Every finding on record at Central Gardens Post Acute

Based on interview, record review, and facility policy review, the facility failed to ensure a Level I Pre-Admission Screening and Resident Review (PASARR) accurately reflected the presence of diagnosed mental illnesses for 1 (Resident #7) of 3 residents reviewed for PASARR requirements. Specifically, Resident #7 had a Level I PASARR completed upon readmission to the facility that did not reflect all their mental health diagnoses. Findings included: An undated facility policy titled, Admission Criteria, indicated, 9. All new admissions and readmissions are screened for mental disorders (MD), intellectual disabilities (ID) or related disorders (RD) per the Medicaid Pre-Admission Screening and Resident Review (PASARR) process. Resident #7's Admission Record indicated the facility originally admitted the resident on 10/03/2020 and most recently admitted the resident on 05/04/2024. According to the Admission Record, the resident had a medical history that included diagnoses of delusional disorders and schizophrenia. Resident #7's Care Plan Report included a focus area, initiated on 02/14/2023, that indicated the resident had a mood problem related to schizophrenia. A discharge Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/26/2024, revealed that at the time of the assessment, Resident #7 had active diagnoses that included psychotic disorder and schizophrenia. Resident #7's Level I PASSAR, completed by a local hospital on 05/03/2024, revealed Section III- Serious Mental Illness, question 10 was answered no to indicate the resident did not have a serious diagnosed mental disorder such as depressive disorder, anxiety disorder, panic disorder, schizophrenia/schizoaffective disorder, or symptoms of psychosis, delusions, and/or mood disturbance. As a result, the resident's Level I PASARR was Negative, and a Level II Evaluation was not required. During an interview on 02/19/2025 at 9:04 AM, the Director of Nursing (DON) stated the Admissions Director and the Marketer were responsible for reviewing PASARRs completed by a hospital at the time of each resident's admission. The DON further stated he expected the admissions team to ensure all pertinent diagnoses were included on PASARRs. The DON stated Resident #7 had diagnoses of schizophrenia and delusional disorder, which were considered serious mental illnesses. The DON further stated Resident #7's Level I PASARR dated 05/03/2024 was inaccurate because it did not reflect the resident's mental health diagnoses. During an interview on 02/20/2025 at 9:08 AM, the Admissions Director stated he received Level I PASARRs from the hospital for new admissions, and he reviewed them for accuracy. The Admissions Director further stated he would have reviewed Resident #7's most recent PASARR dated 05/03/2024 for accuracy and was not sure how the resident's mental health diagnoses were missed. The Admissions Director stated Resident #7's 05/03/2024 Level I PASARR was not accurate, because it did not reflect the resident's mental health diagnoses. During an interview on 02/20/2025 at 10:40 AM, the Administrator stated Level I PASARRs were completed at the hospital prior to each resident's admission. The Administrator further stated Resident #7 went to the hospital in May 2024, and their PASARR was completed by the hospital. The Administrator stated Resident #7's Level I PASARR completed on 05/03/2024 was inaccurate because it did not include their mental health diagnoses, and the admitting staff should have caught the inaccuracy and completed a new Level I PASARR for Resident #7.

Based on observation, interview, and record review, the facility failed to ensure staff implemented enhanced barrier precautions (EBP) when providing care to 1 (Resident #155) of 1 resident requiring EBP observed during the provision of care. Specifically, staff failed to wear a gown during resident care that consisted of touching the resident and their feeding tube. Findings included: An Admission Record revealed the facility admitted Resident #155 on 02/08/2025. According to the Admission Record, Resident #155 had a medical history that included a diagnosis of gastrostomy (surgical procedure to create an opening in the abdominal wall into the stomach) status. Resident #155's Care Plan Report included a focus area, initiated on 02/08/2025, that indicated the resident required tube feeding related to dysphagia (difficulty swallowing). The Care Plan Report also included a focus area, initiated on 02/17/2025, that indicated the resident required EBP during high-contact resident-care activities due to the presence of an indwelling medical device (feeding tube). During a concurrent observation and interview on 02/17/2025 at 10:35 AM, Licensed Vocational Nurse (LVN) #2 entered Resident #155's room and donned a pair of gloves but no gown. While in the room providing care to the resident, LVN #2 was observed leaning over the resident's bed and body, touching the resident's body, and manipulating the resident's feeding tube. LVN #2 stated she should have donned a gown before going into the resident's room, due to the risk of spreading germs. The Infection Preventionist (IP) was interviewed on 02/19/2025 at 12:20 PM. The IP stated if a resident required EBP, and staff went into the resident's room and touched the resident and/or manipulated their feeding tube, she expected staff to wear both a gown and gloves to minimize the risk of spreading germs to other residents and to themselves. The Director of Nursing (DON) was interviewed on 02/20/2025 at 10:09 AM. The DON stated Resident #155 required EBP, and staff should have worn a gown when touching the resident and manipulating the resident's feeding tube. The Administrator was interviewed on 02/20/2025 at 10:13 AM. The Administrator stated staff had been trained to wear gowns when entering a resident's room to provide care if the resident required EBP.

Based on observation, interview, record review, and facility policy review, the facility failed to maintain a medication error rate of less than 5 percent (%). Specifically, the facility had 2 errors out of 30 opportunities, resulting in a medication error rate of 6.67 %, affecting 1 (Resident #39) of 6 residents observed during medication administration. Findings included: A facility policy titled Medication Administration, revised 04/2019, indicated, 10. The individual administering the medication verifies the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. An Admission Record revealed the facility admitted Resident #39 on 07/19/2024. According to the Admission Record, Resident #39 had a medical history that included a diagnosis of unspecified bipolar disorder. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/22/2025, revealed Resident #39 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident had intact cognition. Resident #39's Care Plan Report included a focus area, initiated 10/10/2024, that indicated the resident was at risk for complications related to a sinus infection. An intervention dated 10/10/2024 directed staff to administer medication per physician's orders. The Care Plan Report also included a focus area, initiated 02/18/2025, that indicated the resident had a behavior problem manifested by angry outbursts. An intervention dated 02/18/2025 directed staff to administer medications as ordered. Resident #39's Order Summary Report contained an active order dated 02/01/2025 for Debrox otic solution 6.5 % with instructions to instill 10 drops into both ears twice a week on Wednesdays and Saturdays for ear wax removal. The Order Summary Report also contained an order dated 01/21/2025 for lurasidone hydrochloride (an antipsychotic medication) 20 milligrams (mg) with instructions to give 40 mg (equivalent to two tablets) each morning for bipolar disorder. A concurrent observation and interview on 02/19/2025 at 7:41 AM revealed Registered Nurse (RN) #1 was preparing morning medications for Resident #39. As RN #1 prepared the resident's medications, it was noted she placed only one 20 mg tablet of lurasidone into the medication cup. RN #1 was stopped and asked to read the medication directions on the label and to review the physician's order on the resident's Medication Administration Record (MAR). The nurse then added a second tablet of lurasidone to the medication cup. During medication administration, RN #1 picked up the bottle of Debrox otic solution and placed the bottle into the resident's right nasal passage. The nurse was stopped before she instilled the drops into the resident's left nostril. RN #1 was interviewed immediately upon leaving Resident #39's room. She confirmed she had not read the label correctly for the lurasidone and had only placed one 20 mg tablet into the cup until reminded to read the medication label and orders. RN #1 stated she also made a mistake by instilling the resident's ear drops into the resident's nostril due to being nervous. The Director of Nursing (DON) was interviewed on 02/19/2025 at 9:10 AM and stated that when a nurse gave medications, he expected the nurse to check and make sure the right dose was given to the right patient in the right room by the right route at the right time. The DON stated RN #1 should have read the label carefully for the lurasidone and given two tablets as ordered by the physician. The DON stated he would have expected the ear drops to be administered by the right route for Resident #39. A telephone interview was held with the Consultant Pharmacist (CP) on 02/20/2025 at 7:56 AM. The CP stated he expected nurses to double check medications before administering them to make sure the medications had been prepared correctly, which included making sure the right dose of the right medication was given to the right resident by the right route. The CP stated instilling ear drops into Resident #39's nose and preparing the wrong dose of lurasidone were considered medication errors. The DON was interviewed on 02/20/2025 at 10:00 AM and stated the nurse made medication errors when she gave the medication by the wrong route and did not give the correct dosage of lorasidone. He stated he expected nurses to give the right medication by the right route and expected the right dose to be given. The Administrator was interviewed on 02/20/2025 at 10:15 AM. The Administrator stated he expected the nurses to make sure they gave the right medication, the right dosage, by the right route, to the right resident. The Administrator stated that when RN #1 had not given the right dosage of medication to Resident #39 and administered the ear drops by the wrong route, medication errors were made.

Based on interview and record review, the facility failed to ensure baseline care plan was developed within 48 hours of admission for Resident 6 and a copy of the baseline care plan summary was provided to the resident and/or representative for three of 3 sampled residents (Resident 5, 6, and 7). A Baseline Care Plan (BCP) includes minimum healthcare information necessary to properly care for each resident immediately upon their admission, which would address resident-specific health and safety concerns to prevent decline, injury, such as elopement or fall risk, and would identify needs for supervision, behavioral interventions, and assistance with activities of daily living, as necessary. The deficient practice resulted in Resident 5, 6, and 7, and/or RP not receiving information of the initial plan of care; and had the potential to result in inadequate care and services rendered to the residents. Findings: Review of Resident 5 ' s admission record indicated, admitted to facility on 4/11/24 with diagnoses including rhabdomyolysis (a breakdown of muscle tissue that releases a damaging protein into the blood), kidney disease, pulmonary hypertension (a type of high blood pressure that affects arteries in the lungs and in the heart), and major depressive disorder (persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). Review of Resident 5 ' s Minimum Data Set (MDS, a resident assessment tool) dated 4/15/24, indicated, no cognitive (thought process) impairment. Review of Resident 5 ' s Baseline Care Plan dated 4/11/24, indicated, na (not applicable) under section E. Baseline Care Plan Summary - Resident and/or Resident Representative (RR) participated in the Baseline Care Plan review with a printed/written summary provided . Printed Baseline Care Plan provided via: 2a. In person .2b. Fax .2c. Mail .2d. Email . Review of Resident 6 ' s admission record indicated, admitted to facility on 12/1/23 with diagnoses including cancer of the prostate, cervical disc degeneration (caused by decreased water content of the disc or desiccation which leads to tears in the outer ring or the annulus fibrosus), and glaucoma (a group of eye diseases that can cause vision loss and blindness by damaging a nerve in the back of the eye). Review of Resident 6 ' s MDS dated [DATE], indicated no cognitive impairment. Review of Resident 6 ' s Baseline Care Plan dated 12/1/23, indicated, all sections were not completed within 48 hours. The baseline care plan indicated, Social Services section was completed on 12/4/23, Rehabilitative Services completed on 12/5/23, and Activity Preferences completed on 12/4/23. Further review indicated, Resident 6 ' s Baseline Care Plan Summary dated 12/1/23, indicated, na (not applicable) under section E. Baseline Care Plan Summary - Resident and/or Resident Representative (RR) participated in the Baseline Care Plan review with a printed/written summary provided . Printed Baseline Care Plan provided via: 2a. In person .2b. Fax .2c. Mail .2d. Email . Review of Resident 7 ' s admission record indicated, admitted to facility on 4/23/24 with diagnoses including kidney disease, congestive heart failure (a long term condition in which the heart doesn't pump blood as well as it should), atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), and depression. Review of Resident 7 ' s Baseline Care Plan Summary dated 4/23/24, indicated, na (not applicable) under section E. Baseline Care Plan Summary - Resident and/or Resident Representative (RR) participated in the Baseline Care Plan review with a printed/written summary provided . Printed Baseline Care Plan provided via: 2a. In person .2b. Fax .2c. Mail .2d. Email . During interview and concurrent record review on 4/25/24 at 5:08 PM, the Director of Nursing (DON) reviewed Resident 5, Resident 6, and Resident 7 ' s Baseline Care Plan. The DON acknowledged and stated, Resident 6 ' s baseline care plan was not completed on time and that all sections should be completed within 48 hours. During further interview, the DON stated, na written on the Baseline Care Plan Summary means not reviewed and provided to the resident. Review of facility ' s policy and procedure titled, Care Plans - Baseline, revised December 2022, indicated, A baseline plan of care should be developed for each resident within forty-eight (48) hours of admission. 1. The baseline care plan should include instructions needed to provide effective, person-centered care of the resident, which may include the following: . d. Therapy services; e. Social Services . 4. The resident and/or representative should be provided a written summary of the baseline care plan as guided by the discussion noted above.

Based on Interviews and record reviews, the facility failed to ensure the allegation of resident-to-resident abuse was promptly reported to the State Agency (SA, which is the California Department of Public Health, CDPH) in accordance with the facility ' s policy and procedure for four of 4 sampled residents (Resident 1, Resident 2 Resident 3, and Resident 4). Failure to promptly report allegation of abuse had the potential for further abuse to happen and thereby increasing the chances of harm to the residents. Findings: During a review of Admission Record, dated [DATE], indicated, Resident 1, admitted to facility on [DATE], with diagnoses including: Seizures (involuntary body jerking), Adult failure to thrive, Dementia (loss of memory). Resident discharged on [DATE]. Review of Admission record, dated, [DATE], indicated, Resident 2, admitted to facility on [DATE] with diagnoses including: Compression Fracture Lumbar, Cirrhosis of Liver ( damaged liver from various causes) , Malignant Neoplasm of Larynx (Cancer of the voice box). Patient expired [DATE]. During a review of facility Investigation Summary, dated, [DATE], indicated, on [DATE] at 2125, CNA reported to LN that Resident 2 told him that his roommate alleged splashed liquid in his face. LN separated residents .Resident 2, alert and oriented, interviewed by LN, per resident, was about to go sleep, when other resident who was sitting in his bed, opened the curtain and splashed liquid in my face. It feels like water from a cup .Resident 1 was transferred to another room. Per resident 1, I don ' t know what happened, I did not do anything. I ' m sorry about that. Resident 1is confused at baseline. Assessment done for both residents .Resident 2 was happy when resident 1 was transferred to another room. MD notified, RP notified for both. Local police notified, Ombudsman notified, CDPH notified, SOC faxed . During an interview on [DATE] at 2;14 PM, with Scial Worker Designee (SW), per SW, she remembers the incident, these two were roommates, resident 1 is a wanderer, he has Dementia. Resident 1 splashed water on roommate ' s face, it was in the evening. Resident 2 is alert and oriented, he stated, that his roommate opened the curtain and splashed liquid in his face most likely water from his table. They were separated, resident 1was moved to another room and resident 2 was satisfied and thank staff for the prompt action. During a review of nurses notes for monitoring, for ,d+[DATE]/- [DATE], resident 1, no signs of distress, was in bed all night .confused, walking in hallway wanted to smoke . confused walking in the hallway looking for relative. Refused nicotine patch application but consented when wife arrived . During an interview on [DATE] at 2:33 PM , with Registered Nurse ( RN), PM nurse supervisor, per RN, resident 1, got up and threw water to resident 2. Resident 1 was transferred to another room, and resident 2 like that. There was no issue after that. SOC was completed, left voicemail message with CDPH and Ombudsman. both patients monitoring done, DSD gave inservice to staff on abuse. Mr Papkov was on Hospice and expired [DATE]. During a review of Interdisciplinary Note ( IDT) note, dated [DATE], indicated, at 2125 CNA notified LN that resident that Resident 2 told him that his roommate alleged splashed liquid in his face. LN separated residents .Resident 2, alert and oriented, interviewed by LN, per resident, was about to go sleep, when other resident who was sitting in his bed, opened the curtain and splashed liquid in my face. It feels like water from a cup .Resident 1 was transferred to another room. Per resident 1, I don ' t know what happened, I did not do anything. I ' m sorry about that. Resident 1is confused at baseline. Assessment done for both residents .Resident 2 was happy when resident 1 was transferred to another room. MD notified; RP notified for both. Local police notified with reference number, Ombudsman notified. At 2152 CDPH notified and spoke with [NAME], after 15 minutes [NAME] from CDPH called the facility and informed the LN that they can send the SOC 341 tomorrow morning after 8 PM if having trouble faxing it.At 740 AM,DON faxed the SOC to CDPH, at 0805 , DON called CDPH phone number to verify if the SOC was received, went straight to voicemail, VM was left awaiting response. During an interview on [DATE] at 5 PM, with Director of Nursing (DON), per DON, the RN called the CDPH number to notify about the alleged abuse and faxed the SOC. The faxed machine on [DATE] was not printing receipts, but able to fax out as indicated in the fax machine window message. No confirmation of transmittal page was printed. During an iInterview on [DATE] at 5 PM, with RN, per RN, she called the CDPH number from the website, she has to search the number (unable to give that phone number), and spoke to two people from CDPH,and informed LN that they can send the SOC 341 tomorrow morning after 8 PM if having trouble faxing it. During a review of facility document, Care Plan, initiated [DATE] for both residents, updated, no issues. Interview on [DATE] at 3:23 Pm, with Director of Staff Development (DSD), /DSD, per DSD, Abuse inservices are given every month for all staff. It is given through powerpoint presentation in the conference room. During a review of voicemail messages in the CDPH office on [DATE] at 9AM with CDPH office staff, per office staff no voicemail message left on [DATE] or [DATE], to report abuse . SOC 341 was received in the office on [DATE] via fax. During a record review of Admission Record, dated, [DATE], indicated, Resident 3 admitted to facility on [DATE] with diagnoses including: Compression Fracture of Lumbar vertebra, ( small breaks or cracks in the bones of the spinal column) Osteonecrosis ( death of a bone tissue due to interruption of blood supply), Anxiety Disorder ( uncontrollable feelings of fear). Patient discharged on [DATE]. During a review for Resident 3 ' s MDS- Cognitive Patterns, dated [DATE], indicated, Brief Interview for Mental Status (BIMS), score is 11, no cognitive impairment. During a review of Admission Record, dated, [DATE], indicated, Resident 4 admitted to facility on [DATE] with diagnoses including Intracranial( brain) injury without loss of consciousness s/p pedestrian injured in traffic accident, Hemiplegia (weakness in one side of body) Cervicalgia (formal way of calling neck pain or cervical pain). Patient discharged [DATE]. During a review for Resident 4 ' s MDS- Cognitive Patterns, dated [DATE], indicated, Brief Interview for Mental Status(BIMS), score is 12, no cognitive impairment. During a review of facility ' s Investigation Summary, dated, [DATE], indicated, On [DATE], Resident 3 came back from his appointment at 1550, upon returning to his room, resident 3 informed Administrator in Training (AIT), claiming that his former roommate allegedly stole his Identification card and $32.00 cash .Resident 4 was discharged on [DATE]. Ombudsman was notified via phone. CDPH was informed at 1710 via phone and spoke with [NAME]. Local police were notified. SOC 341 was faxed afterwards. RN called Resident 4 ' s listed number .not answering phone with multiple attempts. Facility not able to get a statement from resident 4 . facility investigation, spoke with the staff worked with resident 3, staff stated no awareness of said allegation, staff also were not notified by resident 3 he has some cash in his possession. Residents interviewed stated, no concerns about care rendered by staff . no mention in his inventory list that he signed that he has cash in possession . During a review on [DATE] at 4PM, of facility document, Inventory of Personal Items, signed by resident 3 on [DATE], no indication of ID or cash on the list. During a review of Interdisciplinary Team (IDT) note, dated [DATE], indicated, on [DATE], Resident 3 came back from his appointment at 1550, upon returning to his room, resident 3 informed Administrator in Training (AIT), claiming that his former roommate allegedly stole his Identification card and $32.00 cash .Resident 4 was discharged on [DATE]. DPOA for patient care was called at 1645 and was informed in regards to patient ' s complain. Ombudsman informed at 1700 via phone call and voicemail was left. CDPH was informed at 1710 via phone and spoke with an agent ([NAME]) and reported the alleged financial abuse. Local police were notified at 1720. PIMG was called at 1725 and was able to talk to PA (Physician Assistant). Ombudsman called back the facility at 1745, LN was able to talk to him in regards to alleged financial abuse .patient monitored for any emotional and psychological distress every shift. During an interview on [DATE] at 5PM, with Director of Nursing, per DON, he called CDPH office and talked to an agent named [NAME] as indicated in nurses notes and IDT notes dated [DATE]. During an interview on [DATE] at 3PM, with Director of Staff Development(DSD), per DSD, the inservice for Abuse is given monthly to all staff via powerpoint. Review of Inservice Lesson Plan dated [DATE], was provided and [DATE] to include, Inventory guidelines. Per DSD, no specific inservice for misappropriation, it ' s a part of the Abuse class. During an interview on [DATE] at 2:15PM, with Social Worker Designee (SW), per SW these residents were roommates, resident 3 was admitted first in that room. There was no complaints from both of them, but that [DATE], alleged financial abuse. The staff will list all personal belongings on admission, money is not in the list. Most patients will want to keep them if alert and oriented. Or we put in safe, patient has to agree to that. During an interview on [DATE] at 9:30 AM, with CDPH office staff, per office staff, no voicemail notification from facility on [DATE], no staff or agent at CDPH named [NAME]. No SOC 341 received via fax on [DATE]. Office received 5day summary on [DATE]. Facility provided transmission verification result with fax number [DATE] (not CDPH fax number). Review of facility Policy and Procedure, Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigation, dated ,d+[DATE], indicated, 2. The administrator or the individual making the allegation immediately reports his or her suspicion to the following agencies: a. The state licensing/certification agency responsible for surveying/licensing the facility .3. Immediately is defined as: a. Within two hours of an allegation involving abuse or result in serious injury .

Based on interview, record review, and observation, the facility failed to provide needed care and assistance in accordance with professional standards of practice when Resident 1, one of one sampled residents, did not receive pain medication or bathroom assistance, throughout the entire night. This failure caused undue suffering and neglect to the resident. Findings: Resident 1 was admitted to the facility on [DATE], at 3:30 PM, for Physical Therapy and Occupational Therapy services after transfer from hospital. Resident 1's diagnoses included, lumbar fracture from fall, back surgery from fall fracture, back pain, high blood pressure, gout (inflammatory joint pain and swelling), urinary tract infection, and liver disease. Required assistance with toileting, transferring, bathing and dressing. Resident is not incontinent of urine (has control of her urine). Alert and oriented, denied pain upon admittance. Resident was medicated prior to transfer from hospital. Resident is [AGE] years old and does not speak English. During an interview and observation on 1/27/2024, at 11:28 AM, at nurses station, son of Resident 1 stated his mother has been waiting for pain medications since yesterday. She had back surgery a week ago and was transferred from hospital to facility yesterday. She has back pain. She has also needed to urinate and had the call light on all night long trying to get help. No one came. In resident's room, Resident looked anxious, distressed, face grimacing. Speaking in Cantonese to son, who translated, Resident stated she walked to bathroom with walker, without assistance, needing help, because she couldn't wait any longer to urinate. Last night her pain level was 8 out of 10. No one ever came to assist her. Later that night she had to go to the bathroom again. She wet her bed and laid in her wet bed until 7:30 AM this morning. Son stated there were no Cantonese speaking staff available and they did not use translater services. She received her first pain medication at 11:30 AM on 1/27/2024. And they never answered her call light all night. Record review of facility policy, revised March, 2018, Activities of Daily Living (ADLs), Supporting indicated, Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene .2. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. Hygiene (bathing, dressing, grooming, and oral care); b. Mobility (transfer and ambulation, including walking); c. Elimination (toileting); d. Dining (meals and snacks); and e. Communication (speech, language and any functional communication systems). 3. Care and services to prevent and/or minimize functional decline will include appropriate pain management . Review of Progress Notes dated 1/27/2024 at 4:44 PM, At 10:30 AM, Director of Nurses (DON) spoke with resident's son, he has some concern regarding the care of his mother, DON acknowledge and informed son he will look at it and address the situation . During a telephone interview on 4/9/2024 at 4 PM, son of resident stated his mother, had a pain scale of 9 out of 10 in the morning due to back pain. Nobody answered the light all night long. She got up by herself and walked to the bathroom by herself and should not have been walking at all, unassisted. (Resident) only speaks Cantonese. They had no one who spoke Cantonese and they did not use interpreter services. She came into facility at 3:30 PM on 1/26/2024 and had received pain medication at the hospital before transfer. When she needed pain medication later that night, they had none. She waited until the next day, 1/27/2024, before they were able to give her pain medications again and they never answered her call light that night . \

Based on observation, interview, and record review, the facility failed to provide a safe and sanitary environment when: 1. The Red Zone (isolation room) door, with Resident 434 inside, was fully open while staff was cleaning the room. 2a. A dirty urinal was hung on the side rail of Resident 44's bed on 5/23/23. 2b. Resident 44's urinal jug containing urine was placed on the overbed table. 3. Staff did not perform hand hygiene after glove removal. 4. Staff did not perform hand hygiene when she entered between two residents' rooms. 5. Staff did not clean and disinfect medical equipment (blood pressure cuff) in between multiple residents (Resident 39, Resident 53, and Resident 44). These failures had the potential for cross contamination of infection that can compromise the health and safety of the residents and the potential to spread infectious disease from one resident to another. Findings: 1. Resident 434 was admitted on [DATE] with diagnoses including septicemia (an infection that occurs when germs get into the bloodstream and spread). Review of Resident 434's Lab Results Report, dated 5/19/23 indicated Resident 434 tested positive for COVID-19 infection (a very contagious disease that spreads quickly, caused by a virus named SARS-CoV-2). During a concurrent observation and interview with Registered Nurse (RN) 1, on 5/23/23 at 1:19 PM, Resident 434's door was closed. A posted signage on Resident 434's door indicated, Red Zone. RN 1 stated, He (Resident 434) is on COVID isolation, tested positive last week. During an observation on 5/24/23 at 2:12 PM, Resident 434's room door was fully open while Resident 434 was inside the room. Housekeeping Staff (HS) was inside Resident 434's room, mopping the floor. During a concurrent observation and interview on 5/24/23 at 2:14 PM, RN 2 verified the aforementioned observation. RN 2 asked HS for the reason for keeping Resident 434's room door open. HS stated, Because I'm cleaning the room. During the concurrent interview on 5/24/23 at 2:14 PM, the Housekeeping Director (HD) stated that the door of Red Zone room should be closed during cleaning. The HD stated, Because we don't want to spread the virus (referring to COVID-19). 2a. Resident 44 was admitted on [DATE] with diagnoses including seizure disorder (unusual electrical activity in the brain that can cause changes in behavior, movement, or feelings) and depression (persistent sadness and a lack of interest or pleasure in previously rewarding or enjoyable activities). Review of Resident 44's Minimum Data Set (MDS, an assessment tool), dated 5/5/23, indicated Resident 44 had moderate cognitive impairment. During a concurrent observation and interview with Resident 44 on 5/23/23 at 9:55 AM, an uncovered urinal jug was hanging on the side rail of Resident 44. Brown-colored particles were found on the opening, in the interior, and exterior of the urinal jug. Resident 44 stated, It's an old one. There's no cover. I want it with cover. It's dirty, I don't want to use it if it's dirty. During a concurrent observation of Resident 44's urinal jug and interview on 5/23/23 at 10:00 AM, Certified Nursing Assistant (CNA) 1 stated, It (referring to the urinal jug) is a week old, it's dirty. It should have a cover, for hygiene. During an interview 5/23/23 at 11:02 AM, RN 1 stated, There should be a cap (referring to the urinal jug). If dirty, it's not supposed to be there. It's unsanitary, not hygienic. 2b. During a concurrent observation and interview on 5/24/23 at 10:55 AM, Resident 44's urinal jug containing amber-colored liquid was placed on Resident 44's overbed table. RN 2 stated, It's urine, about 5 ml (milliliter), not supposed be there, not on the table. He eats there, for infection (control) and patient safety. 3. During a concurrent observation and interview on 5/24/23 at 10:24 AM, CNA 3 was inside room [ROOM NUMBER] with gloved hands. CNA 3 removed her gloves, disposed the gloves in the trash can inside room [ROOM NUMBER], and proceeded to get new gloves without performing hand hygiene. During continued observation, CNA 3 exited room [ROOM NUMBER] while holding the gloves. CNA 3 stated, I should have performed hand hygiene (after glove removal), for infection control. During an interview 5/25/23 at 2:50 PM, the Infection Preventionist (IP) stated that the door of the Red Zone needs to be closed for isolation since there is possibility of spread of the virus because the resident is inside (the isolation room). The idea is to minimize the spread of the virus that's why we keep the door closed. The IP also stated dirty urinals should not be hung on resident's side rails and placed on a resident's overbed table. The IP stated, It's not acceptable. It can be a source of potential contamination, especially, if it's next to drink or food. The IP further stated, Staff should perform hand hygiene after they remove their gloves and before putting on a new one. When requested for a policy and procedure (P&P) for cleaning of the Red Zone room, the IP provided a facility IP&IP titled, Cleaning and Disinfecting Residents' Rooms, revised on 8/2021. The P&P did not address the cleaning of the Red Zone room (isolation room). The IP stated, We don't have a specific policy but we provide education to staff that the door needs to be closed for the Isolation Room. Review of the facility P&P titled, Bedpan/Urinal, Offering/Removing, revised 2/2018 indicated, After Assisting the Resident: 5. Take the bedpan or urinal into the bathroom .7. Empty the bedpan or urinal into the commode. Flush the commode. 8. Clean the bedpan or urinal. Wipe dry with a clean paper towel .Store the bedpan or urinal per facility policy . Review of the facility P&P titled, Handwashing/Hand Hygiene, revised 8/2019 indicated, This facility considers hand hygiene the primary means to prevent the spread of infections. Policy Interpretation and Implementation .7. Use an alcohol-based hand rub containing at least 62% alcohol or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: m. after removing gloves . 44477 4. During an observation on 5/23/23, at 1:02 PM, in hallway, Certified Nursing Assistant (CNA) 1 entered the Resident 49's room without performing hand hygiene (hand washing with soap and water, or cleaning hands with alcohol-based hand sanitizers). Then she exited the room after touching Resident 49 to change his position on the bed with another staff member. CNA 1 did not perform hand hygiene when exiting the room. As soon as she came out of Resident 49's room, she went straight to the next room where Resident 4 was without performing hand hygiene. Then she touched Resident 4's walker and left Resident 4's room, but she did not perform hand hygiene. Then, she went straight to Resident 49's room again and exited without performing hand hygiene. During an interview on 5/23/23, at 1:04 PM, with CNA 1, CNA 1 stated, No when asked if she performed hand hygiene between the two rooms. She stated, No when asked if she was trained to perform hand hygiene between residents' rooms. CNA 1 stated, she did not know that she had to perform hand hygiene between residents' rooms. During an interview on 5/23/23, at 1:12 PM, with Registered Nurse (RN) 1, RN 1 stated, You have to wash (hand) . when asked what to do when going to and from residents' rooms. She acknowledged, CNA 1's practice was not right. During an interview on 5/23/23, at 1:55 PM, with Infection Preventionist (IP), IP stated, Before and after the resident contact when asked about the facility's policy of hand hygiene. She stated, Before you enter the resident room, you have to wash your hands. During an interview on 5/23/23, at 3:00 PM, with IP, IP stated, Whenever staff member touches or in contact with belonging of a resident, staff members are reminded through in-services and on the spot hand hygiene observation to do proper hand hygiene after touching belongings. She also stated, it is the best practice to perform hand hygiene before and after entering a resident room. During an interview on 5/24/23, at 2:22 PM, with IP, IP verified, CNA 1 had already been trained prior to this incident to perform hand hygiene when entering and exiting residents' rooms. Review of the facility's policy and procedure (P&P) titled, Handwashing/Hand Hygiene, revised in August 2019, the P&P indicated, . This facility considers hand hygiene the primary means to prevent the spread of infections . 7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations . b. Before and after direct contact with residents . g. Before handling clean or soiled dressing, gauze pads, etc. k. After handling used dressings, contaminated equipment, etc . 47347 5. Review of Resident 39's MDS (Minimum Data Set, tool used for a comprehensive Resident assessment) dated 5/1/23 indicated that Resident 39 was admitted on [DATE] with medical diagnoses including depression, hypertension (high blood pressure), and hyperlipidemia (high cholesterol). Review of Resident 53's MDS dated [DATE] indicated that Resident 53 was admitted on [DATE] with medical diagnoses including chronic obstructive pulmonary disease (long term condition affecting the lungs), Heart failure, and vascular dementia (cognitive function loss from inadequate blood supply to the brain). Review of Resident 44's MDS dated [DATE] indicated that Resident 44 was admitted on [DATE] with a medical diagnosis of Epilepsy (seizure disorder), Wedge compression fracture of T7-T8 (broken bones in the spine), and Depression. During an observation on 5/23/23 at 09:30 AM in Resident 39's room, it was observed that licensed vocational nurse (LVN)1 took a blood pressure (BP) for Resident 39 and returned the BP cuff to the BP machine without cleaning or sanitizing it. At 10:10 AM in Resident 53's room, it was observed that LVN 1 took the same BP cuff that was used on Resident 39 and took the BP for Resident 53. After taking the BP for Resident 53 the BP cuff was returned to the BP machine without being cleaned or disinfected. At 10:30 AM in Resident 44's room, it was observed that LVN 1 used the same BP cuff ( the one used for Resident 39 and 53) and used it to take Resident 44's BP. After taking the BP for Resident 44 the BP cuff was returned to the BP machine without being cleaned or disinfected During an interview on 5/23/23 at 10:45 AM with LVN 1, LVN 1 stated that the BP cuff should be cleaned and sanitized in between each Resident use. LVN 1 stated that she did not clean the BP cuff in between each Resident use. Review of the undated policy and procedure titled Cleaning and Disinfection of Resident-Care items and Equipment, the policy indicated that Durable medical equipment (DME, medical equipment such as blood pressure cuffs, oxygen sensors etc.) must be cleaned and disinfected before reuse by another Resident.

Based on observation, interview, and record review the facility failed to maintain a medication error rate less than five percent for two out of seven Residents observed (Residents 53 and Resident 8). This created an error rate of 9.68 percent (3 errors out of thirty-one opportunities). This failure had the potential to cause worsening medical conditions for each resident. Findings. 1. Symbicort was not administered during the appropriate time frame for Resident 53 (omission of medication). 2. Depakote delayed release tablets was crushed and administered for Resident 8. 3. Lidocaine patch was not applied to Resident 8 and documented as administered (omission of medication). 1. During an observation on 5/23/23 at 9:49 AM in Resident 53's room, it was observed that licensed vocational nurse (LVN) 1 administered tablet medications only to Resident 53. It was observed that Resident 53 was offered stool softeners, and that Resident 53 refused the stool softener. Review of Resident 53's Medication orders and Medication Administration Record, indicated that Resident 53 had Symbicort (inhaler used for respiratory disorders) due on 5/23/23 at 09:00 AM and it was not administered. During an interview on 5/23/23 at 11:30 AM with LVN 1, LVN 1 stated that the medication Symbicort inhaler was scheduled to be given at 09:00 AM but was not given because the Symbicort inhaler was unavailable. LVN 1 stated that the Symbicort inhaler was ordered earlier (on 5/23/23), and it should be arriving later in the evening or early the next day. Review of the Policy titled Medication ordering and receipt record revised in 2001, indicated that medications should be ordered in advance, based on the dispensing required lead time. 2. & 3. Review of Resident 8's MDS dated [DATE] indicated Resident 8 was admitted on [DATE] with medical diagnoses including Epilepsy (seizure disorder), dysphagia (difficulty swallowing), and cognitive communication deficit (unable to communicate and/or understand). During an observation on 5/24/23 at 8:36 AM, in Resident 8's room, it was observed that LVN 2 crushed and administered Amlodipine (blood pressure medication), Aspirin, Folic Acid, Metformin (medication for diabetes), Gabapentin (medication for seizures), Prednisone(steroid medication), Vitamin B12, and Depakote delayed release tablet (medication used for seizures and other conditions. Delayed release tablets are meant to be absorbed over a period, allowing the medication dose to be released into the blood stream over that time). Review of Resident 8's Medication Administration Record and orders indicated that Resident 8 was scheduled to be given a Lidocaine patch (medication to relieve pain) on 5/24/23 at 09:00 AM. During an interview with LVN 2 on 5/24/23 at 3:00 PM, LVN 2 stated that she crushed the Depakote delayed release tabled because the resident has issues swallowing. When questioned if delayed release tablets should be crushed LVN 2 replied No. LVN 2 stated that she should not have crushed the delayed release tablets and instead should have called the doctor and pharmacy to get a different form of the medication that would be safe to administer. LVN 2 stated that the Lidocaine patch was scheduled for administration at 09:00 AM for Resident 8, and it was not administered because per LVN 2's assessment Resident 8 was not in pain. When it was asked to review the medication record stating that Resident 8 did not receive the Lidocaine patch, the medication record was pulled up but showed that the Lidocaine patch was administered on 5/24/23 at 1:12 PM. LVN 2 stated that the Lidocaine patch was documented but not administered. LVN 2 stated that she gave all the medications at 08:30 AM and then at 1:00 PM went back to document her medication administrations, and at that time incorrectly documented the Lidocaine patch as given. During review of the undated policy titled Documentation of Medication Administration, indicated that administration of medication is documented immediately after it is given. Documentation of medication administration should include date and time of administration, reasons why it was withheld. During review of the undated policy titled Crushing Medications indicated that the nursing staff and/or consultant pharmacist shall notify any attending physician who gives an order to crush a drug that the manufacturer states should not be crushed (for example; long acting or enteric coated mediations). The attending physician or consultant pharmacist must identify an alternative medication or dosage form.

Based on observation, interview, and record review, the facility failed to revise the fall care plan for one of three sampled residents (Resident 6) after his fall incident on 10/26/22. This failure had the potential to put Resident 6 at risk for another fall. Findings: Review of Resident 6's clinical record indicated, Resident 6 was admitted to the facility on [DATE] with diagnoses including mild cognitive impairment (a condition where people experience memory and thinking problems), hypertension (high blood pressure), and history of falling. Review of Resident 6's MDS (Minimum Data Set, an assessment tool), dated 12/3/22 and 5/7/23, indicated, Resident 6 was severely cognitively impaired. During a concurrent observation and interview on 5/23/23, at 11:17 AM, with Resident 6, in his room, Resident 6 was sitting in wheelchair. He was confused with time and place when asked. During an observation on 5/25/23, at 9:23 AM, in hallway, Resident 6 was sitting in wheelchair, and roaming around in the hallway by himself. During an interview on 5/25/23, at 9:30 AM, with Resident 6, he was confused with place when asked. During an interview on 5/25/23, at 11:38 AM, with Director of Nursing (DON), DON stated, He gets up on his own . He frequently roams around with wheelchair. Review of Resident 6's care plan indicated, he fell on [DATE], 10/26/22, 12/23/22, 2/20/23, and 5/20/23. Review of Resident 6's clinical record titled, eINTERACT Change in Condition Evaluation - V 5.1, dated 10/26/22 indicated, .11. Falls . 10/26/2022 . No changes observed . Review of Resident 6's clinical record titled, 02.Nursing -Fall Risk Observation/Assessment - V 2.0(Fall Risk Assessment), dated 10/26/22, indicated, . Score: 24 . in the header. The Fall Risk Assessment indicated, . During the last 90 days the resident has had . 1-2 Falls . 4. Ambulates with problems and with devices (gait is unsteady, slow, lurching) . 11. Scoring . The Score . will appear in the header of this assessment as per the scoring below . C. HIGH RISK 16-42 . During an interview on 5/25/23, at 1:32 PM, with DON, DON stated, Resident 6 had multiple falls before and after his admission to the facility. DON stated, .We don't provide sitter here . We involve them (family member) . There are work to do to prevent fall . when asked about the facility's interventions. But when asked why Resident 6 had multiple falls if the facility's intervention was effective, DON did not answer. DON acknowledged, Resident 6's multiple falls in the facility were excessive. During an interview on 5/26/23, at 12:50 PM, with the Director of Staff Development (DSD), DSD verified, Resident 6 fell on [DATE], 10/26/22, 12/23/22, 2/20/23, and 5/20/23. She stated, Yes when asked if Resident 6's five falls in the facility were a lot for him. During a concurrent interview and record review on 5/26/23, at 2:10 PM, with DSD, Resident 6's care plan was reviewed together. There was no revision of care plan after his fall on 10/26/22. DSD stated, NO when asked if she could see care plan revision on 10/26/22. When asked if the goal was met, she stated, No. When asked if the previous interventions were effective, she stated, No because he fell again. Review of the facility's policy and procedure (P&P) titled, Assessing Falls and Their Causes, undated, indicated, . 1. Falls are a leading cause of morbidity and mortality among the elderly in nursing homes . 6. Appropriate interventions taken to prevent future falls . Review of the facility's P&P titled, Falls and Fall Risk, Managing, revised in March 2018, indicated, . Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling . 5. If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant . Review of the facility's P&P titled, Goal and Objectives, Care Plans, undated indicated, . 5. Goals and objectives are reviewed and/or revised . a. when there has been a significant change in the resident's condition; b. when the desired outcome has not been achieved .

Based on interview and record review, the facility failed to create a baseline care plan based on physician admitting order of one of three residents (Resident 78) reviewed when Resident 78 admitted [DATE] with enteral feeding order, care plan was only initiated on 5/24/23. This failure can result in Resident 1 not getting tube feeding as ordered. Findings: Review of Resident 78's Admission Record indicated, admitted to facility on 5/15/23 with diagnosis including Dysphagia (difficulty in swallowing), Esophageal Cancer (cancer of the tube that runs from the throat to the stomach). Review of Physician Order dated 5/17/23, indicated, Enteral Feed (form of nutrition delivered into the digestive system as liquid) Order, Jevity 1.5 at 100 ml/hr x 8 hours (9:00 PM-5:00 AM), one time in the evening. Review of Care Plan, indicated, resident requires tube feeding r/t (related to) esophageal cancer s/p (status post, after) esophagectomy (removal of esophagus), esophageal stricture initiated 5/24/23. Interview on 5/25/23 with DON, DON stated, care plan should be initiated in 24 - 48 hours upon admission. The MDS (Minimum Data Set, an assessment tool) nurse missed this. Review of the facility Policy and Procedure, Care Plans-Baseline, no date, indicated, A baseline plan of care should be developed for each resident within forty-eight (48) hours of admission. The baseline care plan should include instructions needed to provide effective, person-centered care of the resident, which may include the following . b. Physician's orders .

Based on observation, interview, and record review, the facility failed to implement fall care plan for one of three sampled residents (Resident 6) when there was no landing pad (known as fall mat) in place after his fall incident on 2/20/23. This failure placed Resident 6 at risk for injury from another fall. Findings: Review of Resident 6's clinical record indicated, Resident 6 was admitted to the facility on [DATE] with diagnoses including mild cognitive impairment (a condition where people experience memory and thinking problems), hypertension (high blood pressure), and history of falling. Review of Resident 6's MDS (Minimum Data Set, an assessment tool), dated 12/3/22 and 5/7/23, indicated, Resident 6 was severely cognitively impaired. During a concurrent observation and interview on 5/25/23, at 9:21 AM, with Certified Nursing Assistant (CNA) 2, in Resident 6's room, there was no landing pad in place. There was no sign in Resident 6's room and at the door indicating that he was at high risk of falling. CNA 2 stated, He is not high fall risk when asked. During an interview on 5/25/23, at 11:33 AM, with the Director of Nursing (DON), DON stated, Resident 6 was not at high fall risk although he had a history of falls prior to his admission when asked. During a concurrent interview and record review on 5/25/23, at 11:34 AM, with the DON, Resident 6's clinical record titled, 02. Nursing -Fall Risk Observation/Assessment - V 2.0 (Fall Risk Assessment), dated 8/1/22 was reviewed. The Fall Risk Assessment indicated, . Score: 18 . Type: Admission . in the header. The Fall Risk Assessment also indicated, . The Score and Category will appear in the header of this assessment as per the scoring below . C. HIGH RISK 16-42 . DON stated, high-risk fall scores ranged from 16 to 42 when asked. Then DON acknowledged, Resident 6 was at high risk for falls from his admission to the facility. Review of Resident 6's clinical record titled, eINTERACT Change in Condition Evaluation - V 5.1, dated 2/20/23 indicated, . 11. Falls . 02/20/2023 . CNA discovered patient sitting on floor next to foot of bed with fecal matter rubbed on floor near head of bed and all over bed at 0650 . 7. No changes observed . During a concurrent interview and record review on 5/25/23, at 11:38 AM, with the DON, Resident 6's clinical record titled, 02. Nursing -Fall Risk Observation/Assessment - V 2.0 (Fall Risk Assessment), dated 2/20/23 was reviewed. The Fall Risk Assessment indicated, . Score: 24 . in the header. DON stated, Yes when asked if the score of 24 was high risk for falls. DON stated, CNA 2 would not have known because he was a registry when asked why CNA 2 did not know that Resident 6 was at high risk for falls. When asked if it was reasonable to not know because CNA 2 is a registry, DON did not answer. Review of Resident 6's care plan indicated, . unwitnessed fall 2/20/23 . [NAME] pad (typo of landing pad) in place Date initiated: 02/21/2023 . During a concurrent observation and interview on 5/25/23, at 12:00 PM, with CNA 2 and DON, at the door of Resident 6's room, there was no fall mat on the floor in the room, and no signage of high fall risk. DON acknowledged, the fall mat (landing pad) was not in place. CNA 2 stated, I wasn't aware in front of DON when asked if he was aware that Resident 6 was at high risk for fall. During an interview on 5/26/23, at 10:29 AM, with Director of Staff Development (DSD), DSD stated, No when asked CNA 2's practice that he did not know that Resident 6 was at high risk for falls is acceptable given that Resident 6 had falls in the facility. During an interview on 5/26/23, at 12:27 PM, with the DSD, DSD stated, there was no fall mat (landing pad) in Resident 6's room, then acknowledged they did not implement care plan of 2/21/23 after his fall on 2/20/23. During an interview on 5/26/23, at 12:50 PM, with DSD, DSD verified, Resident 6 fell on [DATE], 10/26/22, 12/23/22, 2/20/23, and 5/20/23. DSD stated, Yes when asked if five falls in the facility were a lot for Resident 6. Review of the facility's policy and procedure (P&P) titled, Assessing Falls and Their Causes, undated, indicated, . 1. Falls are a leading cause of morbidity and mortality among the elderly in nursing homes . 4 . Relevant risk factors must be addressed promptly . 6. Appropriate interventions taken to prevent future falls . Review of the facility's P&P titled, Falls and Fall Risk, Managing, revised in March 2018, indicated, . Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling . 5. If falling recurs despite initial interventions, staff will implement additional or different interventions .

Based on observation, interview, and record review the facility failed to maintain an accurate accountability sheet that documented the number of controlled substances (Oxycodone tablets, pain medication) that should be available for destruction, and an accurate count of controlled substance (Oxycodone tablets) physically available for destruction compared to the documented amount that should be available for destruction for one out of eight residents reviewed (Resident 441). This failure has the potential to cause medication diversion (illegal use of medication not intended by the provider). Findings: Review of Resident 441 Admission Record indicated that Resident 441 was admitted on [DATE], with the medical diagnosis including left hip osteoarthritis (joint and bone disease which causes pain and stiffness), pain in left lower leg, and kidney failure. Resident 441 was discharged from the facility on 1/09/23. During a concurrent interview and observation on 5/24/23 at 11:00 AM, with the Director of Nursing (DON), in the DON's office, it was observed that the medication (Oxycodone tablets) were in the office for destruction and did not have an accountability sheet associated with the medication. It was observed that the DON counted eight Oxycodone tablets. The DON stated that every medication should have an accountability sheet. The DON stated when a medication is in need for destruction the bedside Nurse filled out an accountability sheet that includes the residents name, the medication name, dosage, and quantity to be destroyed. When the medication is given to the DON for destruction, the DON and the bedside Nurse review the accountability sheet, and both individuals sign off on the information's validity. The DON stated that the medication is then kept for destruction in a safe lock box to be destroyed with the Pharmacist later. During an interview on 5/25/23 at 2:00 PM with the DON, the DON stated that an accountability sheet was recovered for Resident 441's Oxycodone tables that documented 12 original tablets, and one tablet was administered, leaving 11 tablets available for destruction. Review of Resident 441 Controlled Substance Accountability sheet for Oxycodone tablet indicated that 12 tablets were available on 1/9/23 and one tablet was administered leaving 11 tablets available. Review of Resident 441's Medication Administration Record (MAR) indicated that one tablet of Oxycodone was administered on 1/9/23 at 07:31 AM. Review of the Receipt of dispensed medication from the facilities automated dispensing unit (ADU, Automated machine that dispenses medication to the nurses) indicated that 11 tablets of Oxycodone were dispensed for Resident 441. During an interview on 5/26/23 at 09:00 AM with the DON, it was stated that the automated dispensing unit (ADU) dispensed 11 tablets for Resident 441, and a receipt from the machine was provided. It was stated the one tablet is recorded as being administered to Resident 441, leaving ten tablets available for destruction. The DON stated that they physically have eight tablets for destruction, and two tablets are unaccounted for. Review of the undated policy titled Controlled Substances reads: Controlled substances are separately locked in permanently affixed compartments. Controlled Substances remaining in the facility after the order has been discontinued or the resident has been discharged are securely locked in area with restricted access until destroyed. Accountability records for discontinued controlled substances are kept with the unused supply until it is destroyed or disposed of as required by applicable law or regulation.

Based on observation, interview, and record review the facility failed to store controlled substances intended for destruction in a separately locked and permanently affixed storage compartment when Oxycodone (controlled substance for pain) tablets and solutions were found on the floor, and in a cardboard box in plain sight, for one out of seven Residents reviewed (Resident 441). This failure had the potential to cause medication diversion (illegal use of medication not intended by the provider). Findings. Review of Resident 441 Admission Record indicated that Resident 441 was admitted on [DATE], with the medical diagnoses including left hip osteoarthritis (joint and bone disease causing pain and stiffness) , Pain in left lower leg, and kidney failure. Resident 441 was discharged from the facility on 1/09/23. During concurrent observation and interview on 5/24/23 at 10:30 AM in the Director of Nursing (DON) office, it was observed that packaged Oxycodone tablets (controlled substance that has a high risk for addiction and dependence) were laying on the floor (unsupervised, unlocked, and in plain sight) next to a cardboard box. It was also observed that the safe lock box where controlled medications were kept for destruction was lifted off the floor and placed on top of the desk. The DON stated that the medications should not be on the floor and should be in a locked safe for destruction. The DON also stated that the safe lock box was lifted off from the floor and placed on the counter to make it easier to review the contents inside. Review of the undated policy titled Controlled Substances, indicated controlled substances are separately locked in permanently affixed compartments. Controlled Substances remaining in the facility after the order has been discontinued or the resident has been discharged are securely locked in area with restricted access until destroyed.

Based on observation, interview and, record review, the facility failed to accommodate food preferences of one of nine sampled residents (Resident 11) when she was served cheeseburger instead of the preferred pork vegetable stir fry during lunch on 5/25/23. This deficient practice had the potential for Resident 11 to experience an unpleasant dining experience due to receiving foods she did not request or like. Findings: Review of Resident 11's Admission Record, indicated Resident 11 was admitted on [DATE]. Review of Resident 11's Minimum Data Set (MDS, an assessment tool), dated 4/27/23, indicated Resident 11 was cognitively intact. During a concurrent observation and interview on 5/25/23 at 12:50 PM, Resident 11 was in her room, eating a cheeseburger. Resident 11 stated I had cheeseburger for lunch and dinner yesterday, and lunch today. I did not request for an alternate menu, so I don't know why I'm having a cheeseburger again. During a concurrent observation of Resident 11 and interview on 5/25/23 at 1:01 PM, the Dietary Manager (DM) confirmed Resident 11 was served cheeseburger for dinner on 5/24/23 and for lunch on 5/25/23. Resident 11 asked the DM what was on the menu for lunch on 5/25/23. The DM stated, Today's menu is pork vegetable stir fry, white rice, and cucumber salad. Resident 11 stated, That would have been nice to have for lunch. During a review on 5/25/23 at 2:33 PM, of Resident 11's tray ticket (menu based on the resident's diet order, standing orders and food preferences) for lunch on 5/23/23, the tray ticket indicated, Diet Order: Regular, Consistent Carbohydrate .Lunch .Regular food only . In a concurrent interview, the DM stated that she verified there was no documented request from Resident 11 for cheeseburger or alternate menu for lunch on 5/25/23. Review of the facility's lunch menu for 5/25/23 indicated, Pork Stir Fry with vegetables, Parsley Rice, Cucumber Salad, and Vanilla Pudding. Review of the undated facility policy and procedure (P&P) titled, Resident Food Preferences, indicated, Policy Statement: Individual food preferences will be assessed upon admission and communicated to the disciplinary team .Policy Interpretation and Implementation . 2. When possible, staff will interview the resident directly to determine current food preferences based on history and life patterns related to food and mealtimes . Review of the undated facility P&P titled, Tray Identification, indicated, Policy Interpretation and Implementation .2. The Food Services Manager or supervisor will check trays for correct diets before the food carts are transported to their designated areas. 3. Nursing staff shall check each food tray for the correct diet before serving the residents .

Based on interview and record review, the facility failed to thoroughly investigate a hip fracture of unknown origin for Resident 1. Missing from the facility's investigation were interviews of: A. Potential witnesses such as roommate(s), neighboring roommates and/or any family members/responsible parties. B. Other residents assigned to the same care area and/or other family members, friends that visited the facility around 11/19/2021. C. Out of the twelve direct care givers working with Resident 1's between 11/15/2021 to 11/19/2021, only two direct care givers (16.7%) were interviewed regarding the hip fracture. Failure to thoroughly investigate a fracture of unknown origin did not ensure the facility could rule out neglect as a possible cause for Resident 1's fracture. Findings: Review of Resident 1's document titled MINIMUM DATA SET (MDS, a standardized resident assessment tool), dated 11/17/2021, indicated she had unclear speech, and sometimes understood others. Her vision was highly impaired. Her BIMS was 0 out of 15 (BIMS=Brief Interview for Mental status, a standardized test for memory and reasoning functions. A score of 0 out of 15 indicates severe impairment in memory and reasoning). According to her MDS: 1. She had no rejection of care; she had no behavior issues. 2. She required extensive assistance of two staff for bed mobility, transfers, and toilet use. 3. She required extensive assistance of one staff with dressing, eating, and personal hygiene. 4. She was totally dependent on staff for bathing. 5. She was frequently incontinent of urine (unable to control urination). 6. She was always incontinent of bowel (unable to control stool). 7. Staff implemented a bed alarm daily to monitor unsafe and unassisted attempts to get out of bed. Review of Resident 1's fall care plan, initiated on 2/12/21, indicated Resident 1 .had a unwitnessed fall on 5/3/2021 . Review of Resident 1's records Central Gardens Post Acute Order Summary Report, printed on 11/23/2021, indicated Resident 1 had multiple diagnoses including: high blood pressure, depression, urine retention, Parkinson's Disease (a progressive disorder that affects the nervous system and the parts of the body controlled by the nerves), diabetes (chronic progressive high blood sugar disease), impaired memory and judgement, history of falling, trouble sleeping, generalized muscle weakness, abnormal pattern of walking, and unspecified convulsions (uncontrolled shaking of the body). Review of a Resident 1's record, titled . - History and Physical Central Gardens Post Acute, dated 11/24/21, indicated . Completely dependent for personal care. From whatever cause(physical or cognitive). Diagnosis this visit: Hip fracture . 11/23/2021 . It is unknown how she fell . However, seems like there was concern for hip pain, so, x-ray of .(hip) was ordered at skilled nursing facility which showed a hip fracture. This prompted transfer to the hospital. Presumed fall from bed Patient essentially bedbound at baseline. Unknown how hip fracture had happened. Review of Resident 1's Routed Notes, dated 11/24/2021, indicated resident 1 after hospitalization for LEFT hip fracture (pathologic fracture) she now returned back to facility for conservative non-surgical management, and ongoing long-term care. Left Hip Fracture (Pathologic fracture of L femoral Neck) - Patient essentially bedbound at baseline. Unknown how hip fracture had happened. Pathologic fracture (fracture caused by disease). Resident 2 was a roommate of Resident 1. During an interview on 10/17/2022 at 11:05 AM, Resident 2's family member stated . My mother been there for a long time.there are several incidents when my mother went to her bathroom by herself and one time, she fell and broke her right hand. She's considered a high fall risk.(some) employees there .(may not be) familiar with my mother's condition or needs. She .(has) dementia not able to communicate or express herself. She speaks (a language other than English) It's very hard to understand her. Unless you are regular employee who works with .(Resident 2) .So over the years, there's .(been) 6-7 times that she has fallen and I have brought it to the attention of everyone .There are times the facility has shortages. Whoever is working there has to cover like a whole wing where they don't have partner or a 2nd worker with them. Review of the facility's investigation documents submitted to this Department indicated the Director of Nursing interviewed two Certified Nursing Assistants (CNAs) regarding Resident 1's hip fracture. These interviews were conducted on 11/22/2021. The facility was asked to provide a list of direct care givers from 11/15/2021 to 11/19/2021. Twelve different direct care givers worked with Resident 1 during this time period. Only two out of 12 were interviewed (16.7%) regarding Resident 1's hip fracture. Additionally, two housekeepers working during that time period were not interviewed. During an interview on 10/11/2022 at 2:47 PM, the DON was asked to provide documented evidence this hip fracture was thoroughly investigated to rule out falls versus a pathological fracture. The DON provided documents that two direct care staff were interviewed regarding Resident 1's hip fracture. The DON was unable to provide documented evidence other direct staff, other residents, and/or family members were interviewed regarding this hip fracture incident. Review of a facility policy titled Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, revised on 09/2022, indicated The individual conducting the investigation as a minimum: a. reviews the documentation and evidence; b. reviews the resident's medical record to determine the resident's physical and cognitive status at the time of the incident and since the incident; c. observes the alleged victim, including his or her interactions with staff and other residents; d. interviews the person(s) reporting the incident; e. interviews any witnesses to the incident; f. interviews the resident (as medically appropriate) or the resident's representative; g. interviews the resident's attending physician as needed to determine the resident's condition; h. interviews staff members (on all shifts) who have had contact with the resident during the period of the alleged incident; i. interviews the resident's roommate, family members, and visitors; j. interviews other residents to whom the accused employee provides care or services; k. reviews all events leading up to the alleged incident; and l. documents the investigation completely and thoroughly.

Based on interview and record review, facility staff failed to accurately assess Resident 3 regarding his wandering behavior. Failure to accurately access Resident 3 may potentially prevent the facility from implementing effective interventions regarding Resident 3's wandering behavior. Findings: Review of a communication from the facility to this Department titled Intake Information, received on [DATE], indicated Resident 3 wandered into Resident 4's room .on [DATE] .(Resident 3) began to look through .(Resident 4's) belongings, . (Resident 3) punched .(Resident 4) in the face. Review of Resident 3's MINIMUM DATA SET (MDS, a standardized resident assessment tool), dated [DATE], indicated staff assessed Resident 3 as exhibiting no wandering behaviors for the last six days (from[DATE] to [DATE]). According to Resident 3's MDS, staff did implement an alarm device for his wandering behaviors. The MDS nurse was interviewed on [DATE] at 2:50 PM regarding the MDS assessment done on Resident 3 on [DATE]. The MDS nurse stated the wandering alarm was implement on [DATE] for Resident 3. The MDS nurse was unable to provide an explanation why Resident 3's behavior (wandering into Resident 4's room on [DATE]) was not captured in Resident 3's [DATE]'s MDS assessment. Review of a CMS (Centers for Medicare & Medicaid Services) publication titled MDS-3.0-RAI-Manual-v1.17, revised on ,d+[DATE], indicated for wandering assessment .1. Review the medical record and interview staff to determine whether wandering occurred during the 7-day look-back period. o Wandering is the act of moving (walking or locomotion in a wheelchair) from place to place with or without a specified course or known direction. Wandering may or may not be aimless. The wandering resident may be oblivious to his or her physical or safety needs. The resident may have a purpose such as searching to find something, but he or she persists without knowing the exact direction or location of the object, person or place. The behavior may or may not be driven by confused thoughts or delusional ideas (e.g. when a resident believes she must find her mother, who staff know is deceased ). Review of a facility policy titled Certifying Accuracy of the Resident Assessment, not dated, indicated . 1. Any person who completes any portion of the MDS assessment, tracking form, or correction request form is required to sign the assessment certifying the accuracy of that portion of that assessment. 2. The information captured on the assessment reflects the status of the resident during the observation (look-back) period for that assessment. Different items on the MDS may have different observation periods.

Based on observation, interview, and record review, the facility failed to maintain shower chairs in safe operating condition when two of three shower chairs found were: 1. both shower chairs had ineffective wheel locks. 2. both shower chairs had back rest issues. Failure to maintain these shower chairs had the potential to put residents at risk for injuries when using these shower chairs. Findings: During a concurrent observation and interview with the Director of Nursing (DON) on 1/27/22 at 2:10 PM, three shower chairs were randomly selected for observation. These shower chairs were constructed of white plastic pipes with small roller type lockable wheels on the legs and blue nylon webbing on the back rest. In room [ROOM NUMBER] ' s shared bathroom, there was a shower chair over the commode. The blue nylon webbing across the back rest of the chair was found to be frayed. Additionally, even with all four wheel locks applied, the chair could still be slide around with minimal force. In room [ROOM NUMBER] ' s shared bathroom, the shower chair was over the commode. There was no webbing across the back rest of the chair. When all four wheel locks were applied, the chair could still be slide around with minimal force. These observations were witnessed by the DON. The DON acknowledged that the observed condition of these two shower chairs were not normal. During a review of the facility ' s policy titled Maintenance Services, not dated, indicated that .The Maintenance Department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times.

Based on observation, interviews and record reviews, the facility failed to have an effective system in place to manage residents ' belongings for Resident 1, 2, and 3, three of six sampled residents. The facility failed to: A. Accurately inventory resident ' s belongings B. Properly store/safe guard resident ' s belongings C. have an effective system in place to update Resident's inventory list on a regular basis These failures resulted in Resident 1 ' s clothing being found stored in Resident 2 ' s closet and Resident 1 ' s inventoried jewelry was missing. Resident 2 had personal items missing for 16 months and her inventory list was not updated to reflect the loss. Resident 3 ' s glasses were not entered into his inventory list upon admission. His glasses went missing and was not replaced by the facility. Failure to have an effective system in place to manage resident ' s belongings has the potential to negatively impact all resident ' s quality of life. Findings: Resident 1 During a concurrent observation and interview on 06/21/2022 at 11:40 AM with the SSD (Social Service Director), Resident 1 ' s clothing was found in Resident 2 ' s closet. Resident 1 was residing in room [ROOM NUMBER]B and Resident 2 was residing in room [ROOM NUMBER]B. room [ROOM NUMBER]B was approximately 6 rooms away from room [ROOM NUMBER]B along a long hallway. The SSD stated Resident 1 and 2 must have switched rooms and staff probably forgot to move Resident 1 ' s clothing into room [ROOM NUMBER]B. Review of Resident 1 ' s record titled Inventory List, dated 01/15/2014, indicated she had an Insigna TV. Observation and search of Resident 1 ' s room with the SSD found no Insigna Television set. Review of an untitled document with Resident 1 ' s name and filed next to the Resident 1 ' s inventory list, dated 03/31/2014 indicated Resident 1 had 4 Necklace 2 Bracelet 1 [NAME] .(with) purple stone 1 pin .(with) white stone 1 pin .(with) green leaf and white flower 1 ring .(with) purple stone 2 rings .(with) white stone clear 8 earrings 1 pendant (green color) . Kept in Narcotic Box . During an observation and concurrent interview on 06/21/2022 at 12:26 PM, the SSD stated the Narcotic Box referenced in Resident 1 ' s document was not actually a narcotic box. It was a big heavy lock box that was at the nursing station in a cabinet. The SSD stated the box was used previously to store resident ' s belongings. The SSD looked thru the nursing station and the DON ' s office and was not able to locate the narcotic box. The SSD stated the narcotic box may have been move since the facility ' s recent remodel in 2020 and he had no idea where the narcotic box was currently located. The SSD discovered other resident ' s item while searching through Resident 1 ' s closet for her missing inventoried items. Found in Resident 1 ' s closet was Resident 4 ' s shirt, a mauve colored jacket with no name, a red bag containing a framed picture and three CD (compact disc: data storage disc) containing Chinese songs (Resident 1 is Japanese), and CNA 1 ' s hand bag. Resident 2 During an interview on 06/21/2022 at 11:40 AM, Resident 2 stated she told staff that she was missing her rosary and her crucifix. Resident 2 stated these items have been missing since February of last year and were of tremendous sentimental value to her. Review of Resident 2 ' s record titled INVENTORY OF PERSONAL ITEMS, dated 02/17/2021, indicated she had 3 . (rosary: prayer beads) cross. During an interview on 06/21/2022 at 11:50 AM, the SSD stated the facility update inventory lists when there are changes. The SSD stated staff update a resident ' s inventory list when a family member brings in items. The SSD stated the facility does not update resident ' s inventory lists on a regular scheduled basis. The SSD nodded in agreement that resident ' s inventory lists may not be up to date and accurate with their current system. Resident 3 During an interview on 06/17/2922 at 2:00 PM, Resident 3 ' s family member stated Resident 1 was admitted to the facility with his glasses. Staff failed to ensure the glasses were entered into Resident 1 ' s inventory list. When Resident 1 was discharged without his glasses, the facility refused to reimburse Resident 1 because the glasses were not on the inventory list. Review of a facility policy title Lost and Found (not dated) indicated .Our facility shall assist all personnel and residents in safe-guarding their personal property. Based on observation, interviews and record reviews, the facility failed to have an effective system in place to manage residents ' belongings for Resident 1, 2, and 3, three of six sampled residents. The facility failed to: A. Accurately inventory resident ' s belongings B. Properly store/safe guard resident ' s belongings C. have an effective system in place to update Resident's inventory list on a regular basis These failures resulted in Resident 1 ' s clothing being found stored in Resident 2 ' s closet and Resident 1 ' s inventoried jewelry was missing. Resident 2 had personal items missing for 16 months and her inventory list was not updated to reflect the loss. Resident 3 ' s glasses were not entered into his inventory list upon admission. His glasses went missing and was not replaced by the facility. Failure to have an effective system in place to manage resident ' s belongings has the potential to negatively impact all resident ' s quality of life. Findings: Resident 1 During a concurrent observation and interview on 06/21/2022 at 11:40 AM with the SSD (Social Service Director), Resident 1 ' s clothing was found in Resident 2 ' s closet. Resident 1 was residing in room [ROOM NUMBER]B and Resident 2 was residing in room [ROOM NUMBER]B. room [ROOM NUMBER]B was approximately 6 rooms away from room [ROOM NUMBER]B along a long hallway. The SSD stated Resident 1 and 2 must have switched rooms and staff probably forgot to move Resident 1 ' s clothing into room [ROOM NUMBER]B. Review of Resident 1 ' s record titled Inventory List, dated 01/15/2014, indicated she had an Insigna TV. Observation and search of Resident 1 ' s room with the SSD found no Insigna Television set. Review of an untitled document with Resident 1 ' s name and filed next to the Resident 1 ' s inventory list, dated 03/31/2014 indicated Resident 1 had 4 Necklace 2 Bracelet 1 [NAME] .(with) purple stone 1 pin .(with) white stone 1 pin .(with) green leaf and white flower 1 ring .(with) purple stone 2 rings .(with) white stone clear 8 earrings 1 pendant (green color) . Kept in Narcotic Box . During an observation and concurrent interview on 06/21/2022 at 12:26 PM, the SSD stated the Narcotic Box referenced in Resident 1 ' s document was not actually a narcotic box. It was a big heavy lock box that was at the nursing station in a cabinet. The SSD stated the box was used previously to store resident ' s belongings. The SSD looked thru the nursing station and the DON ' s office and was not able to locate the narcotic box. The SSD stated the narcotic box may have been move since the facility ' s recent remodel in 2020 and he had no idea where the narcotic box was currently located. The SSD discovered other resident ' s item while searching through Resident 1 ' s closet for her missing inventoried items. Found in Resident 1 ' s closet was Resident 4 ' s shirt, a mauve colored jacket with no name, a red bag containing a framed picture and three CD (compact disc: data storage disc) containing Chinese songs (Resident 1 is Japanese), and CNA 1 ' s hand bag. Resident 2 During an interview on 06/21/2022 at 11:40 AM, Resident 2 stated she told staff that she was missing her rosary and her crucifix. Resident 2 stated these items have been missing since February of last year and were of tremendous sentimental value to her. Review of Resident 2 ' s record titled INVENTORY OF PERSONAL ITEMS, dated 02/17/2021, indicated she had 3 . (rosary: prayer beads) cross. During an interview on 06/21/2022 at 11:50 AM, the SSD stated the facility update inventory lists when there are changes. The SSD stated staff update a resident ' s inventory list when a family member brings in items. The SSD stated the facility does not update resident ' s inventory lists on a regular scheduled basis. The SSD nodded in agreement that resident ' s inventory lists may not be up to date and accurate with their current system. Resident 3 During an interview on 06/17/2922 at 2:00 PM, Resident 3 ' s family member stated Resident 1 was admitted to the facility with his glasses. Staff failed to ensure the glasses were entered into Resident 1 ' s inventory list. When Resident 1 was discharged without his glasses, the facility refused to reimburse Resident 1 because the glasses were not on the inventory list. Review of a facility policy title Lost and Found (not dated) indicated .Our facility shall assist all personnel and residents in safe-guarding their personal property.

Based on observation, interview and record review, the facility failed to develop comprehensive resident-centered care plans for Residents 2, 5, and 6, three of six sampled residents. For Resident 2, she had four items of clothing since admission 18 months ago. This issue was not care planned. Residents 5 and 6 fell recently and there were no new interventions addressing the root cause of their falls nor any new interventions to minimize injuries in the event of a fall. Failure to develop individualized care plans had the potential to negatively impact Resident 2 ' s quality of life. For Resident 5 and 6, failure to develop individualized care plans interventions which target the root cause of their falls and/or new interventions to minimize fall injuries had the potential for Resident 5 and 6 to sustain serious injuries during their next fall. Findings: Resident 2 During a concurrent observation and interview on 06/21/2022 at 11:40 AM with the SSD (Social Service Director), Resident 2 ' s was seen wearing a hospital and a sweater over the hospital gown. Resident 2 ' s closet contained none of her clothing items. The SSD stated that upon admission approximately 18 months ago, Resident 2 came with very few clothing. Review of Resident 2 ' s inventory list titled INVENTORY OF PERSONAL ITEMS, dated 02/17/2021, indicated she had .3 sweaters (and) 1 Pink .(robe) . The SSD stated the facility offered Resident 1 donated clothing and Resident 2 said she did not want to wear other people ' s clothing. The SSD stated the facility also offered Resident 2 a clothing catalog to pick out outfits for purchase and Resident 2 refused. The SSD was asked if this problem was documented and care planned. The SSD searched through Resident 2 ' s records including her care plans and said no, this problem was not documented or care planned. Resident 5 During a concurrent record review and interview on 06/21/2022 at 1:02 PM, the MDS Coordinator was reviewing Resident 5 ' s chart and stated Resident 5 slid down from her wheelchair and fell on [DATE]. Review of Resident 5 ' s chart and care plan found no intervention addressing Resident 5 sliding down from her wheelchair. Resident 6 During a concurrent record review and interview on 06/21/2022 at 1:15 PM, the MDS Coordinator was reviewing Resident 6 ' s chart and stated Resident 6 fell on [DATE] and 05/24/2022. Review of Resident 6 ' s chart and care plan found no new intervention(s) to decrease Resident 6 ' s fall risks and/or ways to minimize her injuries in case of a fall.

Based on observation, interview, and record review the facility failed to ensure staff were aware and implementing infection control practices when: 1. staff failed to move Residents 1 and 2 ' s clothing items upon room change. 2. a staff was storing her hand bag inside Resident 1 ' s closet Failure to implement infection control practices had the potential to subject all residents, visitors and staff to cross contamination and the spread of infectious diseases. Findings: 1. During a concurrent observation and interview on 06/21/2022 at 11:40 AM with the SSD, Resident 1 ' s clothing was found in Resident 2 ' s closet. The SSD stated Resident 1 and 2 must have switched rooms and staff probably forgot to move Resident 1 ' s clothing into room [ROOM NUMBER]B. Review of an email communication with the Administrator on 06/29/2022 at 3:01 PM indicated Resident 1 switched rooms with Resident 2 on 05/23/2022 and staff failed to move Resident 1 ' s clothing for approximately 29 days. Failure to move personal items during a room change and sanitize the closet space had the potential to expose residents and staff to infectious diseases. 2. During a concurrent observation and interview on 06/21/2022 at 12:45 PM with the SSD, CNA 1 ' s hand bag was found in Resident 1 ' s closet. The SSD acknowledged CNA 1 ' s hand bag should not be in Resident 1 ' s closet. During an interview 06/21/2022 at 12:46 PM, CNA 1 confirmed it was her hand bag that was found in Resident 1 ' s closet. CNA 1 stated she should have put her hang bag in the employee lockers down stairs. CNA 1 offered no explanation when asked if she knew the infection control consequences of her action. Review of a facility document titled Employee Lockers and/or Storage Areas (not dated) indicated .Our facility may provide lockers and/or storage areas for employees, at no cost to the employees, for safekeeping of their personal effects. Based on observation, interview, and record review the facility failed to ensure staff were aware and implementing infection control practices when: 1. staff failed to move Residents 1 and 2 ' s clothing items upon room change. 2. a staff was storing her hand bag inside Resident 1 ' s closet Failure to implement infection control practices had the potential to subject all residents, visitors and staff to cross contamination and the spread of infectious diseases. Findings: 1. During a concurrent observation and interview on 06/21/2022 at 11:40 AM with the SSD, Resident 1 ' s clothing was found in Resident 2 ' s closet. The SSD stated Resident 1 and 2 must have switched rooms and staff probably forgot to move Resident 1 ' s clothing into room [ROOM NUMBER]B. Review of an email communication with the Administrator on 06/29/2022 at 3:01 PM indicated Resident 1 switched rooms with Resident 2 on 05/23/2022 and staff failed to move Resident 1 ' s clothing for approximately 29 days. Failure to move personal items during a room change and sanitize the closet space had the potential to expose residents and staff to infectious diseases. 2. During a concurrent observation and interview on 06/21/2022 at 12:45 PM with the SSD, CNA 1 ' s hand bag was found in Resident 1 ' s closet. The SSD acknowledged CNA 1 ' s hand bag should not be in Resident 1 ' s closet. During an interview 06/21/2022 at 12:46 PM, CNA 1 confirmed it was her hand bag that was found in Resident 1 ' s closet. CNA 1 stated she should have put her hang bag in the employee lockers down stairs. CNA 1 offered no explanation when asked if she knew the infection control consequences of her action. Review of a facility document titled Employee Lockers and/or Storage Areas (not dated) indicated .Our facility may provide lockers and/or storage areas for employees, at no cost to the employees, for safekeeping of their personal effects.

Based on food storage and production observations, dietary staff interviews, and record review, the facility failed to ensure food storage, preparation and distribution under sanitary conditions when: 1. Cockroaches were crawling on wall next to the dishwasher unit. Live and dead roaches found in other kitchen areas; 2. Cockroaches were observed underneath and around ice dispensing machine; 3. Cockroaches were observed in and around the dumbwaiter, (A dumbwaiter is a small freight elevator or lift intended to carry objects rather than people), used to transport resident meals; 4. Outside door used for kitchen food deliveries was wide open for three consecutive days, allowing for potential pest penetration; 5. Spoiled oranges and cantaloupes were stored in covered plastic containers; 6. Facility failed to monitor the temperature in the dry storage room; 7. Mice droppings were found in the dry storage room; 8. Facility failed to label open containers of milk in the refrigerator; 9. Metal panels in the dishwashing area showed spaces with missing wall sealant, sealant with black stains in multiple places where water penetration was observed; 10. Multiple tiles on the wall along the dishwashing area were broken and the wall next to the dishwasher unit had a section of 4 x 4 feet with missing tiles and holes on the wall; 11. Ceiling above dishwashing area had black stains; 12. Failed to thaw frozen food safely; 13. During tray line observations a dietary staff did not cover his facial hair. Failure to ensure a sanitary environment in the food storage, preparation and dishwashing areas may result in foodborne illness for residents in the facility and in severe instances may result in death. Findings: During the initial kitchen tour started on 9/27/16 at 9:30 AM with the Dietary Supervisor (DS), and the Registered Dietitian (RD), the following were observed: 1. In the dishwashing area, a room with three walls; observation of the wall behind the dishwasher unit which was in use, showed a space of about 4 by 4 feet with missing tiles right behind and above dishwasher. There were multiple small drill type holes in the same space. About 15 live cockroaches were noticed in one spot. DS and RD were asked to corroborate observation. They both acknowledged. RD stated I saw it, we know we have had this issue with roaches, its on and off .Yes, those roaches come from the other side of that wall . Further observation of the space beneath the dishwashing counters and sinks on both sides of the room indicated dead and live roaches. On the floor along the walls some dead roaches were observed. During an interview on 9/27/16 11:00 AM, the Administrator stated, Yes, I have been aware there are cockroaches in the kitchen. Yes they are everywhere. We've had a pest control company coming twice a month .I knew we had cockroaches .Its the neighborhood and today is a hot day . During a 9/27/16 11:20 AM interview, Administrator was informed an Immediate Jeopardy was declared and the facility was required to start a plan of action to address the risk for harm to all residents due to potential food contamination from the cockroaches in the kitchen. During a 9/28/16 11 AM interview, RD stated, I have been aware of the cockroaches in the kitchen, I have communicated that to administration. RD was asked about environmental monitoring of the kitchen, work hours and responsibilities at the facility. RD stated I come daily for about 3 to 4 hours .meet twice a month with the DS, I go to administration if there are issues and DS does the in-services to dietary staff . Record review of the one report RD provided, and titled, a Consultant Dietitian Report June 30, 2016 made no reference to a cockroaches in the kitchen. By 10/7/16 at the exit conference, no documentation was provided on RD worked hours and of supervision meetings with DS discussing roaches in the kitchen. During a 9/28/16 11:15 AM interview, the Administrator stated we did not have a pest control policy in place. During a 9/29/16 7:45 AM interview, after observing the presence of live and dead roaches in the dishwashing area, Cook 2 stated We had roaches on and off for a couple of months or maybe longer . Record review of a three- paged Food Inspection Report from a inspection visit performed on the same day and dated 9/29/16 from the city department of public health, indicated in the instructions The marked violations are California Retail Food Code violations and must be corrected . On page 2, a circle was marked around violation 31, Rodents, roaches, flies or other animals. On the same page 2, hand written notes included 8. Remove mouse droppings from the dry storage room. Set traps in the dry storage room, open food was noted in pest proof containers. Several observations of the kitchen areas from 9/27/16 to 10/6/16 identified the presence of live and or dead cockroaches: 9/28/16 7:45 AM, live and dead roaches, dishwashing area. DS acknowledged. 9/29/16 7:45 AM, live and dead roaches, dishwashing area. DS and Cook 2 acknowledged. 9/30/16 8:15 AM, live and dead roaches, dishwashing area. Cook 2 acknowledged. 10/1/16 8 AM, live and dead roaches, sink in food production area and in dishwashing area. DS acknowledged. 10/3/16 8 AM, dead roaches, dishwashing area. Administrator acknowledged. 10/4/16 8 AM, live and dead roaches, dishwashing area. DS acknowledged. 10/5/16 8 AM, live and dead roaches, food production area and dishwashing area. DS acknowledged. 10/6/16 7:30 AM, live and dead roaches, food production area and dishwashing area. DS and DON acknowledged. 2. During a 10/1/16 10:15 AM observation of the area around the dumbwaiter terminal on the 1st floor, a dead roach was visible on the top edge of the dumbwaiter. A space on the floor between the dumbwaiter and the ice machine had a glue trap with multiple dead roaches. A couple of live roaches were seen on the floor. During a 10/1/16 10:20 AM concurrent interview with two housekeeping staff members, Housekeeping Staff 1 acknowledged the live and dead roaches and stated: yes, when I see roaches I kill them and clean the area . Housekeeping Staff 2, after acknowledging the live roaches on the floor around the ice machine stated, Yes sir, I do the same . Asked how often she saw roaches, Housekeeping Staff 1 stated: Every now and then. During a 10/1/16 10:45 AM observation of the fire extinguisher box in a hallway across the ice machine and next to a clean linen cart, dead roaches were seen next to the fire extinguisher. During a 10/3/16 10:35 AM interview, the Housekeeping Supervisor (HS) was asked if anyone had reported the presence or roaches around the dumbwaiter and ice machine, HS stated, No, sir. After HS was shown pictures of the roaches seen on 10/1/16, HS stated Yes, sir. We need to do something about it . 3. During a 10/6/16 7:30 AM observation in the kitchen accompanied by DS and Director of Nursing (DON), a dietary staff member opened the dumbwaiter terminal in the kitchen and as two live roaches came out, the staff proceeded to smack them with a small broom. DS stated: There are still some roaches around, we need to keep cleaning. The following were also observed during the initial kitchen tour that started on 9/27/16 at 9:30 AM with the Dietary Supervisor (DS) and the Registered Dietitian (RD): 4. An outside door adjacent to the kitchen was observed open to the outside of the building. A sign, taped on the door read: Please keep this door locked at all times. DS acknowledged open door and stated: Yes, we received our supplies through this door, we are supposed to keep it closed but it is open because the kitchen gets very hot inside . Record review of a three pages Food Inspection Report from a inspection visit performed on the same day and dated 9/29/16 from the city department of public health, indicated in the instructions The marked violations are California Retail Food Code violations and must be corrected . On page 2, a circle was marked around violation 31, Rodents, roaches, flies or other animals. On the same page 2, hand written notes included 9. Install a screen door to the door to the street adjacent the kitchen. This door shall be rodent proof. 5. At the kitchen entrance, environment temperature felt very warm. DS was asked for a temperature of the room. DS acknowledged observation and stated I don't have a thermometer here, it gets very warm and it might be around 80 to 85 degrees . A storage area with metal shelves had four plastic containers covered with lids containing: onions, potatoes, cantaloupes and oranges. DS was asked to take lid off the container with oranges, and spoiled oranges were observed. Upon taking lid off from another container, two cantaloupes had brown spots in their skins. DS acknowledged fruits were spoiled and stated: We'll remove those immediately and discard them . Record review of a facility copy titled Storage of food and non-food supplies indicated under m. Produced is stored at room temperature to hasten ripening or maintain quality 1. Unripe melons, peaches .are stored at 60-75 degrees Fahrenheit (F) until ripe and then moved to refrigerators .3. Potatoes .are stored in the coolest part of the storeroom 50-60 degrees F . 6. The designated dry storage room was observed with the door open and no visible thermometer inside room. DS acknowledged observation and stated yes, we open the door because it gets too hot ., I don't know what happened with the thermometer, I will replace it today . Later random temperature readings from a thermometer placed on the wall of the storage room were: 9/29/16 7:45 AM: 76 degrees F, 9/30/16 8 AM: 78 degrees F, 10/3/16 8 AM: 78 degrees F, 10/4/16 8 AM: 80 degrees F. Record review of a facility policy titled Storage of food and non food supplies indicated under Food Storage Areas a. The storeroom is clean, .preferably maintains a temperature of 50 to 75 degrees F. 7. During the initial kitchen tour that started on 9/27/16 at 9:30 AM with the Dietary Supervisor (DS) and the Registered Dietitian (RD): Behind four wheeled containers of dry staples, mice droppings were observed alone the wall. DS stated: We've had the problem with mice before .there is a pest company that checks . No mice traps were observed in the storage room or in any of the kitchen areas. Later random observations of storage room floor area behind dry staples bins indicated mice droppings on 9/29/16 7:45 AM, 9/30/16 8 AM, 10/3/16 8 AM, 10/4/16 8 AM, 10/5/16 8 AM. No mice traps were observed in any of the kitchen areas. During a 10/6/16 7:30 AM inspection of the dry storage room accompanied by DS and the Director of Nursing DON, mice dropping were observed behind the dry staples bins, and no mice traps were present. DON acknowledged and stated: Yes, I see it .we need to clean it right away. Record review of a facility policy titled, Storage of food and non food supplies indicated under Food Storage Areas 1. Dry storage areas will be equipped with a thermometer. c. The storeroom is protected against rodents and insect . 8. During the kitchen tour that started on 9/27/16 at 9:30 AM with the Dietary Supervisor (DS) and the Registered Dietitian (RD):In one of two refrigerators, three open half gallons of milk were observed to be unlabeled and undated. DS was asked about milk labeling and dating practice. DS stated, We label and date any containers that have been open. These three milk containers should have been dated .I don't know what happened . Record review of a facility policy titled Storage of food and non food supplies indicated under Perishable Storage l. All food items in refrigerators are properly dated, labeled, .v. Milk and dairy products .use as quickly as possible. 9. During the kitchen tour that started on 9/27/16 at 9:30 AM with DS and the RD, the dishwashing area had 2 sides, left and right, each with sinks and silver metal splash counters. A third side between the left and right, had a loaded dishwasher running. The room had a particular smell. DS was asked about that odor and stated Its kind of moldy . At the joints with the adjacent wall, the splash counters were observed with spaces missing and cracked wall sealant that appeared wet due to water penetration. Multiple places had sealant with black stains. During a concurrent interview, when asked about black stains on the sealant, DS stated: It looked like mold. 10. During the kitchen tour on 9/27/16 that started at 9:30 AM, the dishwashing area had 2 sides, left and right, each with sinks and silver metal splash counters. In four places, broken tiles were observed and in the wall behind the dishwasher unit, a space of about 4 by 4 feet had missing tiles and some broken ones. During a 9/27/16 10 AM interview, DS acknowledged the broken and missing tiles sections of the dishwashing area and stated There are plans for remodeling this area, I just don't know when it will happen . 11. During the kitchen tour that started on 9/27/16 at 9:30 AM with the DS and the RD, a space of 2 by 2 feet on a ceiling corner on the left side of the dishwashing area, was observed to have black stains. When asked about the stains, DS stated: It looked like mold to me. Record review of Food Inspection Report from a inspection visit performed on the same day and dated 9/29/16 from the city Department of Public Health, indicated in the instructions The marked violations are California Retail Food Code violations and must be corrected . On page 2, a circle was marked around violation 52, Unclean or degraded floors, walls or ceilings. On page 1 and 2, hand written notes included Wall and ceiling surfaces in the dishwasher room shall be finished and made smooth, washable .The wall shall be free of gaps and caulking shall be totally smooth without crevices . 12. During a 9/30/16 8 AM observation in the kitchen, 2 five pounds frozen shrimp bags were on the food production counter. When asked about the frozen shrimp bags, a dietary staff, Cook 2, stated I have those for lunch today. Review of the posted menu for the day indicated for the main course of lunch Seafood Newburg. Cook 2 was asked how long he would keep the bags on the counter and stated Until I cook it one hour before trayline Asked if until 11 AM, he stated Yes sir. During a 9/30/16 8:10 AM interview after acknowledging frozen shrimps bags on the counter and Cook 2 plan, DS stated It should actually not be there but under running water . Record review of an undated facility policy titled,Food Service Management indicated under Perishable Storage .t. Frozen food will be cooked from the frozen state unless thawing is necessary .2. Food is not thawed at room temperature. Record review of a three pages Food Inspection Report from a inspection visit performed on the same day and dated 9/29/16 from the city department of public health, indicated in the instructions The marked violations are California Retail Food Code violations and must be corrected . On page 2, a circle was marked around violation 32, Improper thawing methods. 13. During a 9/30/16 lunch trayline observation started at about 12 Noon, a dietary staff aide, SA, who had a full beard was assisting with assembling resident trays was not wearing a facial hair restraint. DS was also assisting the assembling of resident meal trays without wearing an clothes protective gear. During a concurrent interview and while present at the trayline observation the Registered Dietitian, RD, when asked about observations on SA and DS, RD stated: You are right, SA should be wearing hair restraint and DS an apron . Review of The Food Code 2013, a uniform system of provisions that addressed the safety and protection of food offered at retail and in food service, stated under section 2-402.11 A. Food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, .designed and worn to effectively keep their hair from contacting exposed food .; section 304.11: Food employees should wear clean outer clothing to prevent contamination of food . During an interview with the facility Administrator on 9/27/16 at 11:20 AM, immediate jeopardy was declared due to the unsanitary conditions related to the roach infestation in the kitchen. The facility submitted an acceptable plan of correction on 10/11/16. An onsite visit was conducted on 10/12/16 and verified that the facility implemented the plan of correction. During an interview on 10/12/16 at 9:30 AM, the Administrator and the Director of Nursing were informed that the immediate jeopardy was removed.

Based on interview and record review, the facility failed to provide adequate supervision to prevent the elopement of one resident (Resident 1) when: 1. there was no documented evidence for the one to two hourly visual checks before 4/18/15 when the elopement took place. 2. the staff (Registered Nurse 1, Certified Nursing Assistant 1) were not alerted when Resident 1 eloped because the front door alarm was turned off on 4/18/15. This deficient practice had resulted in Resident 1's emergency room admission to treat head injury and facial contusion related to a fall outside the facility after she eloped on 4/18/15. Findings: Resident 1 was admitted with [DIAGNOSES REDACTED]. Review of MDS (Minimal Data Set - Resident assessment tool), dated 2/9/15, indicated Resident 1 wandered on 4-6 days during the 7 day look-back period. Review of MDS (Minimal Data Set: a resident assessment tool), dated 2/9/15 and 5/11/15 indicated Resident 1's functional status in Activities of Daily Living Assistance in: Bed mobility, Transfer, Walk in room, Walk in corridor, Locomotion on unit, Locomotion off unit had deteriorated from supervision and setup help only to limited assistance and one person physical assist. Review of the care plan dated, 7/31/14 for problem of agitation and restlessness M/B (manifested/by) attempts to elope indicated under the Nursing approaches : visual checks at least Q (each) 1-2 hour. Review of the care plan dated 2/1/13,for fall with update dates of 1/14/14, 2/18/14, and 5/8/14, indicated: 1) Resident 1 had Fall history on 1/17/13, 9/5/13; Elopement episode on 1/14/14, 5/8/14. 2) Nursing approaches included Hourly rounds to be done on residents for pain, toileting and personal needs. During an interview on 6/10/15 at 11:10 am, the Director of Staff Development (DSD) acknowledged there was no documented evidence for the hourly or two hourly visual checks before 4/18/15 when the elopement took place. During a telephone interview on 6/11/15 at 8:20 am, the Registered Nurse (RN) 1 stated that she was surprised to receive telephone call from the ER (emergency room ) at the General Acute Care Hospital (GACH) on 4/18/15 saying that Resident 1 was brought into the ER S/P (status [REDACTED]. It was the first time she heard it (Resident 1 is missing from the facility); it was around 7:30-7:35 pm. Resident 1 was not wearing a wanderguard at the time. Resident 1 was supposed to wear one as she had previous attempt of elopement, but she had broken so many of them, it costs $100 each. She also stated that the alarm on the front door was not on. RN 1 checked it after she received that call from ER. She also said things could be better if the door alarm and wanderguard were on. At least she would pay attention to the front door every time the alarm sounds. Because it was on a Saturday and in the afternoon, a lot of family members came to visit. RN 1 stated, The alarm would be turned off sometimes. Some of the CNAs (Certified Nursing Assistant) go out to smoke at that time too, thinking they are back soon, sometimes they would turn the alarm off as well. During a telephone interview on 7/8/15 at 3:45 pm, Certified Nursing Assistant (CNA) 1 stated: 1) On that day (4/18/15), there were a lot of visitors came in to help out with the dinner as it was weekend. 2) No wanderguard was on her on that day. She removed it all the time. 3) When the charge nurse told me that Resident 1 was missing, I checked the front door alarm. It was turned off. I turned it on straight away. The nurse said Resident 1 was already in the hospital. During a telephone interview on 7/23/15 at 2:05 pm, CNA 2 stated that the last time he saw Resident 1 on 4/18/15 was at around 5:30 pm when he removed the dinner tray. Record review of Nurse's Notes, dated 4/18/15, indicated: At 19:30 pm, GACH ER called . Resident 1 fell , sustained right facila abrasion, right knee abrasion, right facial bluish discoloration and swelling below right eye. Review of ED (Emergency Department) Provider Notes from the GACH , dated 4/19/15, indicated Resident 1 had [DIAGNOSES REDACTED]. Review of Short Term Care Plan, dated 4/19/15, indicated Resident 1 had impaired skin integrity R/T (related to): right knee abrasion, right below eye abrasion, right below eye swelling, right below eye skin discoloration (contusion). Review of the Nurse's Notes, dated 4/23/15, at 6:00am, indicated still noted right face discoloration and swelling d/t (due to) fall Review of the facility Policy on Wandering, Unsafe Resident, with revised date of 1/21/15, indicated that for residents who were at risk for elopement, Interventions to try to maintain safety will be included in the resident's care plan (Including the use of wander guard). Staff will institute a detailed monitoring plan, as indicated for residents who are assessed to have a high risk of elopement or other unsafe behavior. The facility is equipped with security measures: the front door's alarm goes off every time the doors are open; the front entrance/exit is also equipped with wander guard sensor which is activated when a resident wearing a wander guard bracelet gets within five (5) feet of the front entrance/exit.