Every finding on record at Community Memorial Continuing Care Center

Based on observation, interview and record review the facility failed to ensure food items stored in the refrigerators were clearly labeled and dated to support safe storage practices when:Multiple perishable food items had unclear or incomplete date stamps, preventing staff from determining the appropriate use-by/discard timeframe.A perishable sandwich containing meat and cheese was stored without a label identifying the contents/type of the sandwich. These failures had the potential for residents to consume expired or contaminated food and increase the risk of allergen exposure due to unidentified ingredients, placing residents at risk for foodborne illness and allergic reactions.During an observation and concurrent interview on 1/13/25 at 9:37 a.m. with the Director of Food and Nutrition Services (DFNS) in the facility kitchen's walk-in refrigerator, the following food items were observed, diced watermelon in a 2-ounce (oz) clear plastic container with lid, sour cream in a 2-oz clear plastic container with lid, a brownie on a plate covered with a clear plastic food wrap, and whipped cream in a sealed, cone-shaped manufacturer bag had labels that were not legible. The DFNS confirmed that multiple perishable food items had date markings that were not clearly legible due to poor ink/printing with missing components of the date. The RD stated, 'The labels need to be re-printed to clearly show all parts of the date.'During an observation and concurrent interview on 1/14/25 at 10:53 a.m. with the DFNS in the facility kitchen's Dining Room Refrigerator, a sandwich in a clear food wrap was missing the label with product/sandwich name and ingredients list. DFNS confirmed the sandwich wrapped in a clear food wrap was missing the label with product/sandwich name and ingredients list. The DFNS stated, 'There should have been an orange label on top of the clear food wrap with the name of the sandwich and ingredients list, and needs to removed immediately.During a review of the facility policy and procedure (P&P) titled 'Food and Supply Storage,' last revised 04/2025, the P&P indicated, Use the Medvantage/Freshdate labeling system or complete all sections on a [NAME] orange label. Cover, label and date unused portions of open packages.

Based on interview and record review, the facility failed to ensure a physicians order was obtained for urinary catheter change and care for one of 18 sampled residents (Resident 1).This failure resulted in Resident 1 receiving care without a physician's order.During a review of Resident 1's Face Sheet (FS), dated 1/15/26, the FS indicated, Resident 1 was admitted to the facility on [DATE] with a diagnosis of encephalopathy (any type of disorder, disease or damage that affects your brain's function or structure).During a concurrent interview and record review on 1/15/26 at 3 p.m. with the Minimum Data Set Coordinator (MDSC), Resident 1's urethral catheter assessments and nursing progress notes were reviewed. The review indicated, the urinary catheter was changed on 12/22/25 and 1/10/26, and the urinary catheter was reinserted on 1/14/26. Review of Resident 1's Physician orders, indicated, no evidence of a physician order for urinary catheter change or care. MDSC stated that there should be a physician order for urinary catheter replacement and care for resident's urinary catheter and there isn't.During a concurrent interview and record review on 1/16/26 at 10:55 a.m. with the Director of Nurses (DON), the DON confirmed there were no physician orders for Resident 1's urinary catheter change or care. During a review of the facility's policy and procedure (P&P) titled, Physician Orders, dated 9/2022, the P&P indicated, Provide an electronic process for ordering tests, procedure, exams, treatments, diets and nursing orders using electronic Health Record Order Entry (OE). Orders from a physician who has a privilege at (name of facility) are interfaced into Electronic Health record through their associated software programs, which are then transcribed and implemented by appropriate personnel in an accurate, efficient, expedient and timely manner.

Based on interview and record review, the facility failed to follow its Policy and Protocol (P&P) for 1 of 18 sampled residents (Resident 18) by not ensuring physician review and documented response to the consultant pharmacist's Medication Regimen Review (MRR - a comprehensive, mandatory evaluation of a resident's medication regimen performed by a licensed pharmacist to promote positive outcomes, minimize adverse consequences, and ensure safety) for lorazepam (anti-anxiety medication) regimen when:This failure had the potential to result in Resident 18's continued use of an unnecessary drug (a medication given without a clear ongoing need or proper monitoring and/or adverse medication-related outcomes (harmful side effects)) without appropriate physician oversight and clinical rationale (a documented medical reason for the decision).During a review of Resident 18's admission Record (AR), the AR indicated, Resident 18 is a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including: Anxiety (ongoing excessive worry or nervousness), depression (persistent low mood that affects daily functioning), Pulmonary hypertension (high blood pressure in the blood vessels of the lungs), Cerebral tissue perfusion impairment (reduced blood flow to the brain), and stroke/hemorrhagic (a brain injury caused by bleeding in the brain). During a concurrent interview and record review on 1/15/26 at 3 p.m. with the Minimum Data Set (MDS) nurse, Resident 18's Pharmacist Review of Patient's Drug Regimen (a pharmacist's monthly medication review form) was reviewed and indicated:On 1/31/25 the pharmacist documented, Will ask for GDR on Lorazepam in February. The document was signed by the pharmacist and the Director of Nursing (DON) on 1/31/25.On 2/26/25 the pharmacist documented, Lorazepam 0.5 mg, PO (by mouth), q 6H (every 6 hours), PRN (as needed) anxiety. May we reduce (GDR - a planned decrease in medication dose over time to see if the resident still needs it) Lorazepam? The pharmacist further documented, No response, re-submitting request in March. The document was signed by the pharmacist and the DON on 2/26/25.On 3/27/25 the pharmacist documented, Resubmitting GDR attempt for Lorazepam. The document was signed by the pharmacist and the DON on 3/2725. The MDS nurse was unable to locate documentation in Resident 18's medical record showing physician review and response to the pharmacist's MRR for lorazepam, no physician response, physician acknowledgement, or documented physician decision (to reduce, discontinue, or continue the medication with clinical rationale) was located in the resident's medical record for the above MRR recommendations.During an interview on 1/15/26 at 3:30 p.m. with the DON, the DON acknowledged the facility did not follow up with the physician to ensure the physician reviewed and responded to the pharmacist's MRR recommendations regarding Resident 18's lorazepam regimen. The DON further acknowledged the resident's medical record did not reflect physician documentation addressing the pharmacist's recommendation.During a review of the facility's policy and procedure (P&P) titled, Skilled Nursing Facility Medication Regimen Review, last revised 10/2023, the P&P indicated, The pharmacist provides consultation to the facility and attending physician regarding the medication regimen . Reports of non-urgent irregularities must be acted upon prior to the pharmacist's next monthly review and/or more promptly if there is no action or response, or only an incomplete response to an irregularity . the pharmacist will attempt to contact the physician or nursing staff to obtain a response. If no response is obtained within 5 business days, the facility and pharmacist should contact the facility's medical director for guidance and possible intervention to resolve the issue.

Based on observation, interview and record review, the facility failed to properly label food items for their received, opened and expiration dates before storage. This failure had the potential to cause food borne illnesses to the residents. Findings: During a concurrent observation and interview on 1/13/25 at 10:25 AM, with the Director for Food and Nutrition Services (DFNS), the following food items were found to be unlabeled/undated as to when they were received, opened or when they will expire: one bag of partially opened green beans unlabeled/undated; one bag of blueberries in zip lock bag, unlabeled/undated; one bag of six hamburger patties unlabeled/undated; two bags of turkey sealed unlabeled/undated, one bag of beef sealed unlabeled and undated. The DFNS validated the finding. During a review of the facility's policy and procedure (P&P) titled, Receiving, the P&P indicated in part, J. Date foods prior to placing in storage areas; K. Produce is labeled with the date received

Based on interview and record review, the facility failed to ensure a Certified Nursing Assistants (CNA 1) certification was valid prior to their start of and duration of employment at the facility. These failures had the potential to negatively impact patient care. Findings: During an interview on [DATE] at 9:45 a.m. with Director of Nursing (DON), DON stated, The process is that the manager will receive a one month notice from Human Resources when a staff's license/certification will expire and then we talk to the employee and go from there. We never received anything from Human Resources indicating to not go forward. During a concurrent interview and record review on [DATE] at 10:35 a.m. with [NAME] President of Human Services (VPHS), CNA 1's Personnel File, [undated] was reviewed. The Personnel File indicated, CNA 1 was hired [DATE], as a full time CNA. When CNA 1 applied for the position on [DATE], her certification submitted with her employment application was current and due to expire [DATE]. VPHS stated, At the time of hire we failed to re-verify that [NAME] had renewed her certification prior to starting employment on [DATE] and had been hired with an expired certification. VPHS confirmed, CNA 1 worked 17 days on an expired certification from [DATE] thru [DATE]. During a review of the facility's policy and procedure (P&P) titled, Certification and Licensure Procedures, dated [DATE], the P&P indicated, Human Resources will send monthly reports, and at last one (1) reminder to each Director/Manager identifying license and/or certification expiration dates of their employees.

Based on record review and interview, the facility failed to make sure the assessment accurately reflects the resident's status fo one of three sampled residents (Resident 1) in the Minimum Data Set (MDS) ( A standardized tool used to assess and plan care of residents in Medicare or Medicaid certified facility) on admission for the following: 1. Hearing status 2. Medication received 3. Skin condition This facility failure had the potential to result in poor quality care. Findings: 1. During a review of Resident 1 ' s History & Physical (H&P) on 7/7/23 at 2:22 p.m, dated 6/8/23, the H&P indicated, Resident 1 was deaf, blind in one eye and with diagnosis of chronic pain syndrome. During a continued review of Resident 1's Care Plan (a plan developed to meet resident care) dated, 6/9/23, the Care Plan revealed, Resident 1 was deaf to both left and right ears and with impaired communication secondary diagnosi of dysphagia (swallowing difficulties) and a white board was used for communication. During a review on 7/7/23 at 1:28 p.m., of Resident 1's Nursing Progress Notes (NPN), showed Resident 1 was deaf and staff communicated through writing on a white board or using a phone app. During an interview with the Resident 1 ' s responsible party (RP), on 7/6/23, at 12:28 p.m., the RP confirmed, Resident 1 was 100 percent (%) deaf. The RP further stated, Resident 1 communicate's through a phone app and staff communicates using a white board. During a review of Resident 1's MDS dated [DATE], section B assessment (for hearing) indicated, code 0 Adequate meaning (no difficulty in normal conversation, social interaction, listening to TV). During a concurrent record review and interview with the MDS Coordinator (MDSC) on 8/16, at 11:25 a.m., MDSC confirmed and acknowledged MDS assessment was incorrect because Resident 1's hearing was impaired and needed white board for communication. MDSC agreed, Resident 1 should have been coded 3 Highly impaired - absence of useful hearing. A review of the fscility policy and procedure for MDS assessment titled . Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User ' s Manual (RAI Manual - instructions for completing MDS), Version 1.17.1, dated October 2019, the RAI Manual indicated, > B0200 Ability to hear (with hearing aid or hearing appliances if normally used). Code hearing: 0 Adequate (no difficulty in normal conversation, social interaction, listening to TV). > Code 1 Minimal difficulty - difficulty in some environments (e.g. (example) when person speaks softly, or setting is noisy). > Code 2 Moderate difficulty - speaker has to increase volume and speaks distinctly. > Code 3 Highly impaired - absence of useful hearing. 2. During a review of Resident 1's MDS, Assessment Reference Date (ARD) (The date that signifies the end of the look back period for asseesment ), dated 6/15/23, the N (section for Opioid) was coded 0.Meaning Resident 1 did not recieve any Opioid medication for the observation period. During a review of Resident 1's Medication Administration Record (MAR), dated 6/23/23, the MAR indicated, Resident 1 received an opioid medication during the 7-day look back period, from 6/9/23 to 6/15/23. During a concurrent record review and interview with the MDSC, on 8/16, at 11:25 a.m., dated 6/15, The MDSC acknowledged, the information was inaccurate and acknowledged Resident 1 received an opioid medication for 7 days and the assessment should have been coded 7 instead of 0. During a review of the RAI Manual, Version 1.17.1, dated October 2019, the RAI Manual indicated, N040H Opioid: Record the number of days an opioid medication was received by the resident at any given time during the 7-day look-back period (or since admission/entry or reentry if less than 7 days. 3. During a review of Resident 1 ' s MDS section M, dated 6/30/23, the MDS section M indicated, M0100 code 1 (Resident 1 has a pressure ulcer/injury, a scar over bony prominence or a non-removable dressing/device.) M0210 code 1 (Resident 1 have one or more unhealed pressure ulcers/injuries.) M0300 Current number of unhealed Pressure Ulcers/Injuries at Each Stage, number of Stage 2 pressure ulcers = 1; Number of these Stage 2 pressure ulcers that were present upon admission/entry or reentry = 1. During a concurrent record review and interview with the MDSC, on 8/16/23, at 11:30 a.m., the MDS section M was reviewed. The MDS section M indicated, Resident 1 had one or more unhealed pressure ulcers/injuries, and had 1 stage 2 that were present upon admission/entry or reentry. MDSC explained that Resident 1's skin was assessed on the day of discharge. And the pressure ulcer on the coccyx (tail bone) area had already healed however, Resident 1 had an ongoing stage 1 to the right buttock. MDSC confirmed, the codes for MDS section M was incorrect. The correct code for stage 2 should have been 0 instead of 1. MDSC claimed, she should have clarified the record with the nurse and documented the findings when Resident 1 was assessed. During a review of the RAI Manual, Version 1.17.1, dated October 2019, the RAI Manual section M indicated, If a resident had a pressure injury that healed during the look-back period of the current assessment, do not code the ulcer/injury on the assessment. During a review of the facility ' s policy and procedure (P&P) titled, Nursing documentation -Including Admission, Shift Plan of Care, and Discharge, dated 2/20, the P&P indicated, Document daily and PRN Changes: Skin Risk Assessment is done daily and updated if actual skin impairment occurs. Document system changes or treatment (that is (i.e.) wound measure and care .)

Based on record review and interview, the facility failed to ensure one of three sampled residents (Resident 1), had a doctor' s treatment order for an ongoing right ankle stage 2 (a shallow opening on the skin with red or pink wound bed) pressure injury with accurate documentation of Resident 1's skin condition upon discharge. This failure had the potential to delay treatment and cause Resident 1 to not recieve accurate care. Findings: During a review of Resident 1' s History & Physical (H&P) on 7/11/23 at 3:12 p.m, dated 6/8/23 indicated,Resident 1 was a [AGE] year-old male who was hospitalized due to dysarthria (difficult or unclear speech) and dysphagia (difficulty swallowing), and with diagnosis of deaf and blind in one eye. During a review of Resident 1's Braden Skin Summary Risk Score (tool to assess risk of skin complications) dated 6/8/23, the Braden Skin Summary Risk Score indicated, a score of 11 (score of 14 or less indicates at risk status for pressure ulcer development.). During a review of Resident 1's admission Nursing Progress Notes (NPN), dated 6/8/23, the NPN showed, Resident 1 was admitted with a right buttocks stage 1 pressure injury (a reddened skin that does not turn white when pressed), right ankle stage 2 pressure injury and a left buttock blanchable redness (skin turned white when pressed with fingertips). During a further review of Resident 1's NPN dated 6/19/23 indicated, Resident 1 had a new coccyx (tail bone) stage 2 pressure injury. Further review of the NPN showed, Resident 1 had a new stage 2 pressure injury to the peristomal (around the opening) skin under the gastrostomy (artificial feeding tube) stopper on 6/21/23. During a review of Resident 1's Care Activity, dated 6/21/23 and 6/24/23 indicated, the coccyx stage 2 pressure injury had been resolved. However, a further review of the Care Activity dated 6/29/23, indicated, Resident 1 still had a right buttocks stage 1 pressure injury and right ankle stage 2 pressure injury. A review of Resident 1's discharge NPN dated 6/30/23 also indicated, Resident 1 still had a stage 2 pressure injury on the coccyx and right buttocks. During an interview with the Registered Nurse Supervisor (RNS) on 8/10/23, at 2:50 p.m., the RNS verbalized a skin assessment was done on the day of discharge and an ongoing stage 2 pressure ulcer on Resident 1's coccyx and stage 1 to the right buttock was now stage 2 upon assessment. During a concurrent record review with RNS of Resident 1's Admission Orders, dated 6/8/23, there were no treatment order obtained from the physcian for the right ankle stage 2 found. During an interview with the RNS on 8/10/23, at 2:50 p.m.,RNS ocnfirmed there was no treatment order for right ankle stage 2 pressure ulcer since Resident 1's admission obtained. RNS further acknowledged there should have been a wound care treatment order obtained from the physician to avoid delay of Resident 1's treatment. During a concurrent record review and interview with the MDS Coordinator (MDSC - the person attesting accuracy of the data in MDS), on 8/16/23, at 11:30 a.m., the MDS section M was reviewed. The MDS section M indicated, Resident 1 had one or more unhealed pressure ulcers/injuries, and had 1 stage 2 that were present upon admission/entry or reentry. MDSC stated, Resident 1 ' s skin was assessed on the day of discharge, the pressure ulcer on the coccyx area had already healed and an ongoing stage 1 on the right buttock. MDSC admitted seeing the nursing documentation for multiple pressure injuries during the look back period but did not clarify the record with the nurse and did not document the findings when Resident 1 was assessed. During a record review and interview with the Director of Nursing (DON), on 8/10/23, at 10:57 a.m., the Care Trends Integumentary (skin) was reviewed. The Care Trends Integumentary indicated, pressure ulcer on the coccyx was healed on 6/21/23. Resident 1's monitoring for pressure Injury in the coccyx continued from 6/22/23 to 6/23/23 then the documentation stopped. The DON acknowledged via e mail, Definitely, it appears there are gaps with the documentation. During a review of the facility ' s policy and procedure (P&P) titled, Nursing documentation -Including Admission, Shift Plan of Care, and Discharge, dated 2/20, the P&P indicated, Document daily and PRN Changes: Skin Risk Assessment is done daily and updated if actual skin impairment occurs. Document system changes or treatment (that is (i.e.) wound measure and care .) During a review of the facility ' s policy and procedure (P&P) titled, Skin Assessment: Including Skin Risk, Impaired Skin Integrity, Wound Documentation & Nursing Interventions, dated 2/22, the P&P indicated, It is the policy of Community Memorial Health System (CMHS) that all in-patients have a complete skin assessment, including skin risk, performed and documented within four hours of admission. Patients who are at risk for skin integrity impairment and those with actual skin breakdown will be identified by these assessments .Document skin assessment on Skin Assessment section of Continuing Care Center (CCC) Physical Assessment Group in Meditect (electronic program). Wounds will be assessed and documented on admission and initial identification during stay, weekly and PRN change in condition. The physician should be notified of any wounds identified on admission and throughout hospital stay. CCC - Wounds receiving care and treatment will be documented weekly.

Based on interview, and record review, the facility failed to ensure an account of all controlled drugs in order to minimize loss or diversion of narcotics when narcotic return bin(s) were not emptied on a daily basis. This failure resulted in one tablet of tramadol (narcotic pain medication) 50 mg (milligram, unit of measure) not being accounted for and had the potential for narcotics to be diverted from the facility. Findings: On 6/20/23 the facility reported to the Department a loss of one tramadol 50 mg tablet. The report indicated, on 4/25/23, at 4:13 a.m., Licensed Nurse (LN 1) documented returning one tramadol 50 mg tablet to the facility's Nursing Station 3's (NS 3) external Pyxis (automated system that automates the distribution, management and storage of medications) return bin. The tramadol tablet was not found in the return bin when it was emptied on 6/6/23 by pharmacy technicians. During an interview on 6/28/23 at 10:30 a.m. with Director of Nursing (DON), DON confirmed the missing tramadol 50 mg tablet was unaccounted for and stated the tramadol should have been in the NS 3's return bin on 6/6/23. During an interview on 6/28/23 at 11:41 a.m. with Pharmacy Technician (PT), PT stated, tramadol 50 mg tablet should have been returned to the return bin on 4/25/23, but it was not found when checking NS 3's return bin on 6/6/23. PT stated, the return bin should have been emptied on 4/25/23 and it was not. PT further stated, according to the facility ' s policy return bins are supposed to be emptied every day, but they are not. During an interview on 6/28/23 at 11:51 a.m., with Diversion Program Manager (DPM), DPM stated, tramadol 50 mg was documented as being returned to NS 3's return bin on 4/25/23. When the return bin was emptied on 6/6/23, the tablet was not found in the bin. DPM was unable to recall the last time the return bins were emptied, and stated, They should be emptied daily. During a concurrent interview and document review on 6/28/23 at 12:03 p.m. with Director of Pharmacy (DOP), DOP reviewed documentation when the narcotic return bin was emptied during the year 2023. The documentation indicated, NS 3's return bin was emptied on 2/4/3, 3/22/23, and 4/18/23 . DOP stated the return bin should be emptied every day, and it was not. During a review of the facility ' s internal guidance document titled, Return Bin Instructions, undated, the document indicated, It is the expectation that all return bins are opened with a witness, and checked for returns daily.

Based on observation, interview, and record review, the facility failed to ensure the privacy of protected health information (PHI-is any information in the medical record or designated record set that can be used to identify an individual and that was created, used, or disclosed while providing a health care service such as diagnosis or treatment.) for twenty two of sixty three residents residing in the facility. This facility failure resulted in twenty two residents protected health information potenitally being compromised. Findings: During an observation on 04/18/23 at 1:10 p.m., a four wheeled rolling cart outside of room [ROOM NUMBER] was observed unattended with a laptop computer on it. The computer screen was open. The screen displayed the PHI of twenty-two residents including their name, diagnosis, room number, account number, physician name, isolation precautions (isolation precautions are used to reduce transmission of microorganisms in healthcare and residential settings. These measures are designed to protect patients/residents, staff, and visitors from contact with infectious agents), and resuscitation status (the type of emergent treatment a person would or would not receive if their heart or breathing were to stop). During an interview and concurrent record review on 04/21/23 at 9:30 a.m., with a certified nurse assistant (CNA1), the facility's policy and procedure titled HIPAA Minimum Necessary dated 5/26/2020 was reviewed. The HIPAA Minimum Necessary indicated, [Name of Facility]'s workforce will make reasonable efforts to limit protected health information (PHI) to the minimum necessary. CNA1 confirmed staff are supposed to close their computers and not leave them open when they are not using them. A review of the facility's policy and procedure (P&P) titled, HIPAA Minimum Necessary, dated 5/26/2020, the P&P indicated, Purpose. Provide guidance to [Name of facility] regarding the requirement to adhere to minimum necessary standards when releasing, accessing, or using PHI. Policy: when using or disclosing individually identifiable health information (or when requesting individually identifiable health information from other health care providers, health plans and healthcare clearinghouses), [Name of Facility] and members of [Name of Facility]'s workforce will make reasonable efforts to limit protected health information (PHI) to the minimum necessary to accomplish the intended purpose of the use, disclosure, or request.

Based on interview and record review, the facility failed to ensure staff safeguarded the personal property of one of eighteen sampled residents (Resident 56). When a topical gel cream called Liniment Gel (a topical gel used to temporary relief of muscle or joint pain) that was mailed to the resident in the facility was taken away by a facility staff member and never replaced nor reimbursed. This failure resulted in a resident not having the right to retain and use a personal possession in the facility. Findings: During a concurrent observation and interview on 04/18/23 at 3:22 p.m., in residents' room, when asked if any issues or concerns regarding facility, Resident 56 stated his sister mailed some cream for pain to facility. As he was opening the box a female staff took the medication and stated, you can't have this here. Resident 56 asked surveyor if facility should reimburse for it. Resident 56 stated They took it. It is very expensive. I haven't had no surgery but both knees have pain, used for that. During a concurrent interview and record review with Social Service Worker (SSW) on 4/21/23 at 9:50 a.m., the facility Policy and Procedure (P&P) titled, Theft and Loss dated 05/19/20 was reviewed. The SSW stated that there was a picture that confirmed the cream was received in the facility however, the facility no longer had the cream. The SSW acknowledged the facility did not follow the P&P regarding residents' personal property when Resident 56's cream was taken away from him and was not replaced or reimbursed. During a review of the facility's policy and procedure (P&P) titled, Theft and Loss, dated 05/19/20, the P&P indicated, Purpose: to establish a theft and loss program and implement a procedure and guidelines as required in the California Health and Safety Code for long term care facilities. To educate the [Name of facility] staff regarding the Theft and Loss policy and procedure. Policy: The [Name of facility] will make reasonable efforts to safeguard patient property while a resident of the facility. The facility will reimburse a resident for or replace a stolen or lost patient property at its current value, as required by law .Procedure: All resident's belongings will be marked or tagged for identification purposes.

Based on interview and record review, the facility failed to ensure a follow up/new Preadmission Screening and Resident review (PASRR-mental disability assessment) for Level 1 was done for 1 of 18 residents (Resident 30). This failure had the potential to result in Resident not being adequately assessed to receive recommended care and treatment. Findings: Review of Resident 30's Clinical Record indicated, resident was admitted to the facility with history diagnoses that included acquired absence of right leg below knee, adverse effect of unspecified narcotics, chronic diastolic (congestive) heart failure(when the heart does not relax and fill with blood normally). During a review of Resident 30's clinical documents titled, Preadmission Screening and Resident Review(PASRR-mental disability assessment), dated 09/08/22, the PASRR indicated, Positive (resident with mental disorder condition). Further record review of document titled, Department of Health Care Services (DHCS) letter, dated 9/16/22 for Resident 30 indicated, a PASRR Level II was incomplete and had documented, Unable to complete Level II evaluation .The individual was isolated as a health safety precaution .The case is now closed. To reopen, please submit a new Level I screening. A Review of Resident 30's clinical records showed no new level I PASRR was done after the 9/16/22 recommendation by DHCS. During an interview with a Registered Nurse (RN 1) on 04/20/23 at 10:48 a.m., RN 1 confirmed the Level II PASRR was not done. During an interview with the Director of Nursing (DON) on 4/21/23 at 10:15 a.m, the DON indicated the facility did not have a policy and procedure for PASRR screeening for residents in the facility.

Based on interview and record review the facility failed to initiate a Care Plan (a part of the nursing process which outlines the plan of action that will be implemented during a patient's medical care) for two of 18 sampled residents (Resident 59 and Resident 163) when: 1. Care plans for two antidepressants medications were not initiated for Resident 163 and, 2. A care plan for psychotropics was not initiated for resident 59. These facility failures have the potential to prevent residents from recieving individualized care and services. Findings: During a review of the facility P&P titled, Nursing Documentation-including Admission, Shift, Plan of Care, and Discharge, dated 02/25/2020, the P&P indicated, Collection of data will be systematic, continuous and include assessments and reassessments by various professional disciplines. Problem statements or Nursing Diagnosis, Patient Outcomes (Goals) and Nursing interventions are developed by this documentation and incorporated into the Plan of Care. A review of the facility policy and procedure (P&P) titled, Psychotropic Drug Therapy and Restraint Management, dated 3/28/2017, the P&P indicated, Purpose. To establish a policy and standards, for the provision of safe psychotropic drug and restraints management within the Continuing Care Center (CCC), as required by law; including but not limited to the following: to guide the interdisciplinary team (IDT) in reviewing and attempting alternative interventions and /or behavioral management strategies prior to the use of psychoactive medication. 1. During an interview on 04/18/23 at 11:06 a.m., Resident 163 indicated on initial pool that she is taking medications for her anxiety (A sense of uneasiness, distress, or dread you feel before a significant event). During a record review on 4/19/23 at 11:47 a.m., Resident 163's record indicated, Resident 163 is taking Lexapro (a medication used to treat depression) 20 mg by mouth daily and Cymbalta (a medications used to treat depression, anxiety, panic attacks, and social anxiety disordernt) 30 mg by mouth (PO) every day (QD). During a review of Resident 163's Care Plans (CP) on 4/19/23 at 12:02 p.m., the record revealed there were no care plans initiated for the use of Lexapro and Cymbalta (antidepressant) medications. During a concurrent interview and record review with the Registered Nurse (RN 2) on 4/20/23 at 1:58 PM, RN 2 confirmed there were no Care Plans initiated for the use of both antidepressant medications. During an interview with the Director of Nursing (DON) on 4/21/23 at 9:57 a.m., the DON acknowledged there were no Care Plans initaited for Lexapro or Cymbalta for Resident 163. 40255 During a concurrent interview and observations of resident rooms on 4/18/23 at 12:49 p.m., Resident 59 was observed to be awake in bed and verbally responsive. Resident became tearful at times during interview and stated he misses real food, misses home, had been in hospital for 5 months and then transferred to this facility where he has been for about a month. During a review of the Minimum Data Set (MDS-a standardized assessment tool that measures health status in nursing home residents) for Resident 59, dated 1/30/23, in section I (Diagnosis), the MDS indicated Resident 59 had a diagnosis that included, Adjustment disorder with Depression (stress-related condition where you feel overwhelmed and have a hard time adjusting to a stressful event or change.) During a review of the Patient Active Orders (POA) for Resident 59, dated 4/21/23, the POA indicated Doxepin (a tricyclic antidepressant medication used to treat major depressive disorder) 10 mg (milligrams). During a review of the [Name of Facility]Psychotropic Drug Informed Consent (IC) for Resident 59, dated 1/30/23, the IC indicated, Psychotherapeutic drug (s): Sinequan (Doxepin) Diagnosis: Depression m/b (manifested by) Sadness. During a concurrent interview and record review on 4/21/23 at 11:56 a.m. with the Director of Nursing (DON), the Care Plan for Resident 59 dated 1/30/23, the P&P titled Psychotropic Drug Therapy and Restraint Management, dated 3/28/2017, and the P&P titled, Nursing Documentation-including Admission, Shift, Plan of Care, and Discharge, dated 02/25/2020 were reviewed. The DON confirmed the facility did not have a care plan in place for the use of the psychotropic drug (Doxepin) for Resident 59. The DON further indicated the facility should have implemented a plan of care for the use of the Doxepin for Resident 59.

Based on interview and record review of facility policy and procedures, the facility failed to update and revise a fall care plan for one of 18 sampled residents (Resident 169) after a fall incidence. This facility failure had the potential for new interventions and new fall precations to not be implemented which could potentially prevent Resident 169 form future falls. Findings: During an interview on 4/18/23 at 11:10 a.m, resident 169 on initial pool, indicated she had fallen in the facility recently. During record review on 4/20/23 at 9:05 a.m., Resident 169's record indicated, resident 169 had an unwitnessed fall on 4/15/23 at 6:45 AM, and that Resident 169 was taken to the emergency department and returned back to the facility the same day. During a record review of Resident 169's Care Plan (formal process that correctly identifies existing needs and recognizes a client's potential needs or risks which help guides nurses) on 4/20/23 at 9:24 a.m., a fall care plan was noted to have been initiated on 4/6/23. There were no revisions or updates to the fall care plan interventions that were documented after the resident's fall incidence on 4/15/23. During a concurrent interview and record review with the Nurse Informatics (NI) super user on 4/20/23 at 11AM, the NI agreed there were no revised or updated fall Care Plans noted for Resident 169. During an interview with Director of Nursing (DON) on 4/21/23 at 10 a.m., the DON acknowledged the fall Care Plan was not revised or updated after Resident 169's fall incidence on 4/15/23. The DON further indicated the fall Care Plan for resident 169 should have been updated. During a review of the facility policy and procedure (P&P) titled, CCC Resident Fall Prevention, dated 3/20/2021, the P&P indicated, Document the incident .b. initiate or update the Fall care plan .d, Review and revise the care plan as necessary.

Based on observation, interview, and record review, the facility failed to ensure restorative nursing services (RNA) were provided to two of eighteen sampled residents (Resident 57, Resident 59). This facility failure resulted in Resident 57 and Resident 59 not receiving required services to ensure they maintain, improve, or restore muscle strength, balance, range of motion, and functional mobility. Findings: During a review of the facility policy and procedure (P&P) titled, Nursing Documentation-including Admission, Shift, Plan of Care, and discharge date d 02/25/2020, the P&P indicated, Collection of data will be systematic, continuous and include assessments and reassessments by various professional disciplines. Problem statements or Nursing Diagnosis, Patient Outcomes (Goals) and Nursing interventions are developed by this documentation and incorporated into the Plan of Care. During an observation and interview on 04/18/23, at 12:49 p.m., in residents' room, Resident 59 was alert and lying in bed. Resident became tearful at times during interview and stated he misses real food, misses home, had been in hospital for 5 months and then transferred to this facility where he has been for about a month. Resident 59 had n abdominal wound covered in a clear dressing with a wound drainage to a bag. Resident also noted to have a PICC (a type of long catheter that is inserted through a peripheral vein, often in the arm, used when intravenous treatment is required over a long period.) to upper left and a foley catheter (a tube placed in the body to drain and collect urine from the bladder.) During a review of the Minimum Data Set (MDS-a standardized assessment tool that measures health status in nursing home residents) dated 1/30/23 for Resident 59, in section I (Diagnosis), the MDS indicated Resident 59 had diagnosis including muscle weakness (lack of muscle strength), morbid obesity (being more than 100 pounds over ideal body weight (IBW) and vascular disorder of intestine (a serious condition that can cause pain and make it difficult for your intestines to work properly. In severe cases, loss of blood flow to the intestines can damage intestinal tissue and possibly lead to death.) under section G (Functional mobility- is a person's physiological ability to move independently and safely in a variety of environments to accomplish functional activities or tasks and to participate in the activities of daily living, at home, work and in the community.) the MDS indicated Resident 59 required staff assistance with all mobility tasks. During a review of the physician orders dated 4/21/23 for Resident 59, the physicians orders indicated, Ambulate as tolerated with nursing assistance. During a review off Resident 59's PT (physical therapy) Inpatient Daily Progress Note dated 04/05/23, the PT note indicated, Discharge Summary: patient will benefit from continued ambulation daily by nursing/RNA (RNA-restorative nurse assistant-provides rehabilitation care to help people regain or improve their physical, mental, and emotional health). During an interview and concurrent record review on 04/20/23 at 11:28 a.m. with a community memorial hospital information technology assistant (CMH IT), the electronic medical record (EMR) for Resident 59 was reviewed. The CMH IT confirmed there were no RNA notes or evaluation anywhere in Resident 59's EMR. During a concurrent interview and record review on 04/21/23 at 9:25 a.m. with the director of nursing (DON), the PT (physical therapy) Inpatient Daily Progress Note dated 04/05/23 for Resident 59, and the facility P&P titled, Nursing Documentation-including Admission, Shift, Plan of Care, and discharge date d 02/25/2020 were reviewed. The DON confirmed the facility does not have RNA services at this time. The DON stated, Yes, we have not had them, but we are going to start- I have an RNA book right here. The DON confirmed the facility is not implementing RNA services per the PT recommendation and per the facility's P&P. During a concurrent observation and interview on 04/21/23 at 9:30 a.m. in Resident 59's room with a certified nurse assistant (CNA1), Resident 59 stated, It's not that i don't want to walk- i just needs someone to get me up. CNA1 confirmed Resident 59 should be receiving RNA services per the physician orders dated 4/21/23, and per the PT Inpatient Daily Progress Note dated 04/05/23. CNA1 confirmed Resident 59 had not recieved any RNA services as ordered. 40678 During a review Resident 57's clinical record, the clinical record indicated diagnosis including, difficulty in walking, muscle weakness, and unspecified fall. During a review of the care plan for Resident 57, dated 11/15/22, the care plan indicated, Encourage resident to do self care activity, document functional ability, provide positive reinforcement during activity, bed mobility training, transfer training using walker, education to meet functional goal. RNA 3 times a week for 15 mins. During an interview and record review, with the DON, on 04/20/23, at 1:46 p.m., the DON stated the facility used to have 2 RNAs but during the pandamic they became CNAs. The DON confirmed the facility does not currently have an RNA program and residents who have care plans indicating RNA services are not being implemented or provided on a consistent basis. Review of the flow sheet dated 1/18/23 thru 2/17/23 indicated, RNA services were only performed on the dates of 1/18/23; 2/8/23; and 2/17/23. The DON stated, If RNA activity is not documented on the flow sheet then it wasn't done.

Based on observation, interview, and record review, the facility failed to follow appropriate dress code for food and nutrition services personnel in the kitchen failed to serve food in accordance with professional standards for food service safety. This failure has the potential for cross contamination of food (transfer of harmful bacteria to food when they are not handled properly). Findings: During an observation and interview, with the Cook (Job title for the person responsible for preparing ingredients at an establishment that serves food) and Food and Nutrition Services Director (FNS) on 04/18/23 at 10:15 a.m., Cook was observed not wearing a beard restraint when he entered the kitchen. The FNS confirmed CK1 was not wearing a beard restraint. A review of Policies and Procedures (P&P) titled, Uniform Dress Code in FNS dated 11/26/19, indicated, E. Facial hair must be covered as per local and state regulations. A. Long Term Care: Beard restraints must be worn.

Based on observation, interview and record review, the facility failed to ensure Resident 1's right to family visitation was honored as outlined in the facility visitation guidelines. This failure had the potential to result in the deprivation of emotional support from family needed by Resident 1 for the physical and psychosocial healing process. Findings: During an interview on 01/15/23, at 7:15 a.m., with licensed nurse (LN 1), LN 1, indicated the family of Resident 1 was at the facility during the admission process on the evening of 12/2/22. LN 1 instructed the family to call the facility the next morning to schedule visitation with Resident 1. During an interview on 01/20/23, at 9:20 a.m., with LN 2, LN 2 was facility supervisor the evening of 12/2/22 and instructed Resident 1's family to call to schedule a visit. During a review of the facility document titled, .Continuing Care Visitation Guidelines , undated, the document indicated, there was no evidence that visitation had to be by scheduled appointment. In addition, the document indicated, alternative means of visitation are available at all times . During an interview on 01/23/23, at 1:10 p.m., with the director of nursing (DON), the DON stated,the facility no longer requires family to make an appointment for visitation. Visitor restriction may have been used at one point during the peak of the pandemic, but is no longer policy. During the month of December 2022, scheduling of visitation appointments was not required. Staff should not have provided those instructions to the family during the admission process.

Based on interview and record review, the facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for four of five sampled residents (Resident 1, 2, 3, and 4) by not completing a physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] This failure had the potential for Residents 1, 2, 3, and 4 to have their medical needs unmet. Findings: During a review of Resident 1's Admission Record and History and Physical (H&P), dated 11/29/21, the admission record and H&P indicated, Resident 1 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's Electronic Health Record (EHR - digital version of a patient's paper chart), revealed, there was no evidence of a Monthly physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 2's Admission Record and H&P, dated 11/29/21, the admission record and H&P indicated, Resident 2 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 2's EHR revealed, there was no evidence of a Monthly physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of Resident 3's Admission Record and H&P, dated 11/29/21, the admission record and H&P indicated, Resident 3 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 3's EHR revealed, there was no evidence of a Monthly physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] During a review of Resident 4's Admission Record and H&P, dated 12/30/21, the admission record and H&P indicated, Resident 4 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 4's EHR revealed, there was no evidence of a Monthly physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 10/6/22, at 1:10 p.m., with Licensed Nurse (LN 1), LN 1 stated, the Attending Physicians visit the residents once a month or more if needed and their progress notes should be accessible in the EHR. LN 1 confirmed physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . LN 1 also confirmed there was no physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 10/6/22, at 2:10 p.m., with Director of Nursing (DON), DON confirmed a resident is to be seen by the Attending Physician a minimum of every 30 days and the visits need to be documented in the EHR. DON confirmed the physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . During a review of the facility's policy and procedure (P&P) titled, Amended and Restated Medical Staff General Rules & Regulations of Community Memorial Health System, dated 7/26/22, the P&P indicated, Progress notes for patients hospitalized in the Continuing Care Center must be written as needed and at least once every 30 days.

F551 Rights Exercised by Resident Representative Based on interview and record review, the facility failed to ensure and document in the medical record, a resident's (Resident 1) appointed representative who had the legal authority to make health care decisions for the resident. This failure had the potential for Resident 1 not to receive care and services that can affect quality of life due to legally unauthorized health care desicions made by the representative. Findings: During a review of Resident 1's, medical record, the Inpatient/Outpatient Facesheet (IOF), dated 6/10/22, the IOF indicated, Resident 1 was a [AGE] year-old, single female, admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The IOF also indicated, Resident 1 ' s friend (name and telephone number of friend) as the person to notify. During a concurrent interview and record review, on 7/5/22 at 2:20 p.m., with the Director of Staff Development (DSD), Resident 1's, Case Management/Social Services notes, dated 7/8/21, were reviewed. The notes indicated in part, Family/support system involvement/changes: Patient (referring to Resident 1) has made friends with Local Ombudsman (an advocate or resource for older adults and persons with intellectual disabilities who live in long-term care facilities) and is her contact person. The DSD stated, staff have always contacted Resident 1's friend/local ombudsman (FLO) for any issues affecting the resident. DSD also stated, Resident 1 had appointed the FLO as her contact person. During a review of Resident 1's, medical record, the Physician Communication and Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] .Observed with general decline in condition, appears weak, more sleepy, poor meal intake, and withdrawn. Code Status DNR (Do Not Resuscitate) / DNI (Do Not Intubate) . please advise. The PCPO also indicated the physician order, Does (referring to Resident 1) have DPOA (Durable Power of Attorney - a form for anyone wanting another person to handle matters on their behalf when incapacitated) for healthcare? Hospice should be offered. During a review of the facility-contracted hospice agency's form, titled, Hospice Start of Care Checklist, dated 5/14/22, the caregiver signature line on the form was signed by Resident 1 ' s FLO. During a review of the facility-contracted hospice agency's form, titled, Patient Agreement as to Treatment, Authorization to Pay, and Release of Information, dated 5/14/22, indicated in part, Release of Information: .patient (referring to Resident 1) authorizes release of medical information to (name of FLO). The patient or authorized representative signature line on the form was signed by Resident 1's FLO. During a review of the facility-contracted hospice agency's form, titled, Hospice Consent Form (Notice of Election), dated 5/14/22, the consent form contained the agreement clause, which indicated, I have read the agreement and accept the responsibility to be the primary care person. I will be responsible for providing care or arranging for care, for the patient (referring to Resident 1). The consent form was signed by Resident 1's FLO. During a telephone interview on 7/5/22, at 3 p.m., with Resident 1'ss, FLO, the FLO stated, she had become good friends with Resident 1 about five years ago and was asked if she could be named as Resident 1's contact person. FLO agreed with being named as Resident 1's contact person but denied being the resident ' s legal representative and/or signing a DPOA. During a concurrent interview and record review, on 7/5/22 at 3:15 p.m., with the Director of Nursing (DON) and Director of Staff Development (DSD), Resident 1's medical record was reviewed. The DON and DSD were informed that the FLO denied being Resident 1's legal representative and/or signing a DPOA. The DSD reiterated that Resident 1 had appointed the FLO as the contact person for any issues affecting the resident. A thorough review of Resident 1's medical record did not contain a DPOA or any written, legal documentation authorizing the FLO to make healthcare decisions for the resident. The DON and DSD verified and acknowledged that there was no DPOA or legal documentation of authority in Resident 1's medical record. During a review of the facility's, policy and procedure (P&P), titled Consent for Medical Treatment (Adult, Minor, Substituted, Refusal), dated 11/26/19, the P&P indicated in part, . XI. Adult Consent (Who Can Consent - Patient Without Capacity) . 2) Surrogate decision maker (oral or written appointment by the patient, for duration of stay or illness, maximum 60 days, 3) Agent (appointed in an advance health care directive or power of attorney for health care), 4) Conservator (appointed by court), 5) Court-appointed surrogate decision maker (court appoints a surrogate to make health care decisions, 6) Closest available relative, 7) Interdisciplinary team (consult with Quality/Risk Management) According to the LTCOP (Long-Term Care Ombudsman Program), Organizational Conflicts of Interest (COI) - Examples of Identification, Remedies, and Removal, state offices and local ombudsman entities must have a policy and procedure in place to screen and identify conflicts. An example of a COI, indicated, Provides guardianship, conservatorship or other fiduciary or surrogate decision-making services for residents of long-term care facilities [CFR 1324.21(a)(12)].

Based on observation, interview, and record review, the facility failed to ensure a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility failure resulted in Resident 1 not receiving the required care and services indicated on the order which could potentially harm the resident. Findings: During a review of Resident 1's, Inpatient/Outpatient Face Sheet (FS), dated 3/15/22, the FS indicated in part, Resident 1 is a [AGE] year-old, female, admitted in the facility on 8/13/21 for skilled nursing services, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During a concurrent observation and interview with Resident 1, on 3/15/22 at 11:20 a.m., Resident 1 was observed awake and in bed, watching a television program. Resident 1 was alert, oriented to time, place and person and was coherent in her responses. Resident 1 stated one of her many issues was pain and was currently managed with an [MEDICATION(S)] pump (a small, round device that holds pain medication and is implanted under the skin) implanted in her abdomen to deliver the pain medication. Resident 1 showed the implanted pump's location on her right, lower abdominal area. No cover or dressing was noted over what was observed as a prominent outlining of the pain pump under the skin. Resident 1 stated, The doctor ordered that they (referring to staff) place a dressing over it because it feels like it may rupture. During a review of Resident 1's, written physician order, the order indicated in part, Apply egg crate or gel pad over pump site (abdomen). During a review of Resident 1's, Patient Notes (PN), dated 2/2/22, the PN indicated in part, Patient (Resident 1) went to see (Name of Medical Doctor [MD]) this morning for pain pump refill. Came back in stable condition. Per (Name of MD) apply egg crate or gel pad over pump site. Patient states she used abdominal binder before and will ask son to get her one During a review of Resident 1's, Doctor's Orders (DO), dated 2/11/22, the order indicated, Re: Pain pump skin integrity - cover area above pain pump with abd (abdominal) dressing, CHANGE DAILY and PRN (as needed). During a review of Resident 1's, PNs, dated 2/11-2/19/22, the PNs indicated in part, a MD's order, dated 2/11/22, was entered and scanned. Further review of the PNs indicated, an abdominal pad was applied to (Resident 1's) pain pump area, on 2/12, 2/18, and 2/19/22. No other dates were mentioned. During a review of Resident 1's, SNF (Skilled Nursing Facility) Progress Note, dated 2/19/22, the note indicated in part, Patient Narrative: Pain pump has migrated anteriorly and become more painful . Exam: . Abdominal: . abdomen is distended and non-tender . she has a pain pump located in the ant/lower quadrant, is taut against the skin and mildly painful to touch at the margins During a concurrent interview and record review with a licensed nurse (LN1), on 3/15/22 at 1 p.m., Resident 1's, PN, dated 2/2/22 and DO, dated 2/11/22, were reviewed. LN1 could not confirm if the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During a concurrent interview and record review with a nurse supervisor (NS) and Case Manager (CM), on 3/15/22 at 1:30 p.m., Resident 1's, PN, dated 2/2/22 and DO, dated 2/11/22, were reviewed. NS could not confirm if the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . After further review of the DO, NS and CM verified that the order frequency for the abdominal dressing changes to Resident 1's pain pump area indicated, daily and PRN. NS acknowledged that Resident 1's abdominal dressing changes were not monitored and performed daily. During a review of the facility's policy and procedure (P&P), titled, Order Entry, dated 11/24/20, the P&P indicated in part, .B. Nursing staff will enter orders directly in (system software) as specified in handwritten physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The P&P indicated further, .F. Special Considerations in Ordering: .2) .a) Series order is used when the same procedure is to be ordered more than one time A review of Potter and Perry's, 7th Edition, Mosby's Fundamentals of Nursing, page 419 in the section titled, Legal Implications in Nursing Practice, indicated, Nurses are obligated to follow physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . According to ANA's (American Nurses' Association) book titled, Principles for Nursing Documentation (Guidance for Registered Nurses), copyright 2010, the guidance indicated, in part, Clear, accurate, and accessible documentation is an essential element of safe, quality, evidence-based nursing practice. Documentation of nurses' work is critical as well for effective communication with each other and with other disciplines .Nurses document their work and outcomes for a number of reasons: the most important is for communicating within the health care team and providing information for other professionals .to support the ability of the health care team to ensure informed decisions and high-quality care in the continuity of patient care.

Based on interview and record review, the facility failed to implement an effective and safe discharge for one of 3 sampled residents (Resident 1) who was identified as not being able to be return to their prior living situation during discharge planning. This failure resulted in Resident 1 being in left front of the Resident 1's prior residence, without a plan in place for safe living accommodations and appropriate follow-up care. Findings: On 10/7/21, the Department received an anonymous complaint that Resident 1 was transported by two staff members of the facility in front of an apartment on 10/5/21 at 7 p.m. The resident was just left there. 911 was called and paramedics took the resident to the acute hospital. On 10/7/21, the Department received a call from representatives of the facility who confirmed Resident 1 was transported by two staff members to Resident 1's prior residence and was left there without ensuring Resident 1 had been safely transported to the Rescue Mission and allowed in prior to the 5 P.M. closing time. During a review of Resident 1's record, the record indicated, Resident 1 was admitted to the facility on [DATE], after being at the acute hospital 9/8 - 9/14/21. Resident 1 had been found at home after being on the floor for two to three days covered in blood and was admitted to the hospital with hematuria (blood in the urine) and hypovolemia (dehydration) [CONDITION(S)] (low blood pressure). During a review of Resident 1's SS (Social Services) Initial Evaluation, dated, 9/20/21, the SS evaluation indicated, Resident 1's DPOA (Durable Power of Attorney) is the resident's landlord. Discharge Plan: Return to prior living arrangement. Support person to assist with discharge: Name of landlord. During a review of Resident 1's Social Services Designee (SSD) Note, dated 9/28/21, at 1 p.m., the SSD note indicated, Patient (Resident 1) receive NOMNC (Notice of Medicare Non-Coverage) LCD (last coverage date) 9/30/21. Patient did not wish to appeal .This SSD will continue to assist with patient's self-declared discharged plan. During a review of an SSD note dated 9/28/21, at 7:07 p.m., the SSD note indicated, This SSD spoke with . patient's friend/landlord .with patient present. SSD informed landlord patient received a letter of denial LCD is 9/30/21. Patient stated was returning back to prior living arrangements. Landlord stated, 'that is not possible, the place has been condemned and has to be reconstructed. Landlord further stated, Resident 1's belongings were boxed up and put in storage, we tried to [NAME] as much as we could but had to throw away a lot of stuff that was covered in blood. Patient claimed to have a friend who lives in Oakland and is going to pick him up. Landlord informed patient and SSD she spoke to such friend and he is unable to help the patient and does not have a place for Resident 1 to live. Landlord also stated, that when Resident 1 was at the acute hospital, the Social Worker was informed the patient did not have a place to return to. This SSD was not aware of that information as patient is his own person and stated during his initial assessment that he would be returning home. During a review of a SS Note dated 10/1/21, at 4:07 p.m., the SS note indicated, Pt (Patient) seen today at the request of SSD to review Resident 1's discharge plan .Long term memory intact, with short term a relative weakness. Resident 1 was not fully aware of why (Resident 1) is in the hospital or medical history. Answers were tangential (tends to digress readily from one topic under discussion to other topics). Resident 1 did acknowledge having been evicted by landlord and ignored the eviction .We discussed plans for (Resident 1's) discharge, although (Resident 1) did not have any. During a review of an SSD Note dated 10/4/21, at 5:26 p.m., the SSD note indicated, Patient does not have a medical diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Patient stated will discharge to previous address .This SSD reminded (Resident 1) to be at the Rescue Mission between 4:30-5 p.m. person to notify (landlord) was informed and (landlord) stated, resident's belongings are in her garage boxed up and she did not feel the resident should be discharged . During a review of Resident 1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Diet: Cardiac. Activity: As tolerated with FWW (front wheel walker). Home Health RN/PT/OT. Follow up: Dr . During a review of Resident 1's nurses notes, dated 10/5/21 at 6:50 p.m., the nurse's note indicated, Patient was discharged today at 5:45 p.m. The discharge time was clearly documented as being 5:45 p.m. which is 45 minutes after the Rescue Mission closing time of 5 p.m. The travel time from the facility to the Rescue Mission is 20 to 30 minutes. The distance from the facility to Resident 1's home was approximately one mile. Resident 1 was reminded and note was given to Resident 1 indicating the arrangements made by the SSD to go to the Oxnard Rescue Mission after picking up Resident 1's belongings and car at Resident 1's previous address. During an interview on 10/13/21, at 10:05 a.m., with the Director of Nurses (DON), the DON stated, Resident 1 has been insistent on being discharged because he wanted to gather his belongings and especially his car. Arrangements were made for his discharge date to be 10/5/21 and his instructions after gathering his belongings were to go to the designated rescue mission and he had to arrive by 5 p.m. Transportation was scheduled to pick him up at the facility between 11-12 p.m. but never arrived. Other arrangements were attempted to be scheduled but the transportation never came. Resident 1 discharged from the facility around 5:45 p.m. Two staff members transported Resident 1 in their personal vehicle to the resident's prior apartment, but by this time the Rescue Mission had already closed at 5 p.m. The landlord knew Resident 1 was coming to gather (Resident 1's) belongings, but she was upset that the resident was discharged , and Paramedics were called and Resident 1 was brought to the acute hospital emergency department on 10/5/21 at 7:20 p.m. and was admitted back to our facility on 10/6/21. During an interview on 10/13/21, at 11 a.m., with the SSD, the SSD stated, I was informed of Resident 1 becoming homeless on 9/28/21. From 9/28/21 to 10/4/21 we have not been able to find other accommodations for the resident. Resident 1 was insistent on being discharged to pick up personal belongings and car from former residence. By 10/4/21 the final discharge conversation with Resident 1 took place informing the resident transportation arrangements were made between 11:10-11:40 a.m. on 10/5/21 to discharge to previous address to gather belongings and then needed to be at a designated Rescue Mission with address provided between 4:30-5 p.m. before the mission closes.

Based on observation, interview and record review, the facility failed to ensure: 1. TCS foods (Time Temperature Control for Safety - food that requires time-temperature control to prevent the growth of bacteria) were consistently and accurately cooled down to ensure food safety. 2. Raw poultry, bacon and beef were stored correctly to prevent cross-contamination. 3. A microwave located in a nourishment room was maintained in a sanitary manner. The facility failed to ensure that a cool down system of TCS food was implemented safely related to egg salad and/or tuna salad preparation that was available to residents as an alternate meal selection or snack for 55 of 56 residents residing at the facility. In addition, the facility failed to ensure that a TCS dessert (Mexican rice pudding) was cooled down safely that was to be served with the dinner meal for residents on 11/6/18, excluding those residents with a diet order of dysphagia (difficulty swallowing) Level 2 (ground) diet, dysphagia level 1 (puree) diet, and one resident who received nutrition through a tube feeding. On 11/6/18 at 11:36 AM, the survey team notified the director of nursing (DON) (who had authority to represent administration), the food service director (FSD) and the dietary services supervisor (DSS) of immediate jeopardy (IJ) due to inaccurate and/or lack of cool down for PHF (potentially hazardous foods)/TCS foods. These deficient practices had the potential to cause foodborne illness to the highly susceptible residents currently residing in the facility. According to the FDA (Food and Drug Administration) Food Code (YEAR), A Highly susceptible population means persons who are more likely than other people in the general population to experience foodborne disease because they are: (1) Immunocompromised; . or older adults; and (2) Obtaining food at a facility that provides services such as .health care . On 11/07/18 at 03:38 PM, the IJ was abated in the presence of the administrator, DON and FSD after an acceptable plan of correction was provided by the administrator which included the following; the egg salad, tuna salad and Mexican rice pudding were discarded, GI (gastrointestinal) monitoring of residents was put in place for residents that may have consumed unsafe egg and/or tuna salad that was prepared on 11/2/18 and was available for use as of the morning of 11/5/18, retraining of the FSD, DSS and dietary staff was completed on how to implement TCS monitoring for PHF, dietary staff were trained on what foods constituted PHF foods, and a plan was put into place to provide oversight to ensure future TCS cool down would be implemented safely. Findings: 1. On 11/05/18 at 08:24 AM, during an observation of the kitchen, inside a reach-in refrigerator was a container of egg salad dated 11/2/18, and a container of tuna salad dated 11/2/18 that was prepared at the facility. On 11/05/18 at 09:42 AM, during an observation and concurrent interview, the Cooling Log was reviewed with a cook (Cook 1). The Cooling Log directions had a column that indicated Remove from cooler. Start. Proteins must be 41 degrees F (Fahrenheit) or below or discard. There was an entry for egg salad, dated 11/2/18, in which the first column as described above was blank. The following columns listed Time/Temp (temperature) as follows; as 12:15 PM/ 52 degrees F; 1:45 PM/48 degrees F; 2:15 PM/69 degrees F; 6:15 PM at 40 degrees F. According to the directions on the Cooling Log, 4 hrs (hours) from end cooking time if cold (IE Tuna Salad) must be 41 degrees F or below or discard. Concurrently, Cook 1 verified that temperatures were not taken of the protein foods (i.e.; eggs) once removed from temperature control (the refrigerator), as per the directions on the cooling log. Cook 1 stated the first temperature, and time documented, was taken after the egg salad, and/or tuna salad, preparation was complete. Concurrently, the Food Service Director who was a registered dietitian (RD) (FSD/RD) was present for the above interview with Cook 1. The FSD/RD verified that the first entry for time and temperature for protein salad preparation (egg or tuna) was taken after the preparation was completed. The FSD/RD stated that the time/temperature control was to ensure that potentially hazardous foods were not in the temperature danger zone for more than four hours. The FDA Food Code (YEAR) indicated, Bacterial growth and/or toxin production can occur if time/temperature control for safety food remains in the temperature Danger Zone of 41 degrees F to 135 degrees F for too long. (FDA Food Code (YEAR) Annex, 3-501.16) The FSD/RD reviewed the data entry for the egg salad, dated 11/2/18, and stated the egg salad was in the temperature danger zone for six hours. The FSD/RD stated the egg salad was not prepared safely. A review of the Cooling Log for the tuna salad, dated 11/2/18, had the first temperature listed as 72 degrees F at 12:20 PM, and that it had not reached 41 degrees F until 6:20 PM, six hours later. The FSD/RD verified the log reflected the tuna was in the temperature danger zone for six hours, and was not safe to consume. According to the FDA Food Code, (B) Time/temperature control for safety food shall be cooled within 4 hours to 41 degrees F or less if prepared from ingredients at ambient temperature such as reconstituted foods and canned tuna. (2017 FDA Food Code, 3-501.14 Cooling). A review of the cooling logs from 7/17/18 through 11/2/18 showed 21 of 21 entries for tuna or egg salad had incorrect time/temperature monitoring to ensure food safety. On 11/05/18 at 11:47 AM, the FSD/RD verified that there had been an unsafe system in place related to the time/temperature monitoring to ensure food safety for the egg and tuna salad preparation that was for sandwiches as an alternate meal choice, or snack for residents. The FSD stated, I just spot checked the cooling logs and missed it. The FSD/RD stated she threw out the egg salad and tuna salad, dated 11/2/18, because it was not safe to consume. The FSD/RD stated she was going to start training the dietary staff on the correct TCS monitoring for food safety on that day. On 11/06/18 at 09:12 AM, during an observation and concurrent interview, inside a reach in refrigerator was a large stainless steel pan that was covered and labeled, For patients. The FSD/RD stated the pan contained cooked rice pudding made last evening on 11/5/18 to be served today (on 11/6/18) for residents. The cool down log was reviewed, and the FSD/RD stated, It's not on the cool down log. Concurrently, the dietary services supervisor (DSS) stated the Mexican rice pudding was to be served cold as a dessert to the residents for dinner that night on 11/6/18. The DSS stated the PM cook was the one who cooked the rice pudding and was not here to interview. The DSS stated the PM cook comes in at 10:30 AM. On 11/6/18 at 9:18 A.M., in the presence of the FSD/RD, a telephone interview was conducted with the PM dessert cook (Cook 2). Cook 2 stated he cooked two pounds of rice on 11/5/18 for Mexican rice pudding. Cook 2 stated after the rice was cooked, milk and sugar was added. Cook 2 stated he placed the pan of the cooked rice with the milk out on the counter as it was too hot to put in the refrigerator. Cook 2 stated he placed the pan of the cooked rice in the refrigerator before he went home around 9:30 P.M. Cook 2 was asked if he had taken any temperatures of the cooked rice, and he stated, No, I did not take any temperatures. Cook 2 was asked if he knew what the cooling log was, and he stated, I'm familiar with a cooling log but I don't cook the meat or type of food that goes on the cooling log. Cook 2 stated he was the dessert preparation cook. Cook 2 was asked if rice pudding was a potentially hazardous food, and he stated, The rice isn't but possibly because of the milk. Cook 2 stated he had been in his role preparing desserts for approximately one year. Cook 2 verified again that he did not take any temperatures of the Mexican rice pudding. Concurrently, the FSD/RD was asked if she wanted to clarify any questions with Cook 2, or had any questions for him, and she stated, No. According to the directions on the facility's Cooling Log, .Items to be placed on cooling log: Proteins cooled for later use or salads, mayo (mayonnaise) based salads, rice, beans, potatoes, leftovers that will be used again . According to the (YEAR) FDA Food Code, .(A) Cooked time/temperature control for safety food shall be cooled: (1) Within 2 hours from 135 degrees F to 70 degrees F, and (2) Within a total of 6 hours from 135 degrees F to 41 degrees F or less. (3-501.14 Cooling) According to the (YEAR) FDA Food Code Annex, Safe cooling requires removing heat from food quickly enough to prevent microbial growth. Excessive time for cooling of time/temperature control for safety foods has been consistently identified as one of the leading contributing factors to foodborne illness .,The initial 2-hour cool is a critical element of this cooling process . (3-501.14 Cooling) The facility's policy and procedure titled Food Handling Guidelines (HACCP), approved on 4/25/17, indicated I. Purpose: HAACP (Hazard Analysis Critical Control Point) process is required to assure safe food handling and preparation. II. Policy: A. Food is handled using a HACCP process in accordance with regulatory guidelines. Proper handling procedures and techniques are visually monitored on an ongoing basis ., F. Cold Food Preparation; 1. Potentially hazardous ingredients for food that are in a form to be consumed without further cooking such as salads, sandwiches, filled pastry products, cut leafy greens and produce, and reconstituted foods shall have been chilled to 41 degrees F or below ., J. Cooling; 3. Potentially hazardous food shall be cooled from 140 degrees F to 70 degrees F as measured at its center within two hours and from 70 degrees F to 41 degrees F within an additional four hours for a total cooling time of six hours or less ., Food that have not cooled to 70 degrees within 2 hours of being placed in the cooling equipment must be discarded ., Use the Cooling Log form to document the temperature of the food ., 4. Potentially hazardous food shall be cooled within 4 hours to 41 degrees F if prepared from ingredients at room temperature. Use the Cooling Log form to document the temperature of the food . 2. On 11/05/18 at 08:24 AM, during an observation of the kitchen, inside a reach-in refrigerator was a large pan of raw chicken on a shelf that was stored above a box of uncooked bacon located on a lower shelf. Adjacent to the uncooked bacon was an unopened package of thawing ground beef. A cook (Cook 1) stated the above chicken, bacon and ground beef were to be cooked that day for residents. Concurrently, the Food Service Director who was a registered dietitian (FSD/RD) acknowledged that the raw chicken should not have been stored above raw bacon and raw ground beef as it was a risk for cross-contamination. The facility's policy and procedure titled Food and Supply Storage Procedures (last approved on 4/25/17) indicated, Purpose: To establish guidelines for proper food and supply storage in accordance with local, state and federal regulatory agencies. Policy: All food .used in food preparation shall be stored in such a manner as to prevent contamination and maintain the safety and wholesomeness of the food for human consumption C.5. If raw animal foods are stored on the same rack, store them in the following order from top of the rack to the bottom of the rack: fish, raw shell eggs, whole cuts of beef, pork, ground meat and poultry. 3. On 11/05/18 at 02:29 PM, an observation of a microwave located in a kitchenette near a nursing station was observed. An environmental services staff (EVS 1) stated that the EVS department was responsible for cleaning the microwave. EVS 1 observed the inside of the microwave, and stated, Super dirty. Looks old. The inside of the microwave was observed with extensive dry, discolored food debris on the ceiling, and inside walls of the microwave. EVS 1 was asked how EVS staff were trained on how to clean the microwave. EVS 1 stated they put a chemical called Oxycide that was located in an EVS storage closet on a rag and allow it to have five minutes for contact time on the inside of the microwave. Then the chemical would be wiped off with water. On 11/05/18 at 02:36 PM, an environmental services supervisor (EVS 2) observed the inside of the microwave and verified that it had dry, old food debris. EVS 2 verified the cleaning of the inside of the microwave was the responsibility of the EVS department. EVS 2 was asked how the staff were trained to clean the inside of the microwave. EVS 2 stated he would have to look to see if there was a policy and procedure, and stated, I will ask dietary too. There was no indication on the label of the Oxycide that it was an appropriate chemical to use on a food contact surface, such as inside of a microwave. Concurrently, the Food Service Director stated there was no policy from the food and nutrition services policy and procedure binder on how to clean the inside of the microwave.

Based on observation, interview, and record review, the facility failed to provide supervision and ensure the bed pad alarm (battery operated, weight activated pad that produces an audible alarm if body weight is removed from the pad, or no weight is detected) was connected and operating properly for one of three sampled residents (Resident 1). Resident 1 was identified as a high risk for fall, needing assistance for transfers, known for attempting transfers without asking for assistance, and known to remove the tab alarm (battery operated audible alarm to alert staff of attempts at unassisted transfers and connected to residents clothing by a clip). The failure resulted in Resident 1 getting out of bed without assistance and sustained a right upper shin bone fracture, affecting the knee joint. Findings: The facility policy and procedure titled Tab and Pad Device Use dated 2/7/13, indicated When certified nursing assistants (CNAs) are rounding (checking on residents assigned) at the beginning and end of their shifts, the devices will be checked to see if they are intact and functioning properly. The policy further indicated, all admissions to the care area Will have a pad and/or tab device in place upon admission. Record review of a comprehensive assessment dated [DATE], indicated Resident 1 had a [DIAGNOSES REDACTED]. Resident 1's cognition (mental awareness) was severely impaired. Resident 1 required one person assistance from staff for transfers and bed mobility. Resident 1 was frequently incontinent of urine and bowel. Review of Resident 1's fall risk assessment, dated 11/30/15, revealed Resident 1was at high risk for falls due to falls prior to admission and dementia, to name a few. A tab and bed pad alarm were identified as an intervention to prevent inury due to Resident 1's fall risk, although Resident 1 was known to remove the tab alarm. Review of the plan of care initiated on 12/01/15 (before the fall on 2/22), indicated, Bed pad alarm when in bed to alert staff when Resident 1 attempted to get out of bed unassisted. Tab alarm in wheelchair (W/C) to alert staff when Resident 1 attempted to get out of W/C unassisted. During an interview on 3/7/16, at 12:20 p.m., the director of nursing (DON) explained, on the day of Resident 1s fall (2/22/16 around 7 a.m.), Resident 1 got out of bed unassisted and had an unwitnessed fall. According to the DON, the tab alarm and bed pad alarm did not go off. Resident 1 was found on the floor by staff, next to her bed in her room . During an interview on 3/22/16 at 11:05 a.m., a certified nursing assistant (CNA 1) acknowledged, during her shift, before Resident 1's fall incident on 2/22/16, she did not check (at the beginning around 10:45 p.m., nor prior to giving the day shift CNA report, around 7 a.m.) the bed pad alarm for proper functioning and connection, as was facility policy. CNA 1 acknowledged, she and the morning CNA (CNA 2) were in the hallway during the morning report. CNA 1 explained, Resident 1 was always taking off her tab alarm. During an interview and concurrent observation with CNA 2, on 3/7/16, at 1:25 p.m., CNA 2 explained on the morning of 2/22/16, at approximately 7 a.m., when Resident 1 fell , CNA 2 heard Resident 1 screaming help from her room. At that time, CNA 1 (night shift CNA) and CNA 2 (day shift CNA) were exchanging report at the nursing station, approximately 10-15 feet away from Resident 1's room and not within line of sight of Resident 1's room. CNA 2 explained the facility practice was to give and receive report inside resident's room. CNA 2 went to Resident 1's room and found Resident 1 on the floor. CNA 2 explained not hearing the tab alarm and bed pad alarm warning sounds prior or after Resident 1 fell . CNA 2 confirmed the bed pad alarm was not connected between the green (battery) box and the cord connected to the pad alarm. CNA 2 further explained and demonstrated (on Resident 1's bed) that on the date of the fall, 2/22/16, Resident 1's bed pad alarm was on top of the mattress, a cable used for connecting the bed pad alarm to the battery box was tucked underneath the bed mattress, and a fitted sheet was on top covering the entire mattress. The battery box was hanging on the right side rail. The cable connecting the bed pad alarm to the green battery box was not connected. During an interview on 3/10/16 at 12:35 p.m., restorative nursing assistant (RNA) stated, She (Resident 1) constantly was trying to get up from the wheelchair. She would take off the tab alarms constantly. RNA explained, the tab device clips would be off (Resident 1) most of the time. During an interview on 3/7/16, at 2:49 p.m., license nurse (LN 3) explained, on 2/22/16, at around 7 a.m., LN 3 responded to CNA 2's request for assistance in Resident 1's room. LN 3 reported not hearing any alarms sounding from the tab and bed pad devices when she walked into the room. LN 3 stated, Tab alarm on bed not connected to resident (Resident 1) because she takes them off all the time. During an interview on 3/22/16 at 11:17 a.m., LN 1 explained, on the night of 2/22/16, LN 1 did not check Resident 1's tab alarm and bed pad alarm to see if they were connected and functioning during her night shift. LN 1 indicated, Resident 1 was always taking off her tab alarms. Review of Resident 1's X-ray of the right knee dated 2/22/16 revealed, fracture of the right shin bone affecting the knee joint.