call and proceeded to put on a pair of gloves without performing hand hygiene and finished her medication administration to Resident 1 with gloves on. During an interview on 5/7/2025, at 8:12 a.m. with RN 1, RN 1 stated she should have practiced hand hygiene before putting on a new pair of gloves during medication administration to prevent spread of infection among residents and staff. During an interview on 5/7/2025, at 1:17 p.m. with Infection Preventionist Nurse (IPN), IPN stated the licensed nurses should not be wearing gloves and was not necessary to don a pair of gloves when they are administering oral medications to the residents to maintain resident's dignity. IPN stated hand hygiene should be performed before donning a pair of gloves, after removal of gloves and the use of gloves was not a replacement for hand hygiene or handwashing. IPN stated RN 1 should have practiced hand hygiene in between the tasks during medication administration or before donning a new pair of gloves to prevent spread of infection. During an interview on 5/8/2025, at 7:01 a.m. with the Director of Nursing (DON), the DON stated RN 1 should have washed her hands after removing her gloves and before putting on a new pair of gloves to prevent cross contamination and the spread of germs among the staff and residents. During a review of facility's policy and procedure (P&P) titled, Hand Hygiene Policy, dated 10/3/2024, the P&P indicated Hand hygiene was the primary means to prevent spread of infection. The P&P indicated to use an alcohol- based hand rub (ABHR- refers to a liquid or gel hand hygiene product containing alcohol that is used to kill microorganisms on the hands) or soap and water for the following situations including before preparing or handling medications and after removing gloves.

Based on observation, interview, and record review, the facility failed to ensure the storage, preparation and distribution of food was done under sanitary conditions by failing to: 1.Label open perishable food items on the kitchen shelves with the open-date. 2.Label open foods in the refrigerator with an open date. 3. Label open foods in Residents' refrigerator. This deficient practice placed the facility residents at risk for foodborne illness. Findings: On 5/ 8/ 2024 at 8:15 a.m., during an observation of the kitchen, the following was observed: 1.Baking powder and garlic salt 2 pounds 6 ounces food items were not labeled with an open-date. 2. The refrigerator contained a 1/2 gallon of milk , Salted Carmel Creamer, and planet oat milk 32 fluid ounce that were not labeled with an open-date. 3. The Residents' refrigerator contained 1/2 gallon of milk and 1 container of cottage cheese with no name (of whom it belonged to), or open-date. During an observation and interview on 5/8/2024 at 08:15 a.m., the Dietary Service Supervisor (DSS), stated he usually labels the foods with an open-date . The DSS stated he forgot to label the milk and creamer and stated the policy is when a food item is opened you must date all foods with an open-date so we can know when to throw them out. During an observation and interview on 5/9/2024 at 08:24 a.m., Food Service Worker 2 stated that in the resident's refrigerator there was a 1/2 gallon of milk opened and 1 container of cottage cheese with no date , name, or room number. FSW 2 verified the undated items and stated when residents' food prepared outside the facility comes in, we are to make sure the food is good we take the temperature of that food, put the residents name on it, and their room number. FSW 2 stated if the food item is opened we put the date it was opened on it. She further stated the reason for dating so you will know when the food items become bad and when to discard them. During a review of policies and procedures (P&P) titled FDA U.S. Food & Drug Administration, dated 2017 , the policy indicates refrigerated, Ready- to -eat Time/Temperature control for safety of foods prepared and packaged by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold or discarded, based on the temperature and time combinations specified : 1.The day the original container is open in the food establishment is day 1and. 2.The day or date marked by the food establishment may not exceed a manufacture's use by date if the manufacture determines the use by date based on food safety. During a review of policies and procedures (P&P) titled Policy and Procedure , dated 1/1/2027 revised 1/1/2028 the policy indicates containers brought into the facility (community ) by visitors should be labeled and dated.

Based on interview, and record review, the facility failed to implement a baseline care plan for two of three sampled residents (Residents 1 and 2) who were taking Melatonin (a non-pharmaceutical sleep aid) for sleep difficulty. This deficient practice had the potential to place the residents at risk for prolonged sleep. A. During a review of Resident 2's Admission record, the Admission Record indicated Resident 2 was admitted on [DATE] with diagnoses that included dementia (impaired ability to remember, think, or make decisions that interferes with everyday activities) with agitation, insomnia (difficulty falling asleep, staying asleep, or getting good quality sleep), unsteady gait (walking), and hypertension (high blood pressure). During a review of Resident 2's Minimum Data Set (MDS), a standardize assessment and care planning tool dated 4/7/2024, the MDS indicated Resident 2 was cognitively (mental action or process of acquiring knowledge and understanding ability) moderately intact and required supervision sit to lying, lying to sitting, bathing, required setup assistance in eating, performing oral hygiene, toileting, dressing, personal hygiene, and is independent in ambulating and transferring. The MDS indicated Resident 2 has functional limitation bilaterally (both sides) on the lower (legs, hip) extremities and utilized a cane for ambulating. During a record review of Resident 2 medical records, the records indicated a physician's order dated 4/9/2024 for Melatonin oral tablet 10 milligrams (mg a unit of measure of weight) by mouth every 16 hours (hrs) as needed for sleep difficulty. During a review of Resident 2's Care Plan (CP), there were no CP's or interventions related to sleep difficulty. During a review of the Medication Administration Record (MAR: document that details medications administered to the patients), the MAR indicated that Resident 2 received Melatonin 10mg every day from 4/17/2024 to 5/7/2024. During a concurrent interview and record review on 5/9/2024 at 2:37p.m. Registered Nurse 2 (RN 2) stated care plans are initiated on admission and are updated when there is a change of condition and quarterly. RN 2 stated care plans are kept up to date for each resident to reflect the current care that is given and ensure the interventions are implemented as stated on the care plan. During a concurrent interview and record review on 5/10/24 at 12:13p.m., Licensed Vocational Nurse 2 (LVN 2) stated Resident 2 did not have a care plan for sleep and the sleeping patterns should be documented for residents that are on sleeping medications to see if the medication is working. During a concurrent interview and record review on 5/10/2024 at 2:02p.m. the Director of Nursing (DON) stated residents will need a care plan for sleep to reassess the resident to ensure they are not over sleeping and see if the dose or the order needs to be changed. B.During a review of Resident 1's Admission record, the Admission Record indicated Resident 1 was admitted on [DATE] with diagnoses that included post-traumatic stress disorder, chronic ( a mental health condition that can develop after experiencing or witnessing a traumatic event), psychotic disturbance (a mental disorder characterized by disconnection from reality), dementia (impaired ability to remember, think, or make decisions that interferes with everyday activities), mood disturbance (causes a person to experience extreme happiness, sadness, or both for long periods of time and generalized anxiety disorder ( a condition in which a person has excessive worry and feelings of fear , dread, and uneasiness). During a review of Resident 1's MDS dated [DATE], the MDS indicated Resident 1 was cogitatively intact. The MDS inciated Resident 1 required set up or clean- up assistance with oral hygiene, toileting hygiene , upper body dressing ( the ability to dress and undress above the waist, including fasteners, if applicable ) and lower body dressing ( the ability to undress below the waist, including fasteners, does not include footwear ). During a record review of Resident 1 medical record, the medical record indicated a physician's order dated 12/31/2023 and discontinued on 4/7/2024, for Melatonin oral tablet 3 mg by mouth every 24 hours as needed for insomnia ( a sleep disorder that makes it difficult to fall asleep) During a review of Resident 1's Care Plan (CP), there were no CP's or interventions related to sleep difficulty. During a review of the MAR, Resident 1 received Melatonin 3 mg on 4/7/2024. During a concurrent interview and record review on 5/10/2024 at 09:14 a.m., with the Licensed Vocational Nurse 1(LVN), LVN 1 stated the resident does have a problem with sleeping at night and has an order for melatonin to help with sleep. LVN 1 stated because resident has problems with sleep this needs to be care planned to make sure he gets the right level of care. During a concurrent interview and record review on 5/10/2024 at 1:12 p.m., with the Director of Nursing (DON) , the DON verified there was no care plan for insomnia and stated not being able to sleep is a change of status and needs to be care planed. DON stated care plan helps in monitoring if the medication is effective or not. During a review of the facility's P&P titled, Comprehensive Care Plan dated 5/31/2023, the P&P indicated a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change.

Based on interview and record review, the facility failed to ensure a resident was free from unnecessary drugs for one of three sampled residents (Residents 2) by not monitoring the specific behavior manifestation according to the prescribed antipsychotic (medication used to treat severe mental illness) medication dose ordered. This deficient practice had the potential to result in over use of an antipsychotic medication, without monitoring for the effectiveness and/or ineffective of the medication and can lead to adverse drug reactions. During a review of Resident 2's Admission record) the Admission Record indicated Resident 2 was admitted on [DATE] with diagnoses that included dementia (impaired ability to remember, think, or make decisions that interferes with everyday activities) with agitation, insomnia (difficulty falling asleep, staying asleep, or getting good quality sleep), unsteady gait (walking), and hypertension (high blood pressure). During a review of Resident 2's Minimum Data Set (MDS), a standardized assessment and care planning tool dated 4/7/2024, the MDS indicated Resident 2 was cognitively (mental action or process of acquiring knowledge and understanding ability) moderately intact and required supervision sit to lying, lying to sitting, bathing, required setup assistance in eating, performing oral hygiene, toileting, dressing, personal hygiene, and is independent in ambulating and transferring. aspects of activities of daily living (ADL: personal hygiene, toileting, bathing, dressing). The MDS indicated Resident 2 had potential indicators of psychosis (a disorder that causes loss of contact with reality) such as hallucinations (an experience involving the apparent perception of something not present.) and delusions (a false belief or judgment about external reality), as well as verbal behavioral symptoms, (threatening others, screaming at others), directed towards staff. The MDS indicated Resident 2 is on antipsychotic medications. The MDS indicated resident's current behavior had gotten worse. The MDS indicated Resident 2 has functional limitation bilaterally (both sides) on the lower (legs, hip) extremities and utilized a walking cane for ambulation. During a review of the provider note dated 4/24/2024 at 4:26p.m., the Provider Note indicated that Resident 2 was sent to the emergency department due to an aggressive outburst towards staff that required medication (for aggressive psychotic episodes). Resident 2 received Haldol (an antipsychotic medication) five milligrams ( a unit of measure of weight) intramuscular injection (IM: medication administered by needle deep into the muscles), and once evaluated by a psychiatric nurse practitioner, the order was changed to Haldol 1 mg twice a day and use Ativan as needed for agitation. During a record review of the Order Summary Report (Physician Orders) dated 4/24/2024, the physician's order indicated an order for Haloperidol (also known as Haldol: treat nervous, emotional, and mental conditions) oral tablet 1 mg by mouth two times a day for psychosis per psychiatry recommendation, and an order for Ativan (used to manage anxiety disorders, insomnia, panic attacks) oral tablet 0.5mg (Lorazepam) by mouth every six hours as needed for agitation. There were no orders to monitor Resident 2 for adverse reactions from the medications or medications effectiveness on Resident 2's psychotic behaviors. During a review of the Medication Administration Record (MAR: document that details medications administered to the patients), Resident 2 had an order dated 3/2/2024 and discontinued on 4/9/2024 to receive Seroquel (medication used to treat depressive and manic episodes) oral tablet 12.5mg by mouth two times a day for hallucinations, agitation and anxiousness related to dementia. Seroquel 12.5mg two times a day for hallucinations related to dementia was resumed on 4/9/2024 and was discontinued on 4/24/2024. Additionally, Resident 2 had an order for Seroquel 12.5mg by mouth every 24 hours as needed (PRN) for agitation/fear from 4/9/2024 to 4/24/2024. Resident 2 had received Seroquel 12.5mg PRN on 4/16/2024 at 7:07p.m., 4/18/2024 at 6:49 a.m. and 6:16p.m. During an interview on 5/9/2024 at 2:46p.m. with RN 2, RN 2 stated residents who are on psychotropic medications (antidepressants (treat depression), anti-anxiety medications, antipsychotics, and mood stabilizers) should be monitored for signs and symptoms of suicidal ideation or if they are a threat to others or self as something bad could happen to the resident, if you do not feel well you do not act well, and it is important to help stabilize the resident to become less paranoid, or have less hallucination and delusions. RN 2 stated if the correct psychotropic medications are not given, the medication needs to be adjusted, monitored, and the physician needs to be notified if changes in medication or dosage are necessary. During an interview on 5/9/2024 at 4:34p.m. with the Pharmacist (PharmD), PharmD stated Resident 2 is on the minimal dose of Haldol 1mg twice a day. PharmD stated Haldol 1mg was started to treat agitation rather than for psychosis. PharmD stated the pharmacist will review the medication and check the indication (reason for administration) prior to having it dispensed. PharmD stated medications (indication and dosages) are reviewed every month and will indicate whether the medication needs to be reduced based on the residents' condition. PharmD stated some of the side effects for Haldol included dizziness, cause sedation with a higher dose, and can also cause tardive dyskinesia (muscle stiffness), so the residents should be monitored, and the electronic MAR should be equipped with a section where the nurses document the vital signs. PharmD stated monitoring the resident for side effects and effectiveness is a must and is nonnegotiable. During an interview on 5/10/2024 at 9:05a.m. with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated Resident 2 had episodes of sundowning at night (restlessness, agitation, irritability, confusion that gets worse as the evening sets in), had become aggressive, and will hit her cane on the floor. LVN 2 stated if Resident 2 is having behavioral issues, it will be documented in the behavioral note, however there is no place to document her behaviors on the MAR. LVN 2 stated Resident 2 does not have a section to tally her behavior, but it would be helpful to be able to track her behavior. LVN 2 stated tallying the behavior will help identify whether the medication is effective/not effective or if it is benefiting the resident. LVN 2 stated without tallying the behavior, they would not know whether the medication dose is appropriate or identify the purpose of giving the medications. During a concurrent interview and record review on 5/10/2024 at 12:57p.m. with the Director of Nursing (DON), the DON stated the resident should be monitored to ensure the resident is safe and not harming themselves or others, they are not being treated with unnecessary psychotropic medications where behavior can be managed with the least restrictive measures as there are residents who sundown like Resident 2 with dementia that can exacerbate their condition. During an interview on 5/10/24 at 2:22p.m. with Psychiatric Nurse Practitioner (PNP), PNP stated the Resident 2 would have to be monitored to see if the behaviors are improving or not and would have to change the medication if it is not effective. During a review of the facility's P&P titled, Behavioral Assessment, Intervention and Monitoring dated 5/31/2023, the P&P indicated behavioral or psychological symptoms of dementia (BPSD) describes behavioral symptoms in individuals with dementia that cannot be attributed to a specific medical or psychiatric cause. Current guidelines recommend the use of non-pharmacological interventions for BPSD. The nursing staff will identify, document, and inform the physician about specific details regarding changes in an individual's mental status, behavior, and cognition, including: onset, duration, intensity and frequency of behavior symptoms, any recent precipitating or relevant factors or environmental triggers (e.g., medication changes, infection, recent transfer from hospital). When medications are prescribed for behavioral symptoms, documentation will include: monitoring for efficacy and adverse consequences. The IDT will monitor for side effects and complicated related to psychoactive medications; for example, lethargy, abnormal involuntary movements, anorexia, or recurrent falling. During a review of the facility's P&P titled, Dementia-Clinical Protocol dated 5/31/2023, the P&P indicated the staff and physician will evaluate individuals with new or worsening cognitive impairment and behavior and differentiate dementia from other causes. Individuals with dementia can also have a personality disorder, mental illness, psychosis, delirium, depression, and adverse drug reactions (ADRs), or other conditions causing or contributing to impaired cognition and problematic behavior.

Based on interview and record review, the facility failed to develop care plans for two of five sampled residents (1, 106). Resident 1, who was a high fall risk and received medications which acted as a central nervous system ([CNS] a complex of nerve tissues which controls the activities of the body) depressant (a type of medication which slows down brain activity and causes the muscles to relax) and Resident 106 who had identified care issues on admission but did not have any care plans developed to direct her care. These deficient practices resulted in Resident 1 not being monitored for adverse side effects of prescribed medications which included hypotension (low blood pressure), dizziness, fainting, falls, impaired judgement (difficulty in forming evaluative opinions or reaching conclusions), and impaired psychomotor skills (slowing down of thought and a reduction of physical movements in an individual). These adverse side effects were associated with the use of Quetiapine (Seroquel), an antipsychotic (a class of medicines used to treat psychosis [abnormal condition of the mind]), Lexapro ([Escitalopram] a medication used to treat depression), Levetiracetam (a medication used to prevent and/or treat seizures [uncontrolled body movements]), Lamictal ([Lamotrigine] a medication used to prevent or treat seizures), Amlodipine (a medication used to treat high blood pressure), and Benazepril (a medication used to treat high blood pressure) in combination with alcohol consumption. Resident 106's care needs were not identified and had the potential for her care needs to be overlooked. Findings: During a review of Resident 1's Admission Record (Face Sheet [FS]), the FS indicated Resident 1 was admitted to the facility on [DATE] with diagnosis including unspecified dementia (mental disorder in which a person loses the ability to think, remember, learn, make decisions, or solve problems), seizures, and muscle weakness (lack of strength in the muscles). During a review of Resident 1's Minimum Data Set ([MDS] a comprehensive assessment and care screening tool), dated 5/11/2023, the MDS indicated Resident 1was usually able to understand others and was sometimes understood by others. The MDS indicated Resident 1's cognitive skills for daily decision-making were moderately impaired. The MDS indicated Resident 1 required supervision and setup help only for transfers, dressing, and personal hygiene. The MDS indicated Resident 1 received antipsychotic and antidepressant medications. During a review of Resident 1's Fall Risk Assessment (FRA), dated 9/9/2021, the FRA indicated the resident had a history of falls and received a total score of 55, indicating the resident had a high fall risk. During a review of Resident 1's Order Summary Report ([OSR] physician's orders), dated 5/19/2023, the OSR orders were as follows: 1. On 9/5/2018, two beers every evening with dinner 2. On 11/20/2019, Lexapro 20 milligrams ([mg], a unit of measurement) in the morning for generalized anxiety disorder (excessive worry). 3. On 11/20/2019, Quetiapine 50 mg at bedtime for generalized anxiety disorder. 4. On 1/11/2021, Benazepril Hydrochloride 40 mg in the morning for hypertension. 5. On 8/27/2022, Levetiracetam 1500 mg two times a day for seizure preventions. 6. On 1/26/2023, Amlodipine Besylate 5 mg in the morning for hypertension. 7. On 2/28/2023, Lamictal 200 mg in the morning for seizure prevention. 8. On 3/17/2023, Lamictal 100 mg at bedtime for seizure disorder. During an interview on 5/18/2023 at 12:54 p.m. with the Nurse Practitioner (NP), the NP stated there was no CP for Resident 1 for monitoring the side effects of drinking two beers every night in combination with Resident 1's medications. The NP stated an updated care plan was important to make sure the resident can receive the correct care, monitoring and services. During an interview on 5/19/2023 at 11:45 a.m., with the facility's Pharmacy Consultant (PC), the PC stated Resident 1 should be monitored by the nursing staff for side effects of the medications Resident 1 was taking in combination with his prescribed alcohol consumption. The PC stated Resident 1had a potential risk for hypotension (low blood pressure), dizziness, fainting, falls, impaired judgement (difficulty in forming evaluative opinions or reaching conclusions), and impaired psychomotor skills (slowing down of thought and a reduction of physical movements in an individual) including coordination (the ability to use different parts of the body together smoothly and efficiently). During a review of the facility's undated policy and procedure (P/P) titled, Comprehensive Care Plan, the P/P indicated the comprehensive, person-centered care plan is developed within seven days of completion of the required MDS assessment (admission, annual, or significant change in status). 41699 During a review of Resident 106's Admission Record (Face Sheet), the Face Sheet indicated Resident 106 was admitted to the facility on [DATE] with diagnoses that included dementia (a chronic or persistent disorder that results in progress loss of memory), unsteady gait, hypertensive disorder ([HTN] high blood pressure), coronary atherosclerosis (the buildup of fats, cholesterol and other substances in and on the artery walls), and myocardial infarction (a heart attack). During a review of Resident 106's Minimum Data Set ([MDS] a standardized assessment and care screening tool), dated 4/25/2023, the MDS indicated Resident 106's cognition (ability to think, understand, and reason) was severely impaired. The MDS indicated Resident 106 required supervision with bed mobility, dressing, eating, toilet use, personal hygiene, and transfer. During an interview and concurrent record review on 5/18/2023 at 12:27 p.m., with the MDS nurse, Resident 106's clinic record was reviewed. Resident 106's clinical record indicated there were no CP's developed to address Resident 106's diagnoses and care issues. The MDS nurse stated ideally the care plan must be generated during admission of the resident or at least forty-eight hours after the admission of the resident. The MDS nurse stated, if CPs were not created right away then the potential problem9s) were not captured and there could be a delay in care for the resident. During an interview on 5/18/2023 at 12:32 p.m., the Director of Nursing (DON) stated a CP should be initiated during admission and when there is a COC. During an interview on 5/19/2023 at 9:06 a.m., both the DON and Infection Preventionist Nurse (IPN) stated, care plans must be individualized, and person centered to attain the needs and every need must be addressed. During a review of facility's undated policy and procedure(P/P), titled Comprehensive Assessment, the P/P indicated, comprehensive assessments are conducted to assists in developing person-centered care plans. The admission assessment is a comprehensive assessment for a new resident and, under some circumstances, a returning resident that must be completed by the end of day 14, counting the date of admission to the nursing home as day 1. Significant Change in Status Assessment - The SCSA is a comprehensive assessment for a resident that must be completed when the IDT has determined that a resident meets the significant change guidelines for either major improvement or decline. It can be performed at any time after the completion of an Admission assessment, and its completion dates (MDS/CAA(s)/care plan) depend on the date that the IDT's determination was made that the resident had a significant change. A significant change is a major decline or improvement in a resident's status.

Based on observation, interview, and record review, the facility failed to ensure residents were supervised while smoking and/or did not cigarette lighters accessible and used by them for two of two sampled residents (Residents 1 and 4). These deficient practices resulted in Residents 1 and/or 4 being left alone while smoking cigarettes and having cigarette lighters on their person and/or at their bedside and using it to light their cigarettes unattended. These deficient practices had the potential for burn injuries to occur. Findings: a. During a review of Resident 1's Admission Record (Face Sheet [FS]), the FS indicated Resident 1 was admitted to the facility on [DATE] with diagnosis including unspecified dementia (mental disorder in which a person loses the ability to think, remember, learn, make decisions, or solve problems), seizures (uncontrolled body movements and changes in behavior which occur because of abnormal electrical activity in the brain) and muscle weakness (lack of strength in the muscles). During a review of Resident 1's Minimum Data Set ([MDS] a comprehensive assessment and care screening tool), dated 5/11/2023, the MDS indicated Resident 1 was usually able to understand other and was sometimes understood by others. The MDS indicated Resident 1's cognitive skills for daily decision-making were moderately impaired. The MDS indicated Resident 1 required supervision and setup help only for transfers, dressing, and personal hygiene. The MDS indicated Resident 1 had functional limitations in range of motion ([ROM] full movement potential of a joint) to both of his lower extremities (legs) and used a cane for mobility. During a review of Resident 1's Smoking Evaluation Tool (SET), dated 2/9/2023, the SET indicated Resident 1 was not able to verbalize safe smoking principles, was not able to safely utilize a lighter, and staff should light Resident 1's cigarette. The SET indicated, Resident 1 care plan was reviewed and revised for appropriate supervision and smoking directions for staff to light Resident 1's cigarette. During a review of Resident 1's Care Plan (CP), dated 3/28/2019, the CP indicated Resident 1 smoked. The CP's goal indicated Resident 1 will not suffer injury from unsafe smoking practices through the review date (6/26/2023). The CPs interventions indicated to notify the charge nurse immediately if Resident 1 was suspected of violating the facility smoking policy. The CP indicated the last revision date was 10/4/2022. During a review of Resident 1's Order Summary Report ([OSR] physician's orders), dated 1/8/2023, the OSR indicated Resident 1 was to sit down when outside smoking a cigarette. During an observation on 5/17/2023 at 12:36 p.m., Resident 1 was observed standing on the smoking patio, he pulled a blue cigarette lighter from his right pants pocket, lit a cigarette, and smoked it without staff present to supervise him. After Resident 1 was finished smoking, Resident 1 was observed placing the blue cigarette lighter in a white cup located inside the dining room. During an interview on 5/17/2023 at 12:40 p.m., with Resident 1, Resident 1 stated he was allowed to light his own cigarettes and to smoke anytime he wanted to. Resident 1 stated when he wants to smoke, he goes to the dining room, grabs the blue lighter out of the white cup, smokes his cigarette, then puts the blue lighter in the white cup when he is finished smoking. Resident 1 stated he does not have to ask staff for the lighter because the staff told him where the lighter was located and asked him to make sure he puts the lighter back where he found it when he was done smoking his cigarette. Resident 1 stated he smokes by himself all the time. During an interview on 5/17/2023 at 12:40 p.m., with Licensed Vocational Nurse 2 (LVN 2), the LVN 2 stated Resident 1 was not allowed to light his own cigarettes or smoke unsupervised and should not have access to a lighter because it could lead to accidents such as burning himself or other residents. LVN 2 stated, the lighter should not be kept in a place where residents have direct access to it, and residents were not allowed to keep the lighters in their room. LVN 2 stated, it was all the staff's responsibility to monitor the residents who smoke; however staff allows Residents to smoke wherever they want for fear the residents will become angry. LVN 2 stated Resident 1 does not abide by the smoking schedule, and it was hard to monitor him because he was allowed to smoke cigarettes whenever he wants to and the nurses are sometimes busy with other residents and Resident 1 does not want to wait for staff to light his cigarette for him. During an interview on 5/18/2023 at 12:54 p.m., with a Nurse Practitioner (NP), the NP stated she thought she had reviewed and revised Resident 1's CP to reflect the updated smoking policy indicating; any resident with smoking privileges requiring monitoring while smoking shall have the direct supervision of a staff member, family member, visitor or volunteer worker at all times while smoking b. During a review of Resident 4's FS, the FS indicated Resident 4 was admitted to the facility on [DATE], with diagnosis including chronic obstructive pulmonary disease ([COPD], a group of diseases which cause airflow blockage and breathing-related problems), unspecified asthma (a condition which the airways narrow, swell and may produce extra mucous), and malignant (term used to describe cancer) carcinoid (a slow growing cancerous tumor) tumor (abnormal growth of body tissue) of bronchus (a large airway which leads from the windpipe to the lung) and lung (a pair of spongy, air-filled organs located on either side of the chest). During a review of Resident 4's MDS, dated [DATE], the MDS indicated Resident 4 had the ability to understand and be understood by others. The MDS indicated Resident 4's cognitive skills for daily decision-making were moderately impaired. The MDS indicated Resident 4 required supervision and setup help only by staff for transfers, dressing, and personal hygiene. During a review of Resident 4's SET, dated 2/9/2023, the SET indicated Resident 4 had short term memory loss and poor short-term memory. During a review of Resident 4's CP dated 3/13/2023, the CP indicated Resident 2 smoked. The goal indicated Resident 4 would not suffer injury from unsafe smoking practices through the review date (5/24/2023). The CPs interventions indicated to notify the charge nurse immediately if Resident 4 was suspected of violating the facility's smoking policy, staff were to monitor the cigarette lighter and keep it in the Oak Room, and lighting of cigarettes was monitored by staff. During a review of Resident 4's SET, dated 4/24/2023, the SET indicated Resident 4 was not able to safely utilize a lighter. During a concurrent observation and interview on 5/17/2023 at 12:53 p.m., Resident 4 was observed standing on the smoking patio, he pulled a grey lighter from his right pants pocket, lit a cigarette, and smoked it without staff present to supervise him. Resident 4 stated the grey lighter was his and he keeps it in his room. Resident 4 stated he independently goes to the smoking patio and smokes whenever he wants to smoke. During an interview on 5/17/2023 at 1:35 p.m., with the Quality Assurance Nurse (QA), the QA stated, the purpose of having and implementing their smoking policy, was to prevent accidents, injury and potential harm to the residents who smoke. During a review of the facility's undated Policy and Procedure (P/P), titled, Smoking - Residents, the P/P indicated any smoking related privileges, restrictions, and concerns (for example, need for close monitoring) are noted on the care plan, and all personnel caring for the resident shall be alerted to these issues. Any resident with smoking privileges requiring monitoring while smoking shall always have direct supervision. Lighters, including matches are held in a designated area.

Based on observation, interview, and record review, the facility failed to provide the residents with safe environment at all times. The facility failed to disallow and prevent any portable electric heater to be used in any patient care areas (including tub room) as the portable electric heater is prohibited by NFPA 101, 200 Edition, 19.7.8. This deficient practice had a potential to cause serious physical harm to the residents who were using the tub room. This practice was an electrical hazard and can overload electrical circuits which can cause a fire if the heater were to malfunction. Findings: On January 13, 2016, at 3 p.m., the evaluator conducted an inspection of the tub/shower room in the presence of the Building Supervisor (BS 1), and observed a portable electric heater on the floor connected to an electric outlet. The tub/shower room was warm and moist. There were no staff or residents in the room at that time. On January 13, 2016, at 3:10 p.m., the evaluator informed BS 1 of the repeated deficient practice (using portable electric heater in the tub room) during survey dated October 2, 2014. BS 1 proceeded to remove the portable electric heater and stated, I will get rid of it right now, I just checked this area yesterday. January 13, 2016, at 4:46 p.m., the evaluator conducted an interview with Resident 4 and she stated she just took a shower that morning and the staff put on a portable heater. Resident 4 stated, The small heater warms up the (tub) room. On January 14, 2016, at 9:05 a.m., during an interview, the certified nursing assistant (CNA3) stated the tub room was used for Resident 1, and Resident 1 requires the staff to assist him with personal hygiene. She stated, Resident 1 was showered yesterday. CNA 3 stated a portable heater was used when the staff bathe a resident in the tub room. On January 14, 2016, at 11:15 a.m., during an interview, Staff 2 (Chief of Patient Care Services) stated she was aware the portable heater was in the tub room. Staff 2 stated the portable heater should not be used in the tub room. Staff 2 stated she had ordered a wall heater. Staff 2 was informed during the initial tour (on January 13, 2016), the portable heater was observed in the tub room. On January 14, 2016, at 11:45 a.m., during an interview, BS 1 was asked, What did he do with the portable electric heater that he removed from the tub/shower room on 01/13/2016?, BS 1 stated he placed the heater in a cage located outside the clinic entrance. BS 1 and the evaluator conducted an inspection of the entrance and observed the cage was not secured and the heater was in plain view accessible for its use. On January 14, 2016, at 12 p.m., during an interview, BS 1 was requested for a documented evidence that the Safety Committee discussed and addressed concerns which identified in the Life Safety Code report dated October 4, 2014. BS 1 stated, We discuss all the issues but nothing was documented at the time of the Safety Committee monthly meeting. On January 14, 2016, at 1 p.m., during an interview, the Administrator stated, I just started (working at this facility), I went over the health portion of the recertification report of 2014. I did not go over the Life Safety Code portion of the survey. A record review of the portable heater's owner manual expressly warns users that This heater is not intended for use in bathrooms, laundry areas and similar indoor location. NEVER locate heater where it may fall into a bathtub or other water containers. Extreme caution is necessary when any heater is used by, or near children or invalids, and whenever the heater is left operating and unattended. A review of the Quality Assurance/Improvement Meeting Minutes dated January 13, 2016, the topic for Environment Services and/or Roundtable did not mention the concern of the portable heater in the tub room. On January 14, 2016, at 12:38 p.m., an immediate jeopardy (IJ) was identified regarding the pattern of potential for serious unsafe environment in the residents' tub room. On January 14, 2016, at 12:38 p.m., the CDPH survey team declared an immediate jeopardy and informed the facility's Chief Executive Officer (CEO/Staff 1) and Chief of Patient Care Services (CPCA/Staff 2) of an immediate jeopardy related to unsafe environment. On January 14, 2016, at 2:25 p.m., the IJ was corrected after the facility removed and discarded the portable electrical heater from the tub room.