Every finding on record at Community Convalescent Center of San Bernardino

1. Based on observation, interview, and record review, the facility failed to ensure staff followed accepted infection control practices, including required hand hygiene and glove changes between distinct care tasks, during gastrostomy tube (GT - a tube that is placed directly into the stomach through an abdominal wall incision for administration of food, fluids, and medications) site treatment and medication administration for one (1) of four sampled residents (Resident 8). This failure had the potential to expose Resident 8 at risk for contamination of the GT tract and potential introduction of pathogens during medication administration, increasing the risk for avoidable infection, unnecessary treatment and possible hospitalization. 2. Based on observation, interview, and record review, the facility failed to ensure proper and safe infection control practices were followed when: One of four sampled medication carts (a mobile cart used to store and transport medications and other supplies) medication cart three, was observed with dry brown crusted residue on the tops of two drawers and on the top surface of the medication cart. This failure had the potential to spread infectious disease (disease caused by bacteria, viruses, fungi or parasite) to seventeen medically compromised residents. 3. Based on observation, interview, and record review, the facility failed to follow their Policy and Procedure (P&P) titled, Water Management Program/ Water Safety Plan, dated 2026-2027, when there was no evidence the facility completed required hyperchlorination (a water treatment process that raises the free chlorine concentration far above normal levels for a defined period. It safely kills hard to treat bacteria legionella is water plumbing), consistently flushing of affected fixtures (opening all water outlets like faucets, showers, and valves in a contaminated building to draw highly chlorinated water through the entire plumbing network), inspection of disinfected fixtures (water outlets such as faucets, showerheads, eye washing stations, and drinking fountains that have successfully undergone chemical treatment to eliminate harmful bacteria like legionella), after the facility's water testing identified positive results for legionella bacteria on February 2, 2026, March 6, 2026, April 1, 2026, April 24, 2026, and July 10, 2026 This failure resulted in patient care areas, P122, A202, A204, A206, A208, A209, A210, P105, P107, P110, P118, A211, A212, A218, A220, A222 and A224 being colonized (a bacteria living, growing, and multiplying) with legionella bacteria in a facility caring for a vulnerable population and the potential for legionella bacteria to spread throughout the facility's water system placing 17 vulnerable residents who reside at the facility, at significant risk for respiratory infections that could cause death and jeopardize the health and safety of the residents, staff, visitors, and vendors. Findings: 1.During an observation on July 22, 2026, at 6:55 AM, Licensed Vocational Nurse 1 (LVN 1) was seen performing hand hygiene using alcohol based sanitizer, donning a yellow gown and gloves, and entering Resident 8's room carrying morning medications and G-Tube (gastronomy tube- a medical device placed through the skin of the abdomen directly into the stomach to deliver nutrition, fluids, and medications) treatment supplies. Once at the bedside, LVN 1 was observed removing Resident 8's soiled G-tube dressing containing yellowish green exudate, cleansing the site with water, drying by patting, applying powdered medication and prescribed ointment, and covering the gastrostomy tube area with a clean dressing. Upon completing the GT site treatment, and wearing the same soiled gloves, LVN1 started medication administration. LVN 1 grabbed a 60 ml (militter- a unit of measurement) syringe, aspirated the GT for residual (the amount of fluid remaining in the stomach before a feeding), flushed the GT with 10 mL of water, administered crushed medications by gravity, and performed a second flush, all while still wearing the same contaminated gloves used during GT wound care. During an interview with the LVN 1 on July 22, 2026, at 07:10 AM, in Resident 8's room, LVN 1 acknowledged he did not remove the soiled gloves, and did not performed hand hygiene after finishing GT site care and before administering medication. LVN 1 further stated facility's infection control policy and procedures requires hand hygiene and glove removal after contact with bodily fluids and before medication administration. Furthermore, LVN 1 stated, I forgot to remove my gloves and perform hand hygiene after the GT site care. I usually change gloves and wash my hands between patient care tasks, I'm just very nervous this morning. During a record review on July 22, 2026, at 10:45 AM, Resident' 8's Patient Insurance and Demographics sheet (PID) was reviewed. The PID indicated Resident 8 was admitted at the facility on August 1, 2015. During a record review on July 22, 2026, at 10:55 AM, Resident 8's History and Physical (H&P) dated December 16, 2025, was reviewed. The H&P revealed Resident 8 was admitted at the facility with diagnoses which included seizure disorder (a medical condition that causes sudden, repeated bursts of abnormal electrical activity in the brain), tracheostomy dependance (the state of needing a breathing tube in the neck to live safely. It happens when a person cannot breathe normally through their nose or mouth because of a blocked airway or weak breathing muscles), gastrostomy tube dependence (needing a feeding tube placed directly into the stomach to receive daily nutrition and hydration because a person cannot safely or adequately eat by mouth) and agenesis of corpus callosum (a rare birth defect where the tissue connecting the left and right sides of the brain is partly or completely missing). During an interview with the Infection Preventionist (IP) on July 22, 2026, at 11:15 AM, the IP stated after completing any patient care task, staff members are required to remove soiled gloves and immediately perform hand hygiene and explained that these actions are critical in preventing cross contamination and transmission of infectious agents to other individuals. Furthermore, the IP stated that staff are expected to strictly adhere to the facility's established policies and procedures, as well as to the infection prevention and control protocols by consistently following these guidelines to effectively minimize the risk of cross contamination and help prevent infections from spreading among residents and personnel. The IP also highlighted that maintaining rigorous infection control standards is essential for ensuring a safe environment for patients, staff and visitors. During a concurrent record review and interview with the Interim Director of Nursing (IDON) on July 23, 2026, at 10:16 AM, facility's policy and procedure (P&P) titled, Hand Hygiene effective July 2026, was reviewed. The P&P indicated, PURPOSE: To reduce transmission of pathogenic microorganism to residents and personnel in the facility. POLICY: All staff having direct resident contact will use appropriate hand hygiene . PROCEDURE: 1.0 All employees having direct resident contact will sanitize their hands at least under the following situations: 1.1. At the start of duty, 1.2. Between contacts with residents, 1.3. Before and after any physical contact with resident equipment or personal articles that are likely to be contaminated with bodily secretions, 1.4. Before and after any procedure with residents . RECOMMENDATIONS: 1. Indications for hand washing and hand antisepsis . G. Decontaminate hands after contact with bodily fluids or excretions, mucous membranes, non-intact skin, and wound dressings. H. Decontaminate hands if moving from a contaminated body site to a clean body site during patient care . 6. Other aspects of hand hygiene . E. Change gloves during patient care if moving from a contaminated body site to a clean body site. The IDON acknowledged the P&P was not followed when LVN1 did not remove soiled gloves and did not perform hand hygiene after performing GT treatment and before administering medication via GT to Resident 8. IDON stated that it is expected all employee follow facility's P&P. IDON stated employee should have removed the soiled gloves, performed hand hygiene and put on clean gloves before administering medication via GT. During an interview with the Administrator on July 23, 2026, at 11:25 AM, the Administrator stated all employees are required to adhere to the facility's policies and procedures (P&P) and this standard protocol is a critical component of the facility's infection control program. The Administrator further stated that proper removal of soiled gloves, good hand hygiene, and use of clean gloves are not only fundamental practices for preventing the transmission of infectious agents, but also essential for safeguarding the health and well-being of both residents and staff and minimizing the risk of healthcare-associated infections. The Administrator stated compliance with these practices helps ensure that infection prevention standards are consistently upheld throughout the facility. 2. During a current observation and interview on July 22, 2026, at 8:13 AM, with Registered Nurse Supervisor 1 (RNS 1) and Infection Preventionists (IP), an inspection of medication cart three was conducted. The top of the medication cart was observed to have a visual dry brown crested residue. In addition, two medication cart drawers contain visual dry brown crusted residue. Drawer one contained unpackaged three milliliters (a unit of measurement) syringes (A small hollow tube used for injecting or withdrawing liquids) and drawer two contained unpackaged six milliliter syringes. The medication cart was visibly dirty. RNS 1 acknowledged the medication cart was visibly dirty. The IP was also present and acknowledged the findings. The IP stated medication cards are expected to be cleaned every shift and should be free of visible dirt debris and other contaminants to prevent the spread infections. During a concurrent interview and record review on July 22, 2026, at 12:35 PM, with the IDON, the facility's Policy and Procedure (P&P) titled, Cleaning & Disinfecting of Patient Care Items and Equipment, dated March 2024, was reviewed. The P&P indicated, . The purpose of this policy is to minimize the risk of healthcare associated infections by establishing guidelines for the cleaning and disinfection of equipment.1.0.General guidelines.1.4. the standard of cleanliness is that all patient care equipment should be visibly clean without evidence of blood, body substance, dirt, debris, dust, adhesive tape, stains or spillage present.3.4. Clinical services will be responsible for the routine surface cleaning and disinfection of patient care items that require surface cleaning more often than once a day, when equipment is transferred between patient rooms, and when equipment could be altered or manipulated by wiping (i.e., Crash cart and monitor). The DON confirmed the P&P was not followed and stated that adherence is critical due to the increased infection risk within the resident population. 3. An Immediate Jeopardy (IJ - a situation that has caused or is likely to cause serious injury, harm, impairment, or death to a resident) was called under F 880 483.80 Infection Control -The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections On July 23, 2026, at 4:25 PM, regarding water sources (the specific origins of water entering the building and the internal structural points where that water is stored, treated, or distributed) located in 17 residents' rooms and throughout various areas of the facility, tested positive for elevated levels of Legionella bacteria (bacteria that grows in water systems, such as air conditioners or hot water tanks and can cause legionella disease- a serious form of pneumonia that causes fever, muscle aches, cough, shortness of breath, and other severe respiratory complications which can be life threatening) on February 2, 2026, March 6, 2026, April 1, 2026, April 24, 2026, and July 10, 2026 The IJ was called in the presence of the Administrator (ADMIN), Interim Director of Nursing (IDON), and the Chief Nursing Officer (CNO). An IJ removal Plan (a crisis response strategy developed by the facility to immediately stop an ongoing, critical safety violation that places residents at imminent risk of serious harm, injury impairment, or death) was requested on July 23, 2026 at 5:30 PM. The facility submitted an IJ Removal Plan which was reviewed and accepted on July 24, 2026, at 11:45 AM. The acceptable IJ Removal Plan was verified with the facility to be implemented through observations, interviews, and record reviews. The IJ was removed on July 24, 2026, at 3:06 PM, in the presence of IDON, ADMIN, and CNO. Based on observation, interview, and record review, the facility failed to follow their Policy and Procedure (P&P) titled, Water Management Program/ Water Safety Plan, dated 2026-2027, when there was no evidence the facility completed required hyperchlorination (a water treatment process that raises the free chlorine concentration far above normal levels for a defined period. It safely kills hard to treat bacteria legionella is water plumbing), consistently flushing of affected fixtures (opening all water outlets like faucets, showers, and valves in a contaminated building to draw highly chlorinated water through the entire plumbing network), inspection of disinfected fixtures (water outlets such as faucets, showerheads, eye washing stations, and drinking fountains that have successfully undergone chemical treatment to eliminate harmful bacteria like legionella), after the facility's water testing identified positive results for legionella bacteria on February 2, 2026, March 6, 2026, April 1, 2026, April 24, 2026, and July 10, 2026 This failure resulted in patient care areas, P122, A202, A204, A206, A208, A209, A210, P105, P107, P110, P118, A211, A212, A218, A220, A222 and A224 being colonized (a bacteria living, growing, and multiplying) with legionella bacteria in a facility caring for a vulnerable population and the potential for legionella bacteria to spread throughout the facility's water system placing 17 vulnerable residents who reside at the facility, at significant risk for respiratory infections that could cause death and jeopardized the health and safety of the residents, staff, visitors, and vendors. Findings: During a review of the document titled, Analytic results. Water testing: Q 1 (quarter1) 2026 Viable Legionella Bacteria, the document indicated, .Date sampled: January 6, 2026, and dated reported: February 2, 2026 We are providing you with the Legionella analytical results that were sampled at your facility on February 2, 2026. Water samples of interest were collected and analyzed for the presence of viable Legionella species using the (Centers for Disease Control and Prevention,) CDC Method. Results are expressed as one of the following terms: 1. No Detection (ND): No Legionella is detected in the sample 2. <1 (less than one) colony forming unit/ml (cfu/ml) (unit of measurement colony forming unit/ milliliter): Legionella was detected between the minimum detection limit of 0.4 cfu/ml and 1 cfu/ml in the water sample 3. Whole number: Legionella is detected at 1 (one or less than one) in the sample The goal is zero detectable Legionella in a water source . The following summarizes results from this sampling period: For domestic water (any water used for human consumption, other domestic activities), six (6) of the ten (10) samples showed the presence of Legionella bacteria: - A 203/A201 RR Sink – Cold showed detectable Legionella bacteria with counts at 2cfu/ml. - A 203/A201 RR Sink - Hot showed detectable Legionella bacteria with counts at 6cfu/ml. - A 221/A223 RR Sink – Hot showed detectable Legionella bacteria with counts at 5cfu/ml. - A218/A220 RR Sink - Hot showed detectable Legionella bacteria with counts at 3cfu/ml. - P112/P110 RR Sink - Hot showed detectable Legionella bacteria with counts at 2cfu/ml -A212/A210 RR Sink - Hot showed detectable Legionella bacteria with counts at 6cfu/ml The Following Recommended Actions are Advised: All affected fixtures should be temporarily isolated if directed by Infection Prevention. Examples of System Isolation may consist of 1) Disabling the water supply to the fixture until remediation has been conducted, 2) Isolating the room where the fixture is located from normal use, and 3) Installation of microbiological filters (a system used to remove undesired bacteria or microorganisms from water) to prevent exposure to Legionella. It is recommended that positive fixtures and adjacent taps be thoroughly flushed for 5 minutes a day for a period of 7 to 10 days. It is important to verify the hot water temperature reaches the target temperature implementing a chlorination procedure per the SOP (Standard of Procedure) in your Water Safety Plan, as a majority of samples collected in the domestic water system show the presence of Legionella bacteria. All positive locations should be re-tested following completion of corrective actions to re-establish acceptable control. Continue to follow all preventative actions as part of your Utility Water Safety Program, including routine testing of the water systems During a review of the document titled, Analytic results. Water testing: Q 1 2026 Viable Legionella Bacteria-RETEST, the document indicated, .Date sampled: February 24, 2026, and dated reported: March 6, 2026, . The following summarizes results from this sampling period: For domestic water, four (4) of the six (6) samples showed the presence of Legionella bacteria: -A 203/A201 RR Sink – Hot showed detectable Legionella bacteria with counts at 2cfu/ml. - A 218/A220 RR Sink - Hot showed detectable Legionella bacteria with counts at 4cfu/ml. -P112/P110 RR Sink – Hot showed detectable Legionella bacteria with counts at 19cfu/ml. - A212/A210 RR Sink - Hot showed detectable Legionella bacteria with counts at 26cfu/ml. During a review of the document titled, Analytic results. Water testing: Q 1 2026 Viable Legionella Bacteria-RETEST 2, the document indicated, .Date sampled: March 19, 2026, and dated reported: April 1, 2026, . The following summarizes results from this sampling period: For domestic water, three (3) of the four (4) samples showed the presence of Legionella bacteria: - A 218/A220 RR Sink - Hot showed detectable Legionella bacteria with counts at 31cfu/ml. -P112/P110 RR Sink – Hot showed detectable Legionella bacteria with counts at 17cfu/ml. - A212/A210 RR Sink - Hot showed detectable Legionella bacteria with counts at 77cfu/ml. During a review of the document titled, Analytic results. Water testing: Q 2 2026 Viable Legionella Bacteria, the document indicated, .Date sampled: April 09, 2026, and dated reported: April 24, 2026 . The following summarizes results from this sampling period: For domestic water, four (4) of the six (6) samples showed the presence of Legionella bacteria: -A 202/A204 RR Sink – Hot showed detectable Legionella bacteria with counts at 4cfu/ml. - A 221/A223 RR Sink - Hot showed detectable Legionella bacteria with counts at 26cfu/ml. -Shower Rm Across Director of Nursing Middle Hose – Hot showed detectable Legionella bacteria with counts at 2cfu/ml. - P107/P105 RR Sink - Hot showed detectable Legionella bacteria with counts at 5cfu/ml. During a review of the document titled, Analytic results. Water testing: Q 2 2026 Viable Legionella Bacteria Retest 3, the document indicated, .Date sampled: June 30, 2026, and dated reported: July 10, 2026. The following summarizes results from this sampling period: For domestic water, four (4) of the four (4) samples showed the presence of Legionella bacteria: -A 202/A204 RR Sink – Hot showed detectable Legionella bacteria with counts at 4cfu/ml. - A 221/A223 RR Sink - Hot showed detectable Legionella bacteria with counts at 4cfu/ml. -Shower Rm Across Director of Nursing Middle Hose – Hot showed detectable Legionella bacteria with counts at 5cfu/ml. - P107/P105 RR Sink - Hot showed detectable Legionella bacteria with counts at 7cfu/ml. During a review of the document titled, Analytic results. Water testing: Q 3 2026 Viable Legionella Bacteria, the document indicated, .Date sampled: July 09, 2026, and dated reported: July 22, 2026. The following summarizes results from this sampling period: For domestic water, seven (7) of the seven (7) samples showed the presence of Legionella bacteria: -A 209/A211 RR Sink – Cold showed detectable Legionella bacteria with counts at 15cfu/ml. -A 209/A211 RR Sink – Hot showed detectable Legionella bacteria with counts at 120cfu/ml. - A224 Entry Sink - Hot showed detectable Legionella bacteria with counts at 120cfu/ml. - P118/P120 RR Sink - Hot showed detectable Legionella bacteria with counts at 120cfu/ml - P110/P112 RR Sink - Hot showed detectable Legionella bacteria with counts at 120cfu/ml - A206/A208 RR Sink - Hot showed detectable Legionella bacteria with counts at 120cfu/ml. During a concurrent interview and record review on July 22, 2026, at 2:20 PM, with the Manager of Plant Operations (MPO), the MPO stated he and the Director of Engineering (DOE) are responsible for the oversight of the facilities water testing. The MPO stated the facility's water is tested quarterly for legionella by a contracted company. During a concurrent interview and record review on July 22, 2026, at approximately 2:20 PM, with MPO, the facility document titled, Analytic results: water testing: Q [quarter] 2 2026 viable legionella bacteria dated April 24, 2026, was reviewed. The document indicated that four of the seven domestic water samples were positive for legionella bacteria. The MPO confirmed and validated the water test results was positive for four samples. The MPO stated, he was aware of positive test results but was not sure if the the Director of Facilities (DF) reported the positive result to the admin. The MPO stated, the DF is currently not available. During a concurrent interview and record review on July 22, 2026, at 2:32 PM with the MPO, the facilities policy and procedure (P&P) titled, Water Management Program/Water Safety Plan dated 2026-2027, indicated the following: .1. Introduction. The goal of the Water Management Plan is to control the growth and survival of Legionella and other waterborne pathogens in water systems, and to control epidemics in the facility. This water plan documents the actions that Dignity Community Hospital of San [NAME] Children's Subacute Center employs specifically for the purpose of managing waterborne pathogens (tiny, disease-causing germs, that spread through contaminated water) including Legionella bacteria in the utility water systems.4.3. Domestic Water Flushing. Legionella Bacteria Detection Flushing. The following list of steps should be performed daily, for a minimum of one week, for any location that shows legionella bacteria detection.1. For domestic hot water taps open the fixture and allow the fixture to flush for a period of 5 minutes verify the hot water temperature reaches the target temperature. For patient care areas the target temperature is at least 105 Fahrenheit not to exceed 120 Fahrenheit.2. For the domestic cold water at the same location flush the fixture for the same duration of time that the domestic hot water fixture was flushed.3. For showers, flush the shower for the same duration of time that the hot and cold-water taps were flushed. .Domestic water action plan .is Legionella detected -> yes -> Isolate the system to minimize exposure of water to patients as directed by Infection Prevention -> is localized or systematic -> .Localized. 1. Flush the affected fixtures according to the SOP in Section 4, and record date, time, location on a log sheet. 2. Inspect fixtures and disinfect/descale per SOP in Section 4 or replace the fixtures. 3. Retest for Legionella following corrective actions. 4. If detections persist, a droplet disinfection may be considered by the Water Management Team. .Systematic. 1. Perform System Chlorination (a setup that adds chlorine to water to kill germs like bacteria and viruses) . 2. If applicable, consider Hot Water Storage Tank Disinfection . 3. Flush the affected fixtures according to the SOP in Section 4, and record date, time, location on a log sheet.4. Inspect fixtures and disinfect/descale per SOP in Section 4 or replace the fixtures.5. Retest for Legionella following corrective actions.6. The need for permanent secondary disinfection should be discussed by the water management team-> .Resample for legionella within 5 to 10 days after corrective action. .Note 1: Examples of System Isolation may consist of: 1. Disabling the water supply to the fixture until remediation has been conducted 2. Isolating the room where the fixture is located from normal use 3. Installation of microbiological filters to prevent exposure to Legionella bacteria . The MPO stated, the facility's domestic water action plan was not followed and the chlorination system had not been performed. During a concurrent interview and record review on July 22, 2026, at 3:21 PM, with the infection preventionist (IP), the facility's document, Analytic results: water testing: Q [quarter] 2 2026 viable legionella bacteria, dated April 24, 2026, was reviewed. The IP stated, she had not been made aware of positive legionella water testing for quarter two reported to the facility on April 24, 2026. The IP stated, she tracks infections and identifies the type of infection, bacteria, or organism occurring within facility. A review of the facility's antibiotic stewardship and infection surveillance tracking logs from January 2026 through July 2026 indicated there were no residents with health care associated legionella infections identified within the facility. During a concurrent interview and record review on July 23, 2026, at 8:15 AM with the IDON, the facility document titled, Analytic results: water testing: Q [quarter] 2 2026 viable legionella bacteria, dated April 24, 2026, was reviewed. The document indicated, four of the seven domestic water samples were positive for legionella. IDON stated, they were not aware of the positive legionella bacteria test result. During a concurrent interview and record review on July 23, 2026, at 8:33 AM, with the ADMIN, the facility's document, Analytic results: water testing: Q [quarter] 2 2026 viable legionella bacteria, dated April 24, 2026, was reviewed. The document indicated, four of the seven domestic water samples were positive for legionella. The ADMIN stated I was not aware of the positive legionella water testing results prior to this survey. The ADMIN further stated there was a breakdown in communication between the engineering department and the facility administration resulting in the positive tests results not being communicated. During a concurrent interview and record review on July 23, 2026, at 2:56 PM with the Senior Director of Ancillary Services (SDAS), ADMIN, IDON, MPO, the following facility documents were reviewed: A. Analytic results. Water testing: - Q [quarter] 1 2026 Viable Legionella Bacteria reported dated February 6, 2026, indicated six (6) of the ten (10) samples showed the presence of Legionella bacteria - Q [quarter] 1 2026 Viable Legionella Bacteria retest report dated April 1, 2026, indicated, three (3) of the four (4) samples showed the presence of Legionella bacteria -- Q [quarter] 2 2026 Viable Legionella Bacteria reported dated April 24, 2026, indicated four (4) of the six (6) samples showed the presence of Legionella bacteria - Q [quarter] 2 2026 Viable Legionella Bacteria retest report dated July10, 2026, indicated four (4) of the four (4) samples showed the presence of Legionella bacteria - Q [quarter] 3 2026 Viable Legionella Bacteria reported dated July 22, 2026, indicated, seven (7) of the seven (7) samples showed the presence of Legionella bacteria. B. The facilities policy and procedure (P&P) titled, Water Management Program/Water Safety Plan dated 2026-2027. C. The facility document titled, Project validation and summary report; domestic hot water chlorination performed date June 29, 2026, the document indicated, domestic water chlorination services for the domestic hot water system was completed. During a review of the facility's 2026, Analytic results. Water testing: - Q [quarter] 1 2026 Viable Legionella Bacteria reported dated February 6, 2026, indicated six (6) of the ten (10) samples showed the presence of Legionella bacteria - Q [quarter] 1 2026 Viable Legionella Bacteria retest report dated April 1, 2026, indicated, three (3) of the four (4) samples showed the presence of Legionella bacteria -- Q [quarter] 2 2026 Viable Legionella Bacteria reported dated April 24, 2026, indicated four (4) of the six (6) samples showed the presence of Legionella bacteria - Q [quarter] 2 2026 Viable Legionella Bacteria retest report dated July10, 2026, indicated four (4) of the four (4) samples showed the presence of Legionella bacteria - Q [quarter] 3 2026 Viable Legionella Bacteria reported dated July 22, 2026, indicated, seven (7) of the seven (7) samples showed the presence of Legionella bacteria. Indicated, all water testing conducted in the year 2026 to date contained samples that tested positive for legionella bacteria. The MOP was unable to provide documentation demonstrating that required water flushing (every day for seven to ten days), fixture inspection, water management team involvement, or system chlorination had been completed following the positive legionella test results. The MOP was able to provide documented evidence system flushing chlorination was performed on June 29, 2026, six months after quarter one positive testing results. The SDAS, ADMIN, IDON and MPO acknowledged the facility failed to implement and [NAME]

Based on observation, interview, and record review, the facility failed to ensure food was stored, prepared, and served under sanitary conditions as required when:1. One refrigerator and one freezer were observed without temperature monitoring to ensure food was held at safe temperatures.2. The automatic paper towel dispenser at the handwashing sink in the kitchen was not functioning.3. The microwave contained food splashes.4. The middle basin of the three compartment sink contained old food residue, and the countertop had powder residue.5. Seven of eight frozen meals stored in the freezer were expired.6. During lunch tray line assembly, one nutrition aide in the main kitchen did not wash her hands between glove changes.7. Ten nutritional protein supplements in cart number four were expired These failures had the potential to result in foodborne illnesses and negatively affect residents' health and safety. 1. During a concurrent observation and interview on July 20, 2026, at 8:35 AM in the kitchen, the thermometer in Refrigerator 1 was not working and there was no thermometer in Refrigerator 2's freezer. Charge Nurse (CN) verified thermometer in Refrigerator 1 was not working and there was no thermometer in Refrigerator 2's freezer and stated maintenance was responsible for maintaining the thermometers. During an interview on July 20, 2026, at 8:43 AM with Maintenance (MN), MN confirmed Refrigerator 1 thermometer was not working and there was no thermometer in Refrigerator 2's freezer. MN further stated the refrigerators' temperatures were monitored by remote temperature control system which was not working snice last week and they are in the process of fixing it. During an interview on July 20, 2026, at 9:05 AM with Interim Director of Food and Nutrition Services (IDFNS), IDFNS stated there should be a working thermometer in each Refrigerator to monitor temperatures. During a review of the facility's policy and procedure (P&P) titled, Food and Nutrition Services (FNS): Food Handling, dated June 25, 2024, the P&P indicated, .Procedure or Process:.3. Temperatures of food storage areas and cold food vending are monitored and action is taken to maintain temperatures within ranges recommended by licensing and surveying agencies. a. Each mechanically refrigerated unit storing potentially hazardous food will be equipped with a thermometer and monitor according to regulatory requirements. 2. During a concurrent observation and interview on July 20, 2026, at 8:40 AM in the kitchen, the automatic paper towel dispenser at the handwashing sink was not functioning. CN verified the automatic paper towel dispenser at the handwashing sink not working and stated maintenance was responsible for maintaining automatic paper towel dispensers. During an interview on July 20, 2026, at 8:45 AM with Maintenance (MN), MN confirmed the automatic paper towel dispenser at the handwashing sink was not working. MN further stated it ran out of batteries. During a review of the FDA Food Code, dated 2022, 6-301.12 indicated, Each handwashing sink or group of adjacent handwashing sinks shall be provided with: (A) Individual, disposable towels; (B) A continuous towel system that supplies the user with a clean towel; or (C) A heated-air hand drying device; or (D) A hand drying device that employs an air-knife system that delivers high velocity, pressurized air at ambient temperatures. In addition, Provisions must be provided for hand drying so that employees will not dry their hands on their clothing or other unclean materials. It is known that wet hands transfer bacteria more readily than dry hands. The residual moisture found on the hands after washing allows for bacterial and viral transfer to food or solid surfaces by touch. The method in which hands are dried is a critical factor in reducing chances of cross-contamination by hands to food and environmental surfaces. 3. During a concurrent observation and interview on July 20, 2026, at 8:51 AM in the kitchen, the inside of the microwave was dirty with food splashes. Charge Nurse (CN) confirmed the microwave contained food splashes. CN stated speech therapists use the microwave to sanitize bottles. During an interview on July 20, 2026, at 9:07 AM with the Interim Director of Food and Nutrition Services, IDFNS confirmed the microwave was dirty and stated they should have a food grade sanitizer beside the microwave to clean it after each use. During a review of the FDA Food Code, dated 2022, 4.602.13 indicated, Nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues. In addition, The presence of food debris or dirt on nonfood contact surfaces may provide a suitable environment for the growth of microorganisms which employees may inadvertently transfer to food. If these areas are not kept clean, they may also provide harborage for insects, rodents, and other pests. 4. During a concurrent observation and interview on July 20, 2026, at 8:57 AM in the kitchen, the middle basin of the three compartment sink contained noodles and there was powder residue on the countertop. CN confirmed the middle basin of the three-compartment sink contained noodles and the countertop was dirty with powder residue. During an interview on July 20, 2026, at 9:09 AM with the Interim Director of Food and Nutrition Services, IDFNS confirmed the middle basin of the three-compartment sink and the countertop was dirty and stated it was important to keep it clean for pest control. During a review of the facility's policy and procedure (P&P) titled, Food and Nutrition Services (FNS): Food Handling, Safety and Sanitation, dated June 25, 2024, the P&P indicated, . it is the policy of [Community Convalescent Center of San [NAME]] to follow all local, state and federal standards and regulations in order to provide a safe and sanitary department of FNS. 5. During a concurrent observation and interview on July 20, 2026, at 8:37 AM in the kitchen, seven out of eight frozen meals stored in Refrigerator 2's freezer were expired. CN confirmed seven out of eight frozen meals were expired and threw them out. During an interview on July 20, 2026, at 9:10 AM with the Interim Director of Food and Nutrition Services, IDFNS stated expired food should not be kept in the freezer. During a review of the facility's policy and procedure (P&P) titled, Food and Nutrition Services (FNS): Food Handling, dated June 25, 2024, the P&P indicated, .A. Food and Supply Storage.4. Food storage guidelines are followed for food stored in refrigerators and walk-in coolers.f. Food stored refrigerated will be kept no longer than expiration date. 6. During an observation on July 20, 2026, at 10:08 AM in the main kitchen, Nutrition Aide (NA) did not was her hands between glove changes during lunch tray line assembly. During a concurrent observation and interview on July 20,2026, at 10:49 AM with Interim Director of Food and Nutrition Services and Food and Nutrition Services Manager (FNSM), IDFNS and FNSM stated the NA should have washed her hands between glove changes to prevent contamination. During a review of the facility's policy and procedure (P&P) titled, Food and Nutrition Services (FNS): Food Handling, dated June 25, 2024, the P&P indicated, .Food Handling Guidelines. J. Single-use disposable gloves are worn when preparing foods that will not be cooked again (ready-to-eat foods) or while serving food. i. Gloves are to be placed over clean hands. ii. Gloves are changed between tasks or if punctured or ripped. iii. Hands are washed after gloves are removed. Findings: 7. During a concurrent observation and interview on July 22, 2026, at 8:36 AM with Registered Nurse Supervisor RNS 1, at medication cart number four. During the inspection of cart number four, ten nutritional protein supplements for tube feeding were found stored in the medication cart with an expiration date of July 6, 2026. RNS 1 verified that all ten items were expired with the expiration date of July 6, 2026. RNS 1 stated that the expired nutritional protein supplements should not be available for resident use and acknowledged that the expired protein supplements should have been removed from the medication cart to protect resident's safety. During a interview on July 22, 2026, at 12:30 PM with the Interim Director of Nursing (IDON), the IDON stated that the facility does not have a policy for supply storage and management. The IDON acknowledged the items were expired and should have been discarded. During a review of the facilities policy and procedure titled, food and nutrition services: food handling, dated June 25, 2025, indicated, A. Food and Supply Storage.1. Food and supplies must be stored according to the food safety guidelines and regulatory standards . 2.c. Follow expiration date and food storage time guidelines.

Based on observation, interview, and record review, the facility failed to follow its policy and procedure (P&P) for the administration of eternal feeding (liquid nutrition administered via feeding tube) when one (1) of sixteen sample residents (Resident 7) feeding solution was observed hanging beyond the facility's allowable hang time and remained available for administration. This failure had the potential to place Resident 7 at risk for adverse health outcomes, including bacterial contamination infection associated with administration of expired enteral feeding solutions. Findings: During a review of Resident 7's clinical record, the Record of Admission (contains demographic and medical information), the Record of Admission indicated, Resident 7 was admitted to the facility on June11, 2024 with diagnoses which included [NAME] syndrome ( a very rare condition present at birth that changes how a child's face, jaw, hands, and arms grow), Gastrostomy status (a tube inserted through the abdomen that delivers nutrition and hydration directly to the stomach), and Tracheostomy (an opening in the neck and into the windpipe to help someone breathe). During a review of Resident 7's Order Summary Report, dated [DATE], the Order Summary Report indicated, Pediasure (a nutritional shake designed for children 2 to 13) peptide 1.5 Kilocalorie (Kcal - a unit of measurement) by J tube (a soft plastic tube placed through the skin of the abdomen directly into the small intestine to deliver nutrition, fluids, and medicines) at 60 ml (milliliter- a unit of measurement) per hour times 20 hours continuous dip; on at 1130 and off at 0730. During a concurrent observation and interview on [DATE], at 9:45 AM, with Licensed Vocational Nurse 2 (LVN) 2, in Resident 7's room, observed Pediasure peptide 1.5 Kcal a closed system ready to hang eternal feeding hanging on feed pump. The feeding pump was turned off at the time of the observation. The label on the enteral feeding solution indicated it was hung [DATE], at 2:00 PM. LVN 2 stated the feeding pump had been turned off at approximately 8:00 AM this morning. LVN 2 further stated that enteral feeding solutions are permitted to hang for 24 hours and that the solution had been hung by her the previous afternoon and she must have put the wrong date on solution. LVN 2 verified the hanging enteral feeding solution according to our observation was expired and should not been administered. During an interview on [DATE], at 11: 21 AM with the Interim Director of Nurses (IDON) and the Registered Nurse Supervisor (RNS 1), the IDON stated that closed system ready to hang eternal feeding formulas are to be changed every 24 hours in accordance with the facility's policy. RNS 1 validated that it is the facility's standard practice that enteral feeding solutions are not to remain hanging longer than 24 hours. During a concurrent interview and record review on [DATE], at 12:45 PM, with the IDON, the facility's Policy and Procedure (P&P) titled Closed System Ready-to-hang Containers of formula Procedure for dated [DATE], was reviewed. The P&P indicated, . Ready to hang formula will be used as part of the closed system enteral. Feeding ready to hang formula may hang for a maximum of 24. The IDON acknowledged and stated the policy was not followed.

Based on observation, interview, and record review, the facility failed to ensure medical supplies were labeled and stored in accordance with professional principles when one of one medication storage rooms was found with expired supplies. This failure had the potential for the supplies to be less effective and compromised the health and safety of 17 highly vulnerable residents who reside in the facility.Findings: During a concurrent observation and interview on [DATE], at 7:56 AM, with the Registered Nurse Supervisor 1 (RNS 1), in the medication storage room. An inspection was conducted and the following items were found expired and available for use: 1.One cardiopulmonary resuscitation (CPR) stat (immediate) pads package (a set of two sticky, gel-covered pads that connect to a heart-shock machine (AED) and include a built-in sensor to guide your chest compressions) was found with an expiration date of [DATE]. 2. Sixteen nonstick silver gauze were found with the following expiration dates: fourteen with an expiration date of [DATE] and two with expiration date of [DATE]. RNS 1 verified that all seventeen items were expired. RNS 1 stated that expired supplies should be removed from use by expiration date and not available for use on unit. During a concurrent observation and interview on [DATE], at 8:06 AM, with the Administrator (ADMIN) in the conference room, the ADMIN verified the seventeen medical supplies were expired, the ADMIN stated the staff should have identified and removed the expired supplies from use to protect the safety of the residents. During an interview on [DATE], at 12:15 PM with the Interim Director of Nursing (IDON), the IDON stated the facility does not have a policy for supply storage and management. The IDON acknowledged the items were expired and should have been discarded. The IDON further stated the license staff are responsible for checking expiration dates on supplies.

Based on observation, interview, and record review, the facility failed to ensure one (1) of three sampled residents (Resident 10) was free from physical restraints when on July 20, 2026 Resident 10 was restrained in a wheelchair using a strap harness and a lap belt without documented medical symptoms, without a physician's order, and without an informed consent from the Resident 10's representative prior to restraint use. This failure resulted in Resident 10 being physically restrained without medical necessity, order, or consent, placing Resident 10 at risk for physical and psychosocial harm.Findings: During a record review of the Patient Insurance and Demographics (PID), the PID indicated Resident 10 was admitted at the facility on September 27, 2018. During a record review of the History and Physical (H&P) dated September 30, 2025, the H&P indicated Resident 10 was admitted at the facility with diagnoses which included CHARGE syndrome (a rare genetic disorder present from birth that affects many parts of the body, a gap or missing piece in structures of the eye [like the iris or retina], heart defects, and ear abnormalities), repair of Tetralogy of Fallot (a rare, congenital heart defect present at birth that lowers oxygen levels in the blood), tracheostomy dependance (permanent or long-term need to breathe through a breathing tube in the neck rather than through the nose and mouth) and GT (gastrostomy tube) dependence (needing a feeding tube placed directly into the stomach to receive daily nutrition and hydration because a person cannot safely or adequately eat by mouth). During an observation on July 20, 2026, at 11:05 AM, Resident 10 was seated in a wheelchair in his room. Resident 10 was secured with a strap harness across the chest and shoulders and a lap belt fastened across the waist. Resident 10 was unable to rise or freely move/reposition in the wheelchair while the devices were fastened, meeting the definition of a physical restraint. During an interview with the Licensed Vocational Nurse 4 (LVN 4) on July 20, 2026, at 11:10 AM in Resident 10's room, LVN 4 confirmed the strap harness was fastened across resident's chest and shoulders, and the lap belts was fastened across Resident 10's waist. LVN 4 stated the strap harness and the lap belt are used as a safety measure to prevent Resident 10 from falling out the wheelchair. During a record review on July 21, 2026, at 11:00 AM, Resident 10's Active Order Profile (Active Physician Orders) was reviewed. The Active Order Profile indicated there was no physician order authorizing the use of a strap harness or lap belt for Resident 10. Further review of the clinical record revealed the absence of a physical restraint assessment identifying any medical symptom warranting the use of a restraint. There was no documentation of least-restrictive alternatives attempted, such as positioning, seating modifications, or supervision. Furthermore, there was no informed consent documentation from Resident 10's mother regarding the use of restraints. There was no physical restraint care plan and interventions addressing restraint use, monitoring, duration, or a plan for reduction or removal. During a concurrent record review and interview with Registered Nurse Supervisor 1 (RNS 1) on July 21, 2026, at 11:30 AM, RNS 1 stated there were no current physician orders for the strap harness and for the lap belt for Resident 10. RNS 1 confirmed informed consent had not been obtained from Resident 10's mother. The RNS 1 further confirmed there was no assessment identifying a medical symptom necessitating a restraint, no documentation of least restrictive alternatives attempted, no restraint release/monitoring, and no plan to reduce or remove the restraints. During a concurrent record review and interview with the Administrator (Admin) on July 23, 2026, at 10:55 AM, the facility's policy and procedure (P&P) titled, Restraints, Physical Guidelines for Use and Assessment, effective September 2001 was reviewed. The P&P indicated, Purpose: To assure that physical restraints will only be utilized for the treatment, safety, and protection of the resident when medical symptoms warrant their use and less restrictive measures have been unsuccessful. To ensure that each resident is assessed prior to the use of physical restraints and to involve the resident/representative in the decision pertaining to the benefits of restraint use. To assist in attaining or maintaining his or her highest practical level of physical and psychosocial well-being. POLICY: It is the policy of this facility to assess residents prior to the implementation of restraints to ensure appropriate protocols have been followed, alternative methods have been attempted, and that the least restrictive type of restraint is utilized. The facility will utilize restraints only when necessary to ensure the treatment safety and protection of the residents as permitted by the law in ordered by a physician. The only restraints utilized shall be soft belt, soft tie, wrist restraints, cloth mittens, a chair that prevents rising, lap trays with spring release devices, lap buddy cushions, side rails, or seat belts . All restraints require a physician order and shall only be used during a treatment or for safety . The use of restraints upon the request of the family significant other of a resident will not be permitted . A telephone order for restrained use is acceptable and must be signed by the physician within (5) five days as per state regulations . The physician will obtain informed consent pertaining to the use of restraints from the resident or resident representative . DEFINITIONS: Physical restraint is defined as any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the resident cannot remove easily which restricts freedom of movement or normal access to one body. PROCEDURE: 1.1 All residents will be assessed upon admission in as needed during their hospital stay for physical and behavioral triggers/symptoms, which may necessitate the use of restraints for their safety and well-being . 1.8 All restraints will require a physician order and restrain use will be reflected in the residence care plan. The order obtained from the physician will include the following: 1.8.1 The type of restraint to be used, 1.8.2 Where the restraint will be applied . 1.8.3 The medical reason for the restraint, 1.8.4 Time frames for use, 1.8.5 Release for range of motion, skin check, and repositioning, 1.8.6 Any continuous/additional monitoring of behavior, 1.8.7 The duration for of use not to exceed 30 days(recap) . DOCUMENTATION: 2.1 Complete the physical restraint assessment form in conjunction with the interdisciplinary team and resident/representative, if possible; 2.2 Complete the consent for the use of the ordered physical restraint . 2.5 The Interdisciplinary Team will develop a resident care plan . 2.7 Weekly Progress Note: The licensed nurse will document in the weekly progress note the use of restraints, effectiveness of use, less restrictive measures and their effectiveness and progress towards the goals established by the interdisciplinary team, 2.8 Monthly Reassessment: The Interdisciplinary Team will reassess the use of the restraint, the effectiveness of the action plan, less restrictive measures and their effectiveness, progress on the restrained reduction plan and further action to be taken. This information will be documented on the Interdisciplinary Team Conference Form, 2.9 Quarterly Reassessment: the interdisciplinary team will reassess the use of restraints on a quarterly basis, utilizing the physical restraint assessment form. Any additions, deletions or revisions of the plan will be reflected in the resident's plan of care and on the Physical Restraint Assessment form. The Admin acknowledged the P&P was not followed when Resident 10 was strapped in his wheelchair with a strap harness across his chest and shoulders and a lap belt across his waist. Admin confirmed there were no physician order and informed consent for the strap harness and lap belt, no physical restraint assessment, and no restraint release/ monitoring plan. The Admin stated the chest harness and the lap belt used are for the safety of the resident and confirmed no one obtained the orders from the physician and the informed consent.

Based on observation, interview, and record review, the facility failed to ensure the medication error rate was less than five percent when there were two medication errors observed out of a total of 32 observed opportunities, affecting two of nine observed residents (Resident 1 and 13), resulting in an overall error rate of 6.25 percent when:1. MiraLAX (a medication used to treat and prevent constipation (infrequent bowel movements or passing hard, dry and painful stools) was not administered to Resident 1 within one hour of scheduled time (one hour before and one hour after) according to the facility's policy and procedure (P&P). This failure had the potential to result in ineffective treatment of MiraLAX in Resident 1 and may contribute to constipation not being managed appropriately. 2. Sildenafil (a medication used to treat pulmonary hypertension (high blood pressure that affects the arteries in the lungs and the right side of the heart)) was not administered to Resident 13 within one hour of scheduled time (one hour before and one hour after) according to the facility's policy and procedure (P&P). This failure had the potential to result in ineffective or unsafe pulmonary hypertension management and increased risk of harm to Resident 13's health. Findings: 1. During a review of Resident 1's admission Record (a document that contains demographic and clinical data) and History and Physical (H&P- a document that contains resident's medical history and a hands-on checkup (physical exam)), the admission Record and H&P indicated, Resident 1 was admitted to the facility on [DATE], with diagnoses which included spastic quadriplegic (jerky movements of the muscle with loss of function affecting both arms and legs), cerebral palsy (neurological disorder permanently affecting a person's ability to move, balance and maintain posture) and seizure disorder (a sudden uncontrolled episode of abnormal electrical activity in the brain, often causing involuntary, rapid, and uncontrollable shaking or spasming of the body, staring spells, or loss of consciousness). During a review of Resident 1's Physician Orders, dated February 24, 2026, it indicated, polyethylene glycol 3350 (MiraLAX) 17gm, Feed Tube, Pwd, qDay, for constipation ***Hold for loose stools***. During an observation on July 22, 2026, at 8:44 AM in Resident 1's room, Licensed Vocational Nurse 3 (LVN 3) was observed preparing and administering medications to Resident 1. During a record review of eMAR - Medication Administration Record (digital system used to track and document when residents receive medications) on July 22, 2026, at 12:50 PM, the eMAR indicated LVN 3 documented at 10:01 AM: polyethylene glycol 3350 (MiraLAX) 17gm, Feed Tube, Pwd, qDay, for constipation ***Hold for loose stools*** not given, awaiting pharmacy. During an interview on July 22, 2026, at 12:51 PM in the hallway, with LVN 3, LVN 3 stated MiraLAX was not administered to Resident 1 at the scheduled time (9:00 AM) because they were out of MiraLAX and waiting for pharmacy to deliver it. LVN 3 further stated MiraLAX was late and not given within one hour of scheduled dose time (one hour before or one hour after). During an interview on July 22, 2026, at 12:54 PM at the nurses' station, with Registered Nurse 1 (RN 1), the RN1 stated MiraLAX was not administered to Resident 1 within the acceptable one hour of scheduled time because they were out of MiraLAX and waiting for pharmacy to deliver it. During a record review on July 22, 2026, at 13:30 PM, Resident 1's eMAR dated July 22, 2026, was reviewed. The eMAR indicated MiraLAX was administered at 1:11 PM. 2. During a review of Resident 13's admission Record and History and Physical, the admission Record and H&P indicated, Resident 13 was admitted to the facility on [DATE], with diagnoses which included trisomy 21 (genetic disorder), tracheostomy (a breathing tube placed directly into a person's windpipe to receive oxygen), and ventilator dependence (a person's body cannot breath enough on its own to stay alive, so they must rely on a machine (a ventilator) to do the work of breathing for them). During a review of Resident 13's Physician Orders, dated March 18, 2026, it indicated, Sildenafil 12 mg, Feed Tube, Susp, q8hr [every 8 hours], for Pulmonary Hypertension. During an observation on July 22, 2026, at 10:00 AM, in Resident 13's room, Licensed Vocational Nurse 4 (LVN 4) was observed preparing and administering medications to Resident 13. During a record review on July 22, 2026, at 10:15 AM, the eMAR indicated Sildenafil 12 mg, Feed Tube, Susp, q8hr [every 8 hours], for Pulmonary Hypertension was scheduled at 8:00 AM and LVN 4 documentation administration of Sildenafil at 10:02 AM. During an interview on July 22, 2026, at 10:31 AM with LVN 4, LVN 4 stated Resident 13's Sildenafil should have been administered within one hour of the scheduled time (one hour before or one hour after). LVN 4 further stated Resident 13 received Sildenafil, scheduled for 8:00 AM, at 10:02 AM (62 minutes late), which falls outside the acceptable medication administration time range. During a concurrent interview and record review on July 23, 2026, at 8:40 AM with the Interim Director of Nursing (IDON), the facility's policy and procedure (P&P) titled, Medication Administration, dated April 1994, was reviewed. The P&P indicated, .Procedure: Preparation of Doses- General Instructions 1. Doses Shall be prepared immediately to each resident and shall be administered within one (1) hour of the scheduled dose time. The IDON stated MiraLAX and Sildenafil were not administered within one hour of scheduled dose time. The IDON further stated the P&P was not followed.

Based on observation, interview, and record review, the facility failed to ensure proper and safe infection control practices were followed when: 1. An action plan was not initiated in a timely manner following a positive water test for Legionella (a bacteria that grows in water systems such as air conditioners or hot water tanks and can cause a lung infection) performed on February 4, 2025. 2. An open enteral feeding system (a feeding bag filled with formula that delivers liquid nutrition through a tube to a resident's stomach) was not labeled correctly with the date and time for Resident 7. 3. Sterile respiratory water (a type of water free of germs, used in nebulizers and humidifiers), a tracheostomy mask (a mask that delivers humidified water to a surgical opening in the neck when a resident is unable to breathe normally), and a nebulizer (a device used to deliver medications via mist to a resident's airway) were not labeled with the date and time for Resident 7. These failures had the potential to result in cross-contamination (the transfer of harmful bacteria) causing a preventable infection to 15 residents whose health conditions are already highly compromised. Findings: 1. A review of form titled, Analytic result. Water testing: Q 1 [quarter 1] 2025 Viable Legionella Bacteria, it indicated, .Date sampled: 02/04/2025 [February 4, 2025]. Dated reported: 02/17/2025 [February 17, 2025] We are providing you with the Legionella analytical results that were sampled at your facility on February 4th , 2025. Water samples of interest were collected and analyzed for the presence of viable Legionella species using the CDC Method. Results are expressed as one of the following terms: 1. No Detection (ND): No Legionella is detected in the sample 2. <1 [less than one] colony forming unit/ml (cfu/ml) [unit of measurement colony forming unit/ milliliter]: Legionella was detected between the minimum detection limit of 0.4 cfu/ml and 1 cfu/ml in the water sample 3. Whole number: Legionella is detected at 1 [one or less than one] in the sample. The goal is zero detectable Legionella in a water source . The following summarizes results from this sampling period: For domestic water, five (5) of the ten (10) samples showed the presence of Legionella bacteria: - Rm A 204 RR Sink - Hot detectable Legionella bacteria with counts at < 1cfu/ml. - Rm A 215 RR Sink - Hot showed detectable Legionella bacteria with counts at 1cfu/ml. - Rm A 209 RR Sink - Cold showed detectable Legionella bacteria with counts at 18cfu/ml. - P 106 RR Sink - Hot showed detectable Legionella bacteria with counts at < 1cfu/ml. - P 116 RR Sink - Hot showed detectable Legionella bacteria with counts at < 1cfu/ml The Following Recommended Actions are Advised: . All affected fixtures should be temporarily isolated if directed by Infection Prevention. Examples of System Isolation may consist of: 1) Disabling the water supply to the fixture until remediation has been conducted, 2) Isolating the room where the fixture is located from normal use, and 3) Installation of microbiological filters to prevent exposure to Legionella. It is recommended that positive fixtures and adjacent taps be thoroughly flushed for 5-minutes a day for a period of 7 to 10 days. It is important to verify the hot water temperature reaches the target temperature implementing a chlorination procedure per the SOP [Standard of Procedure] in your Water Safety Plan, as a majority of samples collected in the domestic water system show the presence of Legionella bacteria. All positive locations should be re-tested following completion of corrective actions in order to re-establish acceptable control. Continue to follow all preventative actions as part of your Utility Water Safety Program, including routine testing of the water systems During an interview on April 24, 2025, at 8:15 AM with the Director of Facility Management (DFM), the DFM stated that he manages the Engineering Department responsible for water management at the facility and is aware of the positive water test for Legionella performed on February 4, 2025. During a concurrent interview and record review on April 24, 2025, at 8:30 AM with the Director of Nursing (DON), the DON reviewed the water test result for Legionella performed on February 4, 2025. The DON stated, I was not aware of the positive water test for Legionella report and the recommendation dated February 17, 2025, until today [April 24, 2025]. The DON further stated that the result and recommendation were not communicated to the nursing department for follow-up and implementation. (The action plan was not implemented, leaving 15 residents with tracheotomies exposed to Legionella-contaminated water for two months and seven days.) During an interview on April 24, 2025, at 8:45 AM with the Administrator (Admin), the Admin stated, I was not aware of the positive water test for Legionella performed on February 4, 2025. He further explained that proper communication should have been initiated by the water management committee to both the facility's administration and the nursing department regarding this result and its associated recommendation, but it was not communicated for implementation. The action plan of remediation (corrective measures taken to resolve an identified issue or hazard) is designed to isolate the water system and minimize exposure to Legionella-contaminated water for 15 residents with tracheotomies was not implemented.) During a concurrent interview and record review on April 24, 2025, at 9:00 AM with the DFM, the DFM reviewed the water management program and water safety plan binder but was not able locate any documented evidence of recommendation remediation following the positive water test for Legionella report dated February 17, 2025. The DFM was not able to explain as why both the facility administration and the nursing department were not notified of the positive water test for Legionella. Furthermore, the DFM stated that he should have notified the facility's administrator and DON as soon as the results were available, but he did not. During an interview on April 24, 2025, at 10:00 AM with the Infection Prevention Nurse (IPN), the IPN stated, I was not aware of the positive water test for Legionella until today. I received the result because I mentioned that the surveyor was in the facility and had asked for it. A concurrent interview and record review on April 24, 2025, at 11:00 AM, was conducted with the Admin and DFM. They reviewed the agency's undated policy and procedure (P&P) titled, Water Management Program and Water Safety Plan [name of the facility], which indicated the following: .1. Introduction. The goal of the Water Management Plan is to control the growth and survival of Legionella and other waterborne pathogens in water systems, and to control epidemic in the facility. This water plan documents the actions that [named of the facility] specifically for the purpose of managing waterborne pathogens, including Legionella bacteria in the utility water systems . Domestic water action plan . [chart organization plan] .is Legionella detected -> yes -> Isolate the system to minimize exposure of water to patients as directed by Infection Prevention -> is localized or systematic -> Localized. 1. Flush the affected fixtures according to the SOP in Section 4, and record date, time, location on a log sheet. 2. Inspect fixtures and disinfect/descale per SOP in Section 4 or replace the fixtures. 3. Retest for Legionella following corrective actions. 4. If detections persist, a droplet disinfection may be considered by the Water Management Team. Systematic. 1. Perform System Chlorination . 2. If applicable, consider Hot Water Storage Tank Disinfection . 3. Flush the affected fixtures according to the SOP in Section 4, and record date, time, location on a log sheet. 4. Inspect fixtures and disinfect/descale per SOP in Section 4 or replace the fixtures. 5. Retest for Legionella following corrective actions. 6. The need for permanent secondary disinfection should be discussed by the Water Management Team. -> Resample for Legionella within 5-10 days after corrective actions. Note 1: Examples of System Isolation may consist of: 1. Disabling the water supply to the fixture until remediation has been conducted 2. Isolating the room where the fixture is located from normal use 3. Installation of microbiological filters to prevent exposure to Legionella bacteria . The DFM stated that, according to the facility's P&P, remediation should have been implemented following the positive water test for Legionella, and the water should have been retested afterward. The Admin stated the facility's P&P was not followed and he should have known the result promptly, as the necessary corrective actions would have been implemented immediately. A concurrent interview and record review on April 24, 2025, at 12:30 PM was conducted with the DON and IPN. The DON and IPN reviewed the facility's P&P titled, Performing an Outbreak Investigation, revised March 2021, which indicated, .Policy. Suspected disease outbreaks will be investigated . to ensure that methods to prevent further transmission are implemented Procedures. 1.0 Communication . 2.0 Establishing appropriate control measures . The DON stated the facility does not have a specific P&P for addressing a positive Legionella test and the facility follows this P&P in cases of potential or actual outbreaks. The IPN stated that appropriate control measures to minimize exposure to Legionella-contaminated water should have been implemented immediately, but they were not. Furthermore, both DON and IPN stated that the facility's P&P was not followed. 47360 2. During a review of Resident 7's History and Physical (H&P - a document containing the formal and complete assessment of a resident and the current health problem), dated February 14, 2025, indicated, Resident 7 was admitted to the facility on [DATE] with diagnoses including respiratory failure (the inability of the respiratory system to meet the oxygen needs of the body), tracheomalacia (a weak windpipe that can collapse with breathing or coughing) and gastric-tube dependence (relies on a feeding tube for nutrition instead of eating food by mouth). During an observation on April 21, 2025, at 9:22 AM, in Resident 7's room, an enteral feeding bag was full of formula at Resident 7's bedside. The tube feeding was not connected to the resident and not infusing. The formula bag was dated as 4/2 [April 2] and did not include time it was prepared or nurse's initials. During a concurrent observation and interview, on April 21, 2025, at 9:22 AM, with Licensed Vocational Nurse 1 (LVN 1), in Resident 7's room, LVN 1 confirmed the date was written 4/2 [April 2] on the label and there was no time. LVN 1 stated, the label must be incorrect because 4/2 [April 2] was 19 days ago and the formula bag needs to be changed every 24 hours. LVN 1 stated, the nurse that started the feeding did not correctly date the system and should have dated it as 4/21/25 and there should have been a time on the label as well. LVN 1 stated, time and date is important because the open tube feeding system needs to be changed every 24 hours for resident safety. During a concurrent interview and record review, on April 24, 2025, at 9:06 AM, with the Infection Prevention Nurse (IPN), the facility's policy and procedure (P&P) titled, Administration of Formula Via Feeding Tube, Gravity, Bolus, Pump dated May 2011 was reviewed. The P&P indicated, . 3.1.17 Pump bags, syringe and tubing (open system) are to be changed every 24 hours and properly labeled with date time, and nurses initials . The IPN stated, the formula bag needs to be dated properly to ensure it is changed out every 24 hours to prevent bacterial growth since the open system allows for more formula to be added throughput the day. The IPN further stated, if the bag system is not changed every 24 hours, it could lead to an infection. 3. During an observation on April 21, 2025, at 8:48 AM in Resident 7's room, a tracheostomy oxygen mask was handing outside the crib, it was connected to an oxygen source and sterile water for humidity. The sterile water and the tracheostomy oxygen mask and nebulizer were not labeled as when they needed to be changed. During a concurrent observation and interview, on April 21, 2025, at 9:08 AM with Respiratory Therapist 1 (RT 1), RT 1 was not able to determine when the sterile respiratory water or tracheostomy mask and nebulizer had last been changed and when the resident respiratory items need to be changed next. The RT 1 stated nursing is to change the items out on a regular basis to prevent growth of bacteria (germs) and prevent infection. During a concurrent interview and record review, on April 24, 2025, at 9:22 AM, with the Infection Prevention Nurse (IPN), the facility's policy and procedure (P&P) title, Frequency for Change of Disposable Respiratory Equipment dated May 2022, it indicated, .All disposable respiratory equipment used in the provision of respiratory care, including .aerosol delivery devices, are changed according to the frequency identified for each respective device .3.0 Sterile respiratory water is placed every 48 hours or when depleted . 8.0 Aerosol nebulizers are changed every Monday, Wednesday, and Friday. 8.1 The nebulizer and/or aerosol tubing is changed whenever there is evidence of gross soiling . The IPN stated, the sterile respiratory water needed to be changed every 48 hours. The IPN stated, tubing and nebulizer mask needed to be changed every Monday, Wednesday and Friday. The IPN further stated, these items needed to be labeled to identify when they needed to be changed. The IPN stated, changing these respiratory devices on a regular basis prevents infection and is essential based on the resident population treated at this facility as they all have tracheostomies and require respiratory support.

Based on interview, and record review, the facility failed to implement their policy and procedure (P&P) on antibiotic stewardship (a set of practices aimed at ensuring the safe and effective use of antibiotics [medications used to treat infections]) for one of six sampled residents (Resident 167) reviewed for antibiotic used when the Infection Control Preventionist (ICP) nurse did not accurately analyze the collected data to identify purpose of the antibiotic use to indicate the rationale and common clinical conditions necessary to ensure the appropriate use of antibiotic therapy for Resident 167. This failure had the potential to place Resident 167 at risk for adverse events, including the development of anti-biotic resistant organisms, from unnecessary or inappropriate antibiotic use. Findings: During a review of Resident 167's History and Physical (H&P - a document containing the formal and complete assessment of a resident and the current health problem), dated April 3, 2025, indicated, Resident 167 was admitted to the facility on [DATE] with diagnoses which included Chronic respiratory failure (a long-term condition in which the lungs are unable to provide enough oxygen to the body's tissues) with hypoxia (shortness of breath, fatigue, confusion, and bluish skin) and tracheostomy dependent (a person relies on a tracheostomy tube [a surgical opening in the neck that creates an airway when normal breathing is impaired] for breathing over a long period). During a record review on April 23, 2025, at 3:00 PM of Resident 167's physician's order dated April 11, 2025, the physician's order indicated, . Daptomycin [a powerful antibiotic given through an intravenous (IV - a method of delivering fluids, medications, or nutrients directly into a person's bloodstream) to help treat serious bacterial infections] 275 mg [milligram - unit of measure] IV Q [every] 24 hours. Indication: UTI (Urinary Tract Infection is an infection that affects any part of the urinary system) stop 04/13/25 [April 13, 2025] and Avibactam - Zeftazidime Intravenous [a strong antibiotic administered through an IV to treat serious bacterial infections] 2.5 gr [gram - milligram is unit of measure] IV Q 8 hours indication: infection criteria . CR PSA (a serious bacterial infection caused by Pseudomonas aeruginosa that is resistant to strong antibiotics called carbapenems stop 04/15/25 [April 15, 2025]. During a record review on April 23, at 3:45 PM with the ICP nurse, the ICP nurse reviewed form titled, Revised McGeer Criteria for Infection Surveillance Checklist, indicated as follows: a. Resident name: [Resident 167 name] . UTI . Criteria [was filled to indicated criteria data] .Fever [checked] and . microbiologic criteria [checked] . [ ] UTI criteria met. [ ] UTI criteria not meet. [left blank]. b. Resident name: [Resident 167 name] . Wound infection . Criteria [was filled to indicated criteria data] .Redness [checked] . tenderness [checked] and . fever [checked] . [checked] SSTI [Skin and Soft Tissue Infection] criteria met. The ICP nurse stated the facility used the McGeer Criteria (a criteria helps staff determine whether a patient has a true infection that needs treatment or if the symptoms are due to something else to be able to provide the best treatment) to monitor outcomes of true infection (means that the criteria indicate a real infection) versus untrue infection (patients might show some of these signs but don't actually have an infection) to ensure the appropriate use of antibiotic therapy. During a concurrent interview and record review on April 23, 2025, at 4:05 PM, with the Director of Nursing (DON) and the ICP nurse, the DON and ICP nurse reviewed Resident 167's clinical records of infection notes but was not able locate any documented evidence of infection notes to indicate whether the usage of the two antibiotics was for a true infection or an untrue infection. The ICP nurse stated she should have been conducting an analysis (looking for trends, spikes, or unusual patterns in the data) and reviewing the McGeer Criteria to confirm whether Resident 167 has a true infection, ensuring the appropriate use of antibiotic therapy. During an interview and concurrent record review on April 23, 2025, at 4:15 PM with the DON and ICP nurse, the DON and ICP nurse reviewed the facility's P&P titled, Antimicrobial Stewardship Program [programs to ensure effective and safe use of antibiotics] effective October 2010. The P&P indicated, Purpose: . To provide a guideline for the rational and safe use of antimicrobial- therapy throughout the facility, including the emergency department and long term care units .Antimicrobial medication use will be monitored by a clinical pharmacist under the direction of this physician-led multidisciplinary, collaborative work-group. Discussions with prescribing physicians regarding individual patient therapies will be conducted after evaluation of specific patient demographics and clinical data, evidence-based, national consensus guidelines and local susceptibility information, in order to provide the best possible patient outcomes . Procedure: 1.10 . takes actions on improvement opportunities identified in the antimicrobial stewardship program by collecting, analyzing and presenting antimicrobial use and resistance data to the Infection Control Committee, Pharmacy and Therapeutics Committee, Quality Improvement Committee, or other appropriate committees for review, action and quality improvement . The DON and the IPN stated that the analysis should have been conducted to identify trends in antimicrobial use, prevent unnecessary prescriptions, and reduce the spread of drug-resistant infections, but it was not. Furthermore, the IPN stated that the facility's P&P was not followed.

Based on observation, interview, and record review, the facility failed to ensure safe storage of medications when seven packets of protein supplement (a nutritional supplement given to support dietary needs) were expired and available for resident use. This failure had the potential to affect the health and safety of 15 medically compromised residents placing them at risk for infection and at risk of administering a supplement with decreased potency, that may not achieve desired effect. Findings: During a concurrent observation and interview on April 23, 2025, at 7:30 AM, with Registered Nurse 1 (RN 1), an inspection of medication cart 6 (MC6- a mobile locked cart containing resident medications and supplements) was conducted. Seven protein supplement 15 Grams (a unit of measurement) of protein 60 calorie pouch were found with an expiration date of February 22, 2025. RN 1 stated, the seven protein supplements were expired by 60 days and should have been disposed and not available in the medication cart. During a concurrent interview and record review on April 23, 2025, at 9:06 AM, with the Director of Nursing (DON), the facility policy and procedure (P&P) titled, Safe Storage of Medications, dated January 2023, was reviewed. The P&P indicated, .Medications will be stored under appropriate conditions to maintain medication integrity, promote availability of medication when needed . The DON stated, the facility's P&P was not followed and expired medications and supplements should not be in the medication cart.

Based on observation, interview, and record review, the facility failed to prevent cross contamination from a Certified Nursing Assistant 1 (CNA 1) when CNA 1 did not wash her hands prior to handling a meal tray, and removed food from the tray to heat in the microwave with her bare hands. Furthermore, CNA 1 did not heat the food to the correct temperature. These failures put Resident 10, who was already medically compromised, at risk for food-borne illness (caused by eating or drinking something that is contaminated with bacteria, viruses, or parasites, that can make people sick). Findings: During an interview with the Dietary Services Supervisor (DSS), on April 21, 2025, at 10:15 AM, DSS stated the nursing staff heat the food in the microwave. She stated they heat the food to 165 degrees Fahrenheit (a scale for measuring temperature, in which water freezes at 32 degrees and boils at 212 degrees) and next to the microwave there is a thermometer ( device used to measure temperature) supplied with alcohol pad available to ensure it is heated to the correct temperature. During an observation on April 21, 2025, at 11:30 AM, CNA 1 walked to the kitchen to get Resident 10's lunch from the refrigerator. She did not wash her hands before entering the kitchen. CNA 1 grabbed the lunch tray and walked out of the kitchen to the microwave. She removed the cover from the lunch tray, that had hard boiled eggs, peas and green beans. She removed the hard-boiled eggs with her hands and then put the cover back on and put it in the microwave to 2:22 minutes. After 1:20 minutes she pulled the meal out and felt it with her hands to see if it was warm enough. She put it back in for another 15 seconds. She put the warmed food back onto the tray and carried the tray to the resident's room. During an interview with CNA 1 on April 21, 2025, at 3:10 PM, CNA 1 stated there is not a certain temperature she needs to heat the food. CNA 1 stated she heats up the meals based on the resident preference. She stated she should have washed her hands prior to grabbing the meal from the refrigerator in the kitchen. During an interview with the Licensed Vocational Nurse 1 (LVN 1) on April 22, 2025 at 8:13 AM, LVN 1 stated that the CNA 1 should have taken the temperature of the food and that they provide a thermometer next to the microwave. LVN 1 stated that handwashing should be done prior to handling the meal tray. During an interview with the Registered Dietitian (RD), on April 22, 2025, at 10:01 AM, RD stated the food needs to be heated to 165 degrees Fahrenheit and there is a thermometer for nursing staff to use. RD stated that the nurse should wash her hands prior to handling the meal tray. During a review of the facility's document titled, Food and Nutrition Services Standard Operating Procedure, dated August 1, 2004, the facility's document indicated, 15. Reheating: use appropriate cooking equipment for reheating food to 165 degrees Fahrenheit in less than two hours. In addition, 1. In the FNS (food and nutrition services) Department, all employees associated with the handling of food will wash hands. 2. Hands are to be washed with soap and water at the following times: a. before: i. each shift, ii. Handing food or clean utensils/dishes/equipment, iii. Putting on gloves.

Based on interview and record review, the facility failed to protect against physical abuse for one of three sampled residents (Resident 1) when Resident 1 was slapped on the hand by a School Licensed Vocational Nurse (S/LVN). This failure caused Resident 1 to suffer abuse and fear. Findings: An unannounced visit was made to the facility on [DATE], at 11:34 AM, to investigate a facility reported incident regarding an allegation of physical abuse. A review of Resident 1 ' s face sheet (a document that gives a summary of resident ' s information), undated, indicated an admitted [DATE]. Resident 1 had diagnoses that included chronic respiratory failure (a long-term condition in which the respiratory system is unable to adequately exchange oxygen). During an interview with the Administrator (Admin) on May 29, 2024, at 11:43 AM, the Admin stated he was the facility ' s abuse coordinator. The Admin stated Resident 1 was waiting in the entrance way of the facility with a School Licensed Vocational Nurse (S/LVN) for transport to school. The Admin stated a School District Teacher (Teacher) who taught residents in the facility walked into the facility ' s front lobby and observed the S/LVN tap Resident 1 ' s left hand as Resident 1 reached for his tracheostomy (trach-a procedure to help air and oxygen reach the lungs by creating an opening into the trachea (windpipe) from outside the neck). The Admin stated when Resident 1 reached for his trach again the S/LVN slapped Resident 1 ' s left hand. The Admin stated the teacher did not intervene or go out to the group, she went about her duties and later reported to the Director of Nursing (DON) who had reported to the Admin. The Teacher was unavailable for interview. The DON was unavailable for interview. During an interview with the Admin on May 29, 2024, at 1:11 PM, the Admin stated after interviewing the Teacher and reviewing the documents describing the incident he determined the S/LVN had physically abused Resident 1. A review of the facility ' s policy and procedure titled Notification and Exercise of Rights and Responsibilities, dated September 2009, indicated, Receive care in a safe setting, free from mental, physical, sexual, or verbal abuse and neglect, exploitation, or harassment. You have the right to access protective and advocacy services including notifying government agencies of neglect or abuse.

Based on interviews and facility policy review, the facility failed to have evidence of the implementation of their water management program. This deficient practice affected all 18 residents who currently resided in the facility. Findings included: A review of the facility policy titled, Utility Water Safety Management, last reviewed in February 2024, revealed, Background: Legionnaires' disease is a serious type of pneumonia caused by bacteria, called Legionella, that live in water. Legionella can make people sick when they inhale contaminated water from building water systems that are not adequately maintained. Purpose The purpose of this management program is to reduce the risk for Legionnaires' disease associated with facility water systems and devices. Policy Engineering will implement a water management program that considers the ASHRAE (American Society of Heating, Refrigerating and Air conditioning Engineers) industry standard and the CDC (Center for Disease Control and Prevention), which includes control measures such as physical controls, temperature management, disinfectant level control, visual inspections, and water endpoint testing for pathogens. Maintain routine procedural logs, acceptable ranges for control measures, document the results of testing, and corrective actions taken when test results exceed limits. Responsibility Engineering Department is responsible for management of the Water Safety Program with consultation from a third-party vendor and Infection Control Department. During an interview on 04/17/2024 at 11:50 AM, the Plant Operation Manager stated he was not aware of any water testing conducted in the facility. During an interview on 04/17/2024 at 1:05 PM, the Facility Director stated there had was no assessment of the facility's water system. Per the Facility Director, there should be an assessment to indicate the flow system of water for the facility. The Facility Director stated the assessment was required to identify the risk of growth of waterborne pathogens. During an interview on 04/17/2024 at 2:12 PM., the Infection Preventionist stated she was told engineering would conduct the water management assessment. During an interview on 04/17/2024 at 2:11 PM, the Director of Nursing stated the concern related to the facility's water management system did not fall under her umbrella of duties. During an interview on 04/17/2024 at 1:52 PM, the Administrator stated the water management plan was managed by the facility's Engineering Department. The Administrator stated the assessment could not found, the assessment should be onsite, and staff were trying to locate it.

Based on observation, interview and record review, the facility failed to maintain infection control practices for one of three sample residents (Resident 2) when the facility did not ensure a blood pressure device was stored in a proper place when it was found uncovered inside the Resident 2's restroom in front of the trash can. This failure had the potential to spread infection disease (disease caused by bacteria, virus, fungi) to 26 highly vulnerable residents whose health conditions are already compromised. Findings: During a review of the clinical record for Resident 2, the document title, Patient Insurance & Demographics indicated Resident 2 was admitted on [DATE], for diagnosis of Chronic respiratory failure (a condition that occurs when the lungs cannot get enough oxygen into the blood). During an observation on April 25, 2023, at 2:25 PM in Resident 2 ' s restroom, a vital signs machine was found inside. The vital signs machine was uncovered, unplugged next to the trash can, and a non-use bedside commode. Further observation on Resident 2 ' s restroom, it was observed to be crowded with a trash can linen hamper, a red rocking horse on top of an open toilet, and a blue step stool place on top of the open toilet. During an interview with Certified Nursing Assistant 2 (CNA 2) on April 25, 2023, at 2:31 PM, CNA 2 confirmed the restroom is not the proper place to store a blood pleasure device and stated all the items found on top of the toilet should not be store inside the resident ' s 2 restroom. During an interview with the Registered Nurse (RN 1) on April 25, 2023, at 2:43 PM, RN 1 acknowledge and stated that the blood pressure device should not be place inside of Resident 2 ' s restroom. During a review of the facility ' s policy and procedure Title Standard Precautions dated April 01, 2021, indicated .considers all blood, body substances, and non-intact skin as potentially infectious. Therefore .uses Standard Precautions as a primary component of the infection control program to both protect and prevent the spread of infection control program to both protect and prevent the spread of infections from patient to patient, in accordance with The Centers for Disease Control and Prevention (CDC) guidelines. Elements of Standard Precautions include . 5. Proper handling, cleaning and disinfection of patient care equipment and ./devices. 6. Care of the environment.

Based on interviews, and record review, the facility failed to have a Director of Staff Development (DSD - Orient and educate nursing staff to ensure safe and effective nursing care according to federal, state and facility guidelines) available in the facility to provide ongoing education and evaluation of competencies. These failures had the potential to result in inappropriate care and services for 29 residents residing in the facility. Findings: During an interview on October 20, 2022, at 4:07 PM, with a License Vocational Nurse (LVN 6), LVN 6 stated she completed her annual competencies (application and demonstration of appropriate skills, knowledge and abilities in a clinical setting), at an offsite facility (the general acute care hospital's Education Department). During an interview on October 20, 2022, at 4:11 PM, with Certified Nursing Assistant (CNA 1), CNA 1 stated she completed her annual competencies at the general acute care hospital. CNA 1 further stated she had to go there to complete her annual competencies every year. During an interview on October 20, 2022, at 5:10 PM, with a License Vocational Nurse (LVN 3), LVN 3 stated she completed her annual competencies at the general acute care hospital's Education Department. LVN 3 stated she did not know the name of the DSD. During an interview on October 20, 2022, at 5:12 PM, with a License Vocational Nurse (LVN 2), LVN 2 stated she completed her annual competencies in July 2022 at the Education Department located at the general acute care hospital. LVN 2 further stated she did not know who the DSD was at the facility. During an interview on October 20, 2022, at 5:35 PM, with Registered Nurse Educator (RNE), RNE stated she had been employed by the general acute care hospital and has been DSD for the last three weeks. RNE stated she works at the facility only 10 hours a week and has a second job at another facility making her unavailable for observation and education of CNAs on all shifts. When asked for copies of competencies evaluation provided by the prior DSD, the DSD was unable to produce documented evidence to indicate ongoing education was being provided by the prior DSD to ensure staff are competent to care for the specific type of residents cared for in the facility. The facility did not have a policy and procedure on assessing staff competencies for Licensed Staff or Certified Nursing Assistants based on ongoing evaluation by the DSD or the Director of Nursing (DON). The facility was not able to provide a job description for the DSD.

Based on observation, interview, and record review, the facility failed to maintain infection control practices when: 1. Resident 28's enteral feeding (Nutrition delivered directly into gastrointestinal tract) administration set was not covered with a protective endcap when it was not in use. 2. Two visitors (Visitor 1 and 2) did not wear a mask and did not perform COVID-19 (a highly contagious illness caused by a virus) screening upon entry into the facility on [DATE], in accordance with the facility's policy and procedure. 3. Resident 4's enteral feeding administration set was not covered with a protective endcap when it was not in use. 4. Resident 21's enteral feeding administration set was not covered with a protective endcap when it was not in use. These failures had the potential to spread infectious disease (disease caused by bacteria, viruses, fungi or parasites) to other residents and staff in the facility. Findings: 1. During a review of Resident 28's clinical records, the face sheet (containing demographic information), indicated that Resident 28 was admitted on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 28's document titled Orders, dated October 17, 2022, indicated, [name of the formula], Gtube (gastrostomy tube - a tube inserted through the belly that brings nutrition directly to the stomach), 125 ml [ml - unit of measurement] 5x [times]/day via enteral pump to run at 125 ml/hr (2400, 0800, 1200, 1600, 2200). The original order date was August 23, 2022. During an observation on October 17, 2022, at 9:00 AM, inside Resident 28's bedroom, Resident 28 was sitting on her wheelchair, asleep, with the head of the bed elevated, her enteral feeding administration set tubing was not protected by an endcap when it was not in use. During a concurrent observation and interview on October 17, 2022, at 9:20 AM, inside Resident 28's bedroom, with the Registered Nurse (RN 2), RN 2 inspected Resident 28's enteral feeding administration set tubing and acknowledged the end of the enteral tubing was not capped. RN 2 stated that the end of the tubing should be capped while it is disconnected because it can cause an infection to Resident 28. During a concurrent interview and record review, on October 18, 2022, at 10:55 AM, with the Director of Nursing (DON), the facility's policy and procedure (P&P) titled, Administration of Formula Via Feeding Tube, Gravity, Bolus, Pump, reviewed December 2019, was reviewed. The P&P indicated, . 3.0 Pump or Infusion controller Method . 3.1.9. close the roller clamp and recap the tubing. The DON stated the staff did not follow the policy. The DON further stated the end of the Gtube must be covered with the endcap to prevent infection. 2. During an observation on October 20, 2022, at 7:25 AM, one Visitor (Visitor 1) was inside of the facility standing in the hallway. Visitor 1 was not wearing a face cover and did not perform COVID-19 screening at the table located in the lobby area. During an observation on October 20, 2022, at 7:27 AM, a second Visitor (Visitor 2) was inside of the facility standing in the hallway and met with Visitor 1. Visitor 2 was not wearing a face cover and did not perform COVID-19 screening at the table located in the lobby area. During a subsequent interview on October 20, 2022, at 7:33 AM, with Visitor 1, Visitor 1 stated he did not know he had to wear a mask and get screened for COVID-19 upon entrance to the facility at 7:00 AM. During a follow up interview on October 20, 2022, at 7:35 AM, with Visitor 2, Visitor 2 stated he did not know he had to wear a mask and get screened for COVID-19 upon entrance to the facility at 7:00 AM. Visitor 2 further stated he entered the facility through a door located next to the laundry room. During an interview on October 20, 2022, at 7:41 AM, with the Director of Nursing (DON), the DON stated all visitors were expected to perform COVID-19 screening upon entering the facility and to wear a mask. During a review of facility document titled Visitor/Vendor Temperature and Screening Questionnaire for COVID-19. Long Term Care. NCU/PSA, dated October 20, 2022, Screening questionnaire indicated, Visitor/Vendor Name, Time In, Temperature upon entry, Cough/congestion, SOB (Shortness of Breath), Sore Throat, Not feeling Well or Headache, Fever or Chills, Runny Nose or Sneezing, Fatigue or Muscle Pain, New Loss of Smell or Taste, N&V (nausea and vomiting), Diarrhea/Soft Stool or Stomach Cramps. There was no documented evidence that Visitor 1 and Visitor 2 were screened for COVID-19 upon entrance to the facility. During a concurrent interview and record review, on October 20, 2022, at 11:22 AM, with the Administrator (Admin), the facility's policy and procedure (P&P) titled, Revised Visitation Policy During COVID Pandemic, revised October 13, 2022, was reviewed. The P&P indicated, .1.0 .The facility will ask visitors to self-screen at the facility entrance by recording the temperature and answering questions regarding covid related symptoms . 9.0 while in the facility, the visitor must wear a hospital issued mask at all times (provided at the entrance) and practice proper hand hygiene . The Admin stated the policy was not followed. 3. A review of Resident 4's clinical record titled, Physician's Note, dated October 18, 2022, indicated the resident was admitted on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During an observation on October 19, 2022, at 11:10 AM, Resident 4 was not in his room. Resident 4's enteral feeding (nutrition delivered directly into stomach and intestinal tract) was not in use and was observed at the bedside. The feeding and water flush lines were seen draped over the top of the feeding machine and pole. The lines were dangling freely without an end cap, exposed to the open air. During a concurrent observation and interview with a Licensed Vocational Nurse (LVN 3), on October 19, 2022, at 11:45 AM, in Resident 4's room, LVN 3 inspected Resident 4's enteral tube feeding and confirmed the end of the tubing did not have a cap. LVN 3 stated that when a resident is disconnected from tube feeding, the end of the line should be capped. LVN 3 further stated when the line is not capped, it could introduce bacteria back to the resident, when reconnected again. During a concurrent interview and record review with the Director of Nursing (DON) on October 20, 2022, at 3:58 PM, the facility's policy and procedure (P&P) titled Administration of Formula via Feeding Tube, Gravity, Bolus, Pump, reviewed December 2019, the P&P indicated .3.0 Pump or Infusion Controller Method .3.1.9 Close the roller clamp, and recap tubing. The DON stated they did not follow their policy and procedure. The DON further stated the tube feeding lines are expected to be capped when not in use, because if the end of the tubing is left exposed there is an increased risk of infection for the resident. 4. A review of Resident 21's clinical record titled, Physician's Note, dated October 20, 2022, indicated the resident was admitted on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During an observation on October 19, 2022, at 11:12 AM, Resident 21 was not in her room. Resident 21's enteral feeding (nutrition delivered directly into the stomach and intestinal tract) was not in use and was observed at the bedside. The feeding and water flush lines were seen draped over the top of the feeding machine and pole. The lines were dangling freely without an end cap, exposed to the open air. During a concurrent observation and interview with a Licensed Vocational Nurse (LVN 4), on October 19, 2022, at 11:50 AM, in Resident 21's room, LVN 4 inspected Resident 21's enteral tube feeding and confirmed the end of the tubing did not have a cap. LVN 4 stated when the tube feeding is not in use, it should be capped. LVN 4 pointed to the tubing, near where it enters into the machine, and stated there is usually a cap taped here, it should be right here, I'm not sure where it's at. During a concurrent interview and record review with the Director of Nursing (DON) on October 20, 2022, at 3:58 PM, the facility's policy and procedure (P&P) titled Administration of Formula via Feeding Tube, Gravity, Bolus, Pump, reviewed December 2019, the P&P indicated .3.0 Pump or Infusion Controller Method .3.1.9 Close the roller clamp, and recap tubing. The DON stated they did not follow their policy and procedure. The DON further stated the tube feeding lines are expected to be capped when not in use, because if the end of the tubing is left exposed there is an increased risk of infection for the resident.

Based on observation, interview, and record review the facility failed to ensure secure storage of medications when three medication carts were unlocked on three separate occasions: 1. On October 18, 2022, at 7:50 AM, a medication cart, unlabeled, was left unlocked while unattended by a licensed nurse. 2. On October 19, 2022, at 5:30 AM, a medication cart # 1, was left unlocked while unattended by a licensed nurse. 3. On October 20, 2022, at 11:20 AM, a medication cart # 3, was left unlocked while unattended by a licensed nurse. This failure had the potential for medications to be accessed and dispersed by an unauthorized person, in a vulnerable population of 29 residents. Findings: 1. During an observation on October 18, 2022, at 7:50 AM, four medication carts (a cart used by licensed nurses to transport medication to resident rooms) were in the hallway while all staff were at the morning huddle (staff meeting at the beginning of the shift) at the nurses' station. One cart, unlabeled, was observed located outside room [ROOM NUMBER]. It was left unlocked and unattended by a licensed nurse. During a concurrent observation and interview, on October 18, 2022, at 8:06 AM, with a Licensed Vocational Nurse (LVN 5), LVN 5 opened the drawers of the medication cart and acknowledged the cart was left unlocked. LVN 5 counted eleven drawers in the medication cart containing medications for five residents and after reviewing the contents, there were no controlled medications inside the drawers. LVN 5 stated she was assigned to the cart and forgot to lock it before she went to the huddle. LVN 5 further stated the cart must be kept locked when unattended. During an interview on October 18, 2022, at 8:20 AM, with the Director of Nursing (DON), the DON stated medication carts were expected to be locked when left unattended. During a concurrent interview and record review, on October 19, 2022, at 1:30 PM, with the Pharmacy Manager (PM), the facility's policy and procedure (P&P) titled, Safe Storage of Medications, revised February 2020, was reviewed. The P&P indicated, .2.1. Medication carts and treatment carts containing medications must be locked unless under direct supervision of the nurse or other licensed/registered personnel . The PM stated the facility did not follow their policy and procedure. The PM further stated the medication carts were expected to be kept locked when unattended because someone who was not authorized can take the medications away from the cart. 2. During an observation on October 19, 2022, at 5:30 AM, a Licensed Vocational Nurse (LVN 1) walked away from Medication Cart 1 without locking and securing the cart. No other licensed nurse were observed in the hallway. During an interview on October 19, 2022, at 5:40 AM, with LVN 1, LVN 1 confirmed she left the medication cart unlocked and stated she went down the hall and forgot to lock it. LVN 1 opened the drawers of the medication cart and verified it contained 12 drawers with medications in them, for six different residents. LVN 1 further stated the medication cart should have been locked. During a concurrent interview and record review with the Pharmacy Manager (PM), on October 19, 2022, at 1:30 PM, the facility's policy and procedure (P&P) titled, Safe Storage of Medications, dated February 2020, was reviewed. The P&P indicated, . 2.1 Medication carts and treatment carts containing medications must be locked unless under the direct supervision of the nurse or other licensed/registered personnel. The PM stated they did not follow their policy and procedure. 3. During an observation on October 20, 2022, at 11:20 AM, a Licensed Vocation Nurse 2 (LVN 2) walked away from Medication Cart 3 without locking and securing the cart. No other licensed nurse staff were observed in the hallway. During an interview on October 20, 2022, at 11:26 AM, with LVN 2, LVN 2 confirmed she left the medication cart unlocked, and stated she went into a resident room across the hall and forgot to lock it. LVN 2 opened the drawers of the medication cart and verified it contained 11 drawers with medications in them, for six different residents. LVN 2 further stated the medication cart should have been locked. During a concurrent interview and record review with the Director of Nursing (DON), on October 20, 2022, at 4:02 PM, the facility's policy and procedure (P&P) titled, Safe Storage of Medications, dated February 2020, was reviewed. The P&P indicated, . 2.1 Medication carts and treatment carts containing medications must be locked unless under the direct supervision of the nurse or other licensed/registered personnel. The DON stated they did not follow their policy. The DON further stated the carts should have been locked, in order to prevent medications being taken by someone who doesn't have the license to do so.

Based on interview and record review, the facility failed to ensure a nutritional assessment was completed upon admission for one of three residents (Resident 25) reviewed for nutrition. This failure had the potential to place Resident 25 at risk of weight loss and dehydration (condition caused by the loss of too much fluid from the body). Findings: A review of Resident 25's clinical record, Physician Note, dated October 20, 2022, indicated the resident was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review indicated that the resident was completely dependent on a gastrostomy tube (G-Tube, a tube placed into the stomach) feeding and total [MEDICATION(S)] nutrition (TPN - a nutrition solution introduced into the body by way of the blood stream) for adequate maintenance of nutrition and hydration. During an interview with the Director of Nursing (DON), on October 19, 2022, at 8:45 AM, the DON reviewed Resident 25's clinical record and was unable to find documented evidence to indicate Resident 25's nutritional assessment was completed upon admission. The DON stated there was no assessment done until seven days after admission. During an interview with a Registered Nurse (RN 1), on October 19, 2022, at 11:00 AM, RN 1 stated when the Registered Dietician (RD) needs to be notified of a new admission, the nursing staff just call and leave them a message, and nothing was placed into the electronic charting system. RN 1 stated there was no way to tell if the RD had been notified of a resident's admission. During a concurrent interview and record review with the Director of Nutritional Services (DNS), on October 19, 2022, at 3:05 PM, the facility's policy and procedure (P&P) titled Nutritional Assessment, dated April 1997, was reviewed. The P&P indicated, Residents admitted to the Neurological Care Unit (NCU) or Pediatric Subacute Unit (PSA) will be assessed by the 3rd day of admission .Residents on the NCU or PSA are reassessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . The DNS stated there was not a nutritional assessment done within three days of admission. She further stated they did not follow their policy and procedure.

Based on observation, interview, and record review, the facility failed to ensure licensed nursing staff wasted (disposed of) controlled drugs (any drug or therapeutic agent-commonly understood to include narcotics, with a potential for abuse or addiction, which is held under strict governmental control) in accordance with the facility's policy and procedure titled, Controlled Substance Waste, dated reviewed February 2020, for 29 residents. This failure had the potential to cause drug diversion (the transfer of any legally prescribed controlled substance from the individual for whom it was prescribed to another person for any illicit use) and accidental exposure. Findings: During a medication storage observation and interview with a Licensed Vocational Nurse (LVN 3) on October 17, 2022, at 2:36 PM, LVN 3 explained how she wasted narcotic medication. LVN 3 stated if she needed to waste a narcotic medication, she would ask another nurse to join her as a witness. LVN 3 stated she would put the narcotic medication in the disposal container affixed to the side of the medication cart. Observation of the container showed the container to be approximately 12.75 inches tall by 10.5 inches wide with a tennis ball sized round opening at the top. The container appeared to be made of a thick, hard plastic material. The container held used medication cups and medication wrappers. No fluid or gel was visualized at the bottom of the container. LVN 3 stated she would chart the wasting at an automated medication dispensing system along with the witness nurse. During a medication storage observation and interview with a Licensed Vocational Nurse (LVN 4) on October 17, 2022, at 2:51 PM, LVN 4 explained how she wasted narcotic medication. LVN 4 stated if she needed to waste a narcotic medication, she would ask another nurse to join her as a witness. LVN 4 stated she would crush the narcotic pill then put it in the disposal container affixed to the side of the medication cart. Observation of the container showed the container to be approximately 12.75 inches tall by 10.5 inches wide with a tennis ball sized round opening at the top. The container appeared to be made of a thick, hard plastic material. The container held used medication cups and medication wrappers. No fluid or gel was visualized at the bottom of the container. LVN 4 stated she would chart the wasting at an automated medication dispensing system along with the witness nurse. During an observation and interview with the Director of Nursing (DON), on October 17, 2022, at 3:17 PM, the DON inspected the container on the medication cart LVN 3 and LVN 4 had indicated disposing/wasting narcotic medication. The DON stated, I don't think this is right because it does not have the gel at the bottom. I will check with pharmacy. During an observation and interview with a Pharmacy Manager (PM) and LVN 4 on October 17, 2022, at 3:41 PM, the PM inspected the container on the medication cart LVN 3 and LVN 4 had indicated disposing/wasting narcotic medication. The PM stated the nurses could not use this container to waste narcotics because it did not contain a gel which would inactivate the narcotic. LVN 4 asked the PM if she crushed the narcotic first could she waste it in the container on the medication cart and the PM stated, No. It must be in the container with the gel at the bottom. During an interview and record review with the PM on October 17, 2022, at 4:00 PM, the PM reviewed the facility's policy and procedure titled, Controlled Substance Waste, dated reviewed February 2020. The PM stated LVN 3 and LVN 4 did not follow the facility's policy and procedure and did not know the proper procedure for wasting narcotics. A review of the facility's policy and procedure titled, Controlled Substance Waste, dated reviewed February 2020, indicated, Purpose: To outline the process for proper and secure disposal of controlled substance waste utilizing the secure controlled substance waste container which renders the product non-retrievable and un-recoverable. Policy: Controlled substance waste will be disposed of in the designated controlled substance waste containers. Responsibility of all licensed staff authorized to dispense, prepare, administer and/or waste-controlled substances to adhere to these guidelines for disposal of controlled substance waste. Procedure: .Only controlled substances will be disposed of in the secure controlled substance waste containers. The system can accept tablets, capsules, patches, and liquid waste. All other medication waste will be disposed of in an appropriate pharmaceutical waste container. The secure disposal unit is for medication only. Do not insert syringes, vials ampules or other objects into the openings.

Based on observation, interview, and record review, the facility failed to ensure licensed nursing staff followed physician's orders for flushing (to clear by using a prescribed amount of water) G-tube (gastrostomy tube-a tube inserted through the belly that brings nutrition or medications directly to the stomach) lines before, after and in-between medication administration for two of 14 residents (Residents 21 and 29). This failure had the potential to cause an interaction to occur between medications resulting in a reduced drug effect, or drug toxicity, as well as clogging the G-tube. Findings: 1. A review of Resident 21's face sheet (a document that gives a summary of resident's information), undated, indicated Resident 21 was admitted to the facility on [DATE], with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . During Resident 21's medication administration observation and interview on October 19, 2022, at 5:48 AM, with a Licensed Vocational Nurse (LVN 5), LVN 5 poured 10 different medications into 10 individual pill cups. LVN 5 poured eight ounces of water into a paper cup. LVN 5 approached Resident 21, lifted her shirt away from her belly to access the G-tube and inserted a catheter syringe (a syringe without a needle whose principal use was to flush or clean a gastrostomy tube and to inject fluid through the G-tube) to the end of the G-tube. LVN 5 took the paper cup with the water and poured some water into the catheter syringe. LVN 5 stated he poured five (5) ml (milliliters-a unit of measurement) of water into the catheter syringe to clear the G-tube. LVN 5 then poured the first pill cup with a dissolved medication into the catheter syringe and poured some water from the paper cup after the medication. LVN 5 stated he poured five (5) ml of water after each medication to flush the G-tube in-between each medication. When one of Resident 21's medications was very thick in consistency, LVN 5 was observed pouring water directly into the medication. LVN 5 stated he used the water to thin the thicker mediations to help them go down the G-tube more easily. Between the ninth and tenth medications LVN 5 was observed pouring a couple drops of water in-between the medications. LVN 5 stated he had run out of water and was unable to provide the five (5) ml flush in-between medications nine and 10. LVN 5 stated he would not be able to clear the G-tube at the end of the medication administration because he had run out of water. During an interview and record review, on October 19, 2022, at 6:43 AM with LVN 5, LVN 5 reviewed Resident 21's physician's order, dated January 22, 2020, that indicated, Flush G-tube with 10 ml of water before and after medications and 2 [two] ml of water between each med. [medication]. LVN 5 stated he should have cleared Resident 21's G-tube with 10 ml of water before and after and did not. LVN 5 stated he should have flushed with 2 (two) ml of water instead of 5 (five) ml of water in-between medications. LVN 5 stated he had run out of water to flush because he used it to thin some of the thicker medications. LVN 5 stated he had not followed Resident 21's physician's order. 2. A review of Resident 29's face sheet (a document that gives a summary of resident's information), undated, indicated Resident 29 was admitted to the facility on [DATE], with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . During Resident 29's medication administration observation and interview on October 19, 2022, at 8:05 AM with a Licensed Vocational Nurse (LVN 6), LVN 6 poured nine (9) different medications into nine (9) individual pill cups. LVN 6 poured an unknown amount of water into a paper cup. LVN 6 approached Resident 29, lifted his shirt away from his belly to access the G-tube and inserted a catheter syringe (a syringe without a needle whose principal use was to flush or clean a gastrostomy tube and to inject fluid through the G-tube) to the end of the G-tube. LVN 6 took the paper cup with the water and poured some water into the catheter syringe. LVN 6 stated she poured 30 ml (milliliters-a unit of measurement) of water into the catheter syringe to clear the G-tube. LVN 6 then poured the first pill cup with a dissolved medication into the catheter syringe and poured some water from the paper cup after the medication. LVN 6 stated she poured 10 ml of water after each medication to flush the G-tube in-between each medication. LVN 6 continued with Resident 29's medication administration pouring 10 ml of water after each medication. After the ninth and last medication LVN 6 stated she was flushing Resident 29's G-tube with 30 ml of water. During an interview and record review, on October 19, 2022, at 9:02 AM with LVN 6, LVN 6 reviewed Resident 29's physician's order, dated September 26, 2022, that indicated, Flush G-tube with 10 ml of water before and after meds. [medications]. LVN 6 stated she should have cleared Resident 29's G-tube with 10 ml of water before and after and did not. LVN 6 stated she should not have flushed with 10 ml of water in-between medications. LVN 6 stated she had not followed Resident 29's physician's order. During an interview with the Director of Nursing (DON) on October 19, 2022, at 11:10 AM, the DON stated LVN 5 and LVN 6 should have followed Resident 21 and 29's physician's orders respectively, and they did not. The DON stated LVN 5 and LVN 6 did not follow the facility's policy and procedure titled, Medication Administration Through a Feeding Tube, dated September 2009. During an interview with a Pharmacy Manager (PM) on October 19, 2022, at 1:18 PM, the PM stated a G-tube flush should happen before and after the medication administration and in-between each medication. The PM stated if the medications were not flushed in between they could react with each other, and the tube could become clogged. The PM stated the facility's policy and procedure titled, Medication Administration Through a Feeding Tube, dated September 2009, was not followed. A review of the facility's policy and procedure titled, Medication Administration Through a Feeding Tube, dated September 2009, indicated, Purpose: To administer medications via the .gastrostomy, . tube in those residents who are unable to take medications orally. Policy: Medications will be administered via the feeding tube by an RN [Registered Nurse] or LVN [Licensed Vocational Nurse], per physician's orders. Procedure: .Crush pills, tablets, or empty contents of capsules in separate containers, and mix with water . Place liquid medications in separate containers. (Do not mix medications with each other or with formula).Flush tube with water after all medications are given.

Based on interview and record review, the facility failed to follow their policy and procedure on change of condition (COC) when nursing services did not promptly notify the resident's family for a suspicion of resident-to-resident abuse for one of three sampled residents (Resident 2). This failure resulted in a delay to inform the family of a new treatment plan thereby causing a violation of Resident 2's rights for notification of changes. Findings: An unannounced visit was conducted to the facility on [DATE], at 2:00 PM, to investigate a complaint related to an allegation of inappropriate infection control practices. A review of Resident 2's Face Sheet (contains demographic and medical information), showed Resident 2 was admitted to the facility on [DATE], with diagnoses of Hirschsprung disease (a birth defect that causes difficulty passing stool) and total parenteral dependence (TPN-a special formula given through the vein when someone cannot or should not receive feedings by mouth). A review of Resident 2's Plan of Care, dated April 17, 2022, showed the following: Suspected Abuse by Another Resident. 1. Monitor vital signs 2. Monitor resident's skin for any redness, swelling, scratches, or skin discoloration. 3. Monitor for any signs of pain 4. Keep suspected abuser away from resident to keep safe 4. Notify MD (medical director) of any changes. A review of Resident's 2 Change of Condition Note, (COC) dated April 18, 2022, showed the following: Condition Change Impact: Suspected abuse. Unwitnessed hitting on the face by another resident. Date and time physician contact attempted: April 17, 2022, at 8:00 PM. Date and time responsible party contact: April 18, 2022, at 3:00 PM. Change of Condition Actions: Care plan updated, and new physician orders received. The facility did not notify Resident 2's family prior to the end of the assigned shift regarding Resident 2's COC. Resident 2's family was notified 28 hours after the facility identified a suspicion of resident-to-resident abuse. During an interview with the Director of Nursing (DON), on April 25, 2022, at 2:40 PM, in the conference room, the DON confirmed Registered Nurse 1 (RN 1) did not notify Resident 2's family regarding the COC, within the facility's mandated timeframe. The DON stated RN 1 should have notified Resident 2's family on April 17, 2022, prior to the end of the shift or prior to RN 1 leaving the facility. During a telephone interview with RN 1, on June 8, 2022, at 8:34 AM, RN 1 stated, on April 17, 2022, she was responsible for notifying Resident 2's family regarding the COC, and she did not notify Resident 2's family until the following day (April 18, 2022). RN 1 stated she was very busy on April 17, 2022, and she did not have time to notify Resident 2's family of the suspected abuse and updated plan of care. RN 1 stated she should have notified Resident 2's family prior to leaving the facility. A review of the facility's policy and procedure titled Change in Resident Condition-Notification of Changes, reviewed December 2019, showed the following: .2.3. The nurse in charge is responsible for notification of physician and family or legal representative prior to the end of assigned shift when a change in a resident's condition is noted .

Based on observation, interview and record review, the facility failed to maintain a clean, sanitary and orderly environment for a universe of 27 residents, by failing to keep resident care equipment clean and properly stored. This failure had the potential to spread disease causing organisms. Findings: On 6/6/12 at 10:00 AM, the pediatric long-term care facility was toured. The pediatric residents that resided in the facility were residents who had neurological disorders and congenital birth defects. The residents on this unit received respiratory, ventilator and [MEDICAL CONDITION] care, which made them more susceptible to respiratory infections. The tour was conducted with the Environmental Services Supervisor (EVSS) from the acute care hospital), and Engineering Supervisor from the acute care hospital. During the tour the following deficient practices were identified: 1. Two residents were observed in the classrooms sitting in their wheelchairs holding stuffed animals and toys that were constantly being dropped on the floor and chewed on by the residents. The toys on the top of the tables could not be identified if they were clean or dirty. There were cluttered tables and drawers covered with dust that were filled with residents' toys that were soiled from powdered cosmetics and personal food items belonging to staff, along with other miscellaneous items. There were boxes of toys with a dried liquid substance and stuffed animals mixed with other staff personal items and cleaning supplies in the closet which included a dust broom and dust pan stored in a drawer with resident care items, a bottle of liquid potpourris, bottles of food seasonings and a dirty step stool placed on top of a toy bin. The television and TV cart was dusty, the VCR cover was broken and detached. Tutor 1 from the school district was asked about the condition of the toys that were being stored in the closet and in the classroom environment. Tutor 1 stated that there was not enough room. When asked who was responsible for cleaning the toys and the room, both tutors stated that it was their responsibility. The Administrator confirmed that 19 of 27 children use the room and toys for school. The Administrator also removed all the items from the drawers and closets then returned the toys to the tutors to take to the school district to have cleaned. The above findings were confirmed during the tour by the Director of Nurses (DON), EVSS and Maintenance and it was stated that the closet in each room needed to have shelves installed so that staff can organize the supplies. During an interview on 6/6/12 at 2:30 PM, the DON agreed that the classroom equipment and the toys used by the residents were not being properly stored, cleaned and sanitized according to the cleaning policy and removed all of the items from the room. When asked who provided oversight for the tutors in the classroom she stated, "No one." She further stated that she was responsible for the tutors. 2. The Respiratory Therapy clean supply room had approximately 23 ventilator oxygen tubing's piled on an uncovered cart which was open to the environment. The RCP stated that the tubing was clean and ready for use. There were boxes of supplies in the closets and on shelves that were cluttered and disorganized. There was no system in place for the rotation of supplies. There was a box of adapter cuffs with a manufacturer date of 2/6/01, with a mailing label that had turned yellow. The Respiratory Therapist and RCP 1 confirmed the above findings during the tour. 3. The Activity storage supply closet was cluttered and the shelves were covered with debris, a copious amount of rodent droppings and a bottle of charcoal lighter fluid was observed. There were multiple items stored on the floor. The staff popcorn machine and cart was dusty and there was evidence of past rodent activity on the cart. During an interview on 6/6/12 at 2:40 PM with the Activity Designee, she stated that she was not aware of the responsibility of the upkeep of the activity storage closet and that the closet was being shared by environmental services. She further stated that while removing all of the items from the activity closet she found a hole in the wall the size of a golf ball. Fresh plaster was observed on the wall. 4. The Physical Therapy room cabinet under the sink was observed to have broken equipment, phones and stereos that were covered with dust. Multiple rodent droppings were observed on the bottom of the cabinet. A container of comet was also stored in the Patient Care supply cabinet. During an interview on 6/6/12 at 2:45 PM with the Senior Physical Therapist of Rehab services, she stated that the gym was used for physical therapy, speech therapy and occupational therapy. When asked who was responsible for the cleaning of the room she stated that everyone was supposed to clean up after themselves and housekeeping should clean the cabinets and floors. When asked if there was a cleaning schedule she stated, "No." During an interview on 6/6/12 at 2:50 PM with the EVSS, when asked who provided oversight to ensure that housekeeping was maintained for all departments she stated that she provided monthly oversight and inspections but she needed cooperation from staff. She also stated that everything found in all of the storage closets and rooms was left from when the skilled nursing facility was closed in 2004. When asked does the facility have a separate pest control program and log, she stated "no" and that the pest control program was managed by the hospital and they (the hospital) have the contract and kept all the work orders together. The EVSS further stated that the facility calls the EVS department to notify them of any pest activity. A review of the hospital policy titled, "Storage of Hazardous Materials and Waste", received from the acute care hospital, indicated that departments where hazardous materials were used, must provide adequate storage for their hazardous chemicals and waste. The facility was unable to provide a policy specific to the distinct part skilled nursing facility. A review of the hospital policy titled, "Equipment , Supplies and Space" (1.6) indicated that storage space for equipment and supplies where they can be maintained in a secure, clean and orderly fashion. The facility was unable to provide a policy specific to the distinct part skilled nursing facility. During an interview with the DON on 6/8/12 at 8:45 AM, the DON stated that the policies and procedures implemented in the facility had not gone through an approval process by the facility's policy committee prior to use in the facility. The DON stated that she was unaware that the policies had to go through an approval process, since the policies and procedures originated from the general acute care facility (hospital). On 6/7/12 at 12:55 PM, the survey team met with the Director of Nurses (DON) and members of the facility's administrative staff, as determined by the DON. (The DON was in-charge and the designee in the absence of the Administrator, who was not present during the survey.) The survey team informed the facility that an Immediate Jeopardy (IJ) had been identified due to the unsanitary conditions identified in the facility on 6/6/12, which had the potential to result in possible harm to residents, due to the resident's susceptibility to infection. On 6/8/12 at 2:10 PM, the facility presented an acceptable Plan of Correction (POC) to the survey team. After a review of the POC and verification that the facility was sanitary, and had a plan in place to maintain sanitary conditions, the IJ was abated on 6/8/12 at 2:50 PM.

Based on observation and interview, the facility failed to ensure that the on-site kitchen was maintained in a clean and operational manner for a potential universe of 99 residents, which had the potential to result in harm due to the facility not being able to prepare food and meet the oral nutritional needs of residents. There was also the potential for harm due to the facility not being able to utilize the kitchen to store food, prepare and cook meals for a possible universe of 99 residents, staff and visitors, if occupancy of the facility was required during an emergent or disaster situation. Findings: During an interview with the Director of Nurses (DON) on 6/7/12 at 9:30 AM, the DON verified that the facility had an on-site kitchen, that was not being used to prepare meals for the pediatric residents who received oral meals. The DON verified that the meals were prepared in another facility and are transported from across the street at meal times. An observation was made of the facility's on-site kitchen on 6/7/12 at 10:05 AM, with the Registered Dietitian (RD) and the Director of Food Services (DFS), from the general acute care hospital. During the tour the following was observed. 1. There was no refrigerator in the on-site kitchen. 2. There were no sanitizing agents in the on-site kitchen, or within the facility, to utilize the 3 compartment sink, since there was no automatic dishwasher. 3. The essential equipment such as the oven, stove, grill and steam warmer table were not in a operating condition, due to the fact that there was no gas supply attached to operate the equipment. 4. There was a greasy residue and dust observed on the vents, within the hood located over the stove and the grill. During an interview with the DFS on 6/7/12 at 10:10 AM, the DFS verified that there was no refrigerator within the on-site kitchen to store foods below 41 degrees Fahrenheit, if needed. The RD was interviewed on 6/7/12 at 10:20 AM, during the on-site kitchen tour. During the interview the RD verified that since there was no automatic dishwasher located in the kitchen, the 3 compartment sink technique for washing and sanitizing dishes, utensils and other cookware would have to be used, if necessary. The RD verified that there were no sanitizing agents in the on-site kitchen or within the facility needed to sanitize washed items, if the 3 compartment sink dishwashing technique had to be used. The RD confirmed that the sanitizing agents should have been kept on-site in the on-site kitchen or within the facility, in case they were needed. The RD also verified that there was a greasy residue and dust on the vents, within the hood located over the stove and the grill. The RD stated that the kitchen was not routinely cleaned and did not know the last time the vents had been cleaned. The DFS from Community Hospital of San Bernardino was interviewed again on 6/7/12 at 10:25 AM. During the interview the DFS stated that the essential equipment such as the oven, stove, grill and steam table had not been operated since 2004, and he did not know if the equipment was operational. During a subsequent interview with the DFS on 6/7/12 at 10:35 AM, the DFS stated that the oven, stove, grill and steam table were not functional because the gas supply to the equipment was disconnected. On 6/7/12 at 12:55 PM, the survey team met with the Director of Nurses (DON) and members of the facility ' s administrative staff, as determined by the DON. (The DON was in-charge and the designee in the absence of the Administrator, who was not present during the survey.) The survey team informed the facility that an Immediate Jeopardy (IJ) had been identified due to the facility not having a sanitary and operational on-site kitchen, which had the potential to result in possible harm to residents, staff and visitors, if the facility was not prepared to store and prepare food under sanitary conditions with functional essential equipment. On 6/8/12 at 2:10 PM, the facility presented an acceptable Plan of Correction (POC) to the survey team. After review of the POC and verification that the facility had a sanitary and operational on-site kitchen. On 6/8/12 at 2:25 PM the facility's on-site kitchen was toured and observed. During tour the following was observed. 1. There were sanitizing agents in the on-site kitchen to sanitize washed, if the 3 compartment sink dishwashing technique had to be used. 2. The essential equipment such as the oven, stove, grill and steam table were operational. 3. The vents within the hood, located over the oven and grill had been cleaned. On 6/8/12 at 2:45 PM the survey team informed the DON that the IJ was abated.