Every finding on record at Corona Health Care Center

Based on observation, interview, and record review, the facility failed to ensure, for one of three residents reviewed (Resident 2):1.Ongoing monitoring and assessment were provided, when there was a change of condition of injuries sustained from resident's fall to the posterior (back) head and right arm on February 5, 2026;2. There was no physician order to address the skin tear on the right arm; and3. There was no care plan developed to address the fall incident with injuries on February 5, 2026.These failures had the potential for injuries sustained from a fall incident not to monitored for any complications related to the fall and injuries. Findings:On February 24, 2026, at 9:55 a.m., an unannounced visit was conducted at the facility to investigate a complaint involving quality of care and treatment. On February 24, 2026, at 2:25 p.m., an observation with a concurrent interview was conducted with Resident 2. Resident 2 was observed in bed, alert, and conversant. Resident 2 stated she had some pain in her right neck and right shoulder. On February 24, 2026, Resident 2's medical record was reviewed. Resident 2 was admitted to the facility on [DATE], with diagnoses which included specified disorders of bone density (conditions where bones are abnormally dense and weak, leading to increased fracture risk) and history of falling (previously fallen and is at a higher risk of falling again).A review of Resident 2's Care Plan, revised on August 5, 2023, indicated, .has a potential for skin tear .r/t (related to) generalized fragile skin .will be free from skin tears .if skin tear occurs .treat per facility protocol .notify MD (medical doctor) .family .A review of Resident 2's Minimum Data Set (MDS - a resident assessment tool), dated December 31, 2025, indicated Resident 2 had a BIMS (Brief Interview of Mental Status-a cognitive assessment tool) score of 11 (moderate cognitive impairment). A review of Resident 2's Skin Initial/Weekly Assessment, dated February 5, 2026, at 2:26 p.m., indicated, .Resident is s/p (status post-after) fall .February 5, 2026 posterior head noted with mild erythema (a temporary form of skin irritation) . intact, no open area noted .overall area approx (approximately): 3.2 x (by) 0.5 centimeters (cm - unit of measurement) .raised lump to the back of resident head .approx: 2.1x0.7cm 0.5cm raised intact, no drainage .Rt (right) arm skin tear approx: 3.0x2.1cm .open, skin flap partially attached .wound bed red .moist with dermis (thick, tough middle layer of skin located directly beneath the outer layer) exposed, periwound (the skin immediately surrounding a wound) .skin is thin and fragile .moderate drainage .A review of Resident 2's COC (Change of Condition)/INTERACT ASSESSMENT FORM, dated February 5, 2026, at 2:27 p.m., indicated, .change in condition.fall.started on February 5, 2026.skin changes .discoloration.site.right elbow.discoloration.does resident have pain.yes.7 (pain rating on 0-10 scale).chronic.location.back, injuries and complaints.resident was found in the restroom on the floor.recommendations: transfer to hospital ER (emergency room).A review of Resident 2's Pain Assessment, dated February 5, 2026, at 2:35 p.m., indicated, .resident is s/p fall .has pain noted to the right arm related to skin tear .and posterior part of head .A review of Resident 2's Progress Notes: Incident Note, dated February 5, 2026, at 2:44 p.m., indicated, .patient was observed on the floor in her bathroom .patient was lying on the floor on her right side .her head was resting on the bathtub .skin assessment was done with treatment nurse .skin tear noted on right arm .other skin intact .per patient she hit her head to bath tub .patient c/o (complained of) back pain .and pain in back of head .A review of Resident 2's Progress Notes: Skin/Wound Note, dated February 7, 2026, at 1:14 p.m., indicated, .during patient care .resident also noted to have dark maroon ecchymosis (bruise) .to the right upper extremity (right upper arm) with scab .consistent with recent fall .area is intact .however, resident reports pain . to the affected extremity MD is aware .Further review of Resident 2's record indicated there was no documented evidence of the status or condition of the right upper arm skin tear, right elbow discoloration or back of head raised areas/erythema after there was a change in condition on February 5, 2026. There was no documented evidence of wound treatment order provided to right arm skin tear. In addition, there was no updated care plan to address the unwitnessed fall, right upper arm skin tear, right elbow discoloration, back of head raised areas/erythema or risk for bleeding after the change of condition on February 5, 2026. On February 24, 2026, at 3:19 p.m., a concurrent interview and record review was conducted with the Director of Nursing (DON). The DON stated the facility process following a fall incident was the Licensed Nurse (LN) would complete the COC documentation under the fall, pain, and skin assessment, and would update care plans. The DON stated the LN was required to monitor the resident's neurological status, pain, skin status, and document in the resident's electronic medical record (EMR) every shift for 72 hours. On February 24, 2026, at 4:03 p.m., a concurrent interview and review of Resident 2's record was conducted with the DON. The DON verified Resident 2 did not receive wound care treatment to the right arm skin tear. The DON stated Resident 2's back of head and right arm skin tear/bruising was not monitored during the 72-hour time frame by the LN. The DON stated Resident 2's back of head and right arm skin tear/bruising should have been monitored by the LN. A review of the facility's policy and procedure titled, Fall-Clinical Protocol, revised March 2018, indicated, .the nurse shall assess and document/report .recent injury .especially head injury .the staff .with the physician's guidance .will follow up on any fall with associated injury .until the resident is stable .and delayed complications .such as late fracture or subdural hematoma (a dangerous collection of blood trapped between the brain's outer covering and the brain surface, usually caused by head injury) .have been ruled out or resolved .Delayed complications .such as late fractures and major bruising .could occur hours or days after a fall .while signs of subdural hematomas or other intracranial bleeding .could occur up to several weeks after a fall .A review of the facility's policy and procedure titled, Care Plans, Comprehensive Person-Centered, revised March 2022, indicated, .measurable objectives .timetables to meet the resident's .physical, psychosocial and functional needs .is developed and implemented .for each resident .Assessments of residents are ongoing and care plans are revised .as information about the residents .and the residents' conditions change .the interdisciplinary team (a group of healthcare professionals) reviews .and updates the care plan .when there has been a significant change in the resident's condition .

Based on observation, interview and record review, the facility failed to ensure, for one or three residents reviewed for accidents (Residents 24 and 57):1.Two person-assistance was provided during incontinent care (cleaning the resident while in bed after periods of urination or bowel elimination) in accordance with the plan of care, for Resident 24. This failure resulted to Resident 24 fell from the bed, complaint of pain and swelling at the right thigh, which indicated fracture (broken bone) to the right thigh, and subsequently was sent out to the acute care hospital for further management; 2. The smoking paraphernalia (cigarette and lighter) were stored in a secured container according to facility policy and procedure, for Resident 57. This failure has the potential to place Resident 57 at risk for smoking related accidents Findings:1.On July 21, 2025, at 3 p.m., Resident 24 was observed inside the room, awake and lying on an air loss mattress (designed to distribute the patient's body weight over a broad surface area and help prevent skin breakdown) with raised sides to the bilateral head of the bed and foot of the bed. Resident 24 was not able to answer questions. On July 22, 2025, Resident 24's record was reviewed. A review of Resident 24's admission Record, indicated Resident 24 was admitted on [DATE], with diagnoses which included bilateral osteoarthritis (a chronic joint disease characterized by the breakdown of cartilage, the protective tissue that cushions the ends of bones in joint) of knee, right knee contracture (condition where a muscle, tendon, or joint becomes permanently shortened and stiff, limiting its range of motion), muscle weakness, and difficulty in walking.A review of Resident 24's Care Plan, dated June 21, 2024, indicated .resident has an ADL (Activities of Daily Living - fundamental self-care tasks essential for independent living, which include basic activities like bathing, dressing, eating, toileting, transferring) self-care performance deficit and needs substantial assist with mobility and ADLs.Interventions.Resident requires 2 person assist in toileting. A review of Resident 24's History and Physical, dated February 18, 2025, indicated Resident 24 did not have the capacity to understand and make decisions.A review of Resident 24's Fall Risk Assessment, dated April 15, 2025, indicated Resident 24 was high risk for falls.A review of Resident 24's Minimum Data Set (MDS - an assessment tool), dated April 16, 2025, indicated Resident 24 needed total assistance with rolling left and right and personal hygiene. Resident 24 was dependent for toileting hygiene and had functional impairments to bilateral upper and lower extremities (arms, hands, legs, and feet).A review of Resident 24's Progress Notes, indicated the following:-July 10, 2025, at 9:57 p.m., .According to the CNA (Certified Nursing Assistant), At 2120 (9:20 p.m.) resident was being changed.CNA.was trying to turn resident to the side away from her while grabbing on the chux (disposable, absorbent under pads designed to protect surfaces like mattresses and furniture from fluids), when resident flip from the order (sic) side of the bed away from the CNA.resident fell using the lateral side of her body to hit on the floor. The CNA was not sure if resident landed on the floor with left or right side of the body.Primary ambulance (first ambulance dispatched to an emergency call to initiate patient care and transportation) called.-July 11, 2025, at 8:46 a.m., .Resident returned back from hospital @ (at) 0800 (8 a.m.).no pain upon arrival to the facility.;-July 12, 2025, at 5:39 p.m., .Right lower extremity contracted ( a condition where the tissues surrounding the joints and muscles in your right leg become stiff, tightened, or shortened, leading to restricted movement and potentially deformity) from hip and knee bent toward the left side.patient c/o (complaint of) right hip and knee pain.PCP (Primary Care Physician).gave order to have x-ray (a photographic or digital image of the internal composition of something, especially a part of the body).-July 13, 2025, at 10:41 a.m., .received abnormal X ray result and noted with Distal (refers to a part of the body that is farther away from the center of the body than another part) femur Fracture (a break in the femur, also known as the thighbone, which is the longest and strongest bone in the human body).new order to transfer patient to (name of hospital).-July 13, 2025, at 6:59 p.m., .Resident came back from the ER (Emergency Room.@ 1700 (5 p.m.).resident came back with right leg wrapped with bandage.A review of Resident 24's general acute hospital (GACH) records titled, ED Provider Note, dated July 13, 2025, indicated the following:- .Pt (patient) had fall approx. (approximately) 2 (two days ago.Facility noticed pt had right thigh area swelling and had CT (Computer Tomography - a medical imaging technique that uses X-rays to create detailed cross-sectional images of the body's internal structures, such as organs, bones, and blood vessels) done today. Pt found to have Distal femur fracture from CT scan today.;- .When asked, pt admits to some right knee pain.; - .XR (x-ray) Right Femur (thigh).There is a displaced fracture (a type of bone fracture where the broken bone fragments are no longer aligned with each other) of the distal femur.; and-, .Per Orthopedics (the branch of medicine dealing with the correction of deformities of bones or muscles), conservative treatment is the best recommendation given patient's condition.Acute fall (a sudden, unintentional descent resulting in a person coming to rest on the ground or another lower surface, whether assisted or unassisted, and with or without injury) with right distal femur fracture.Ace wrap ( a long strip of stretchable cloth that you can wrap around to provide support and comfort to an injured area) for comfort.Pain regimen.On July 22, 2025, at 10:55 a.m., during an interview with CNA 1, CNA 1 stated the following regarding Resident 24;-Dependent on staff for all ADLs;-Required low air loss mattress with no bed rails (bars attached to a bed that serve as a barrier to prevent patients from falling out or to aid in movement and positioning);-CNA 1 was changing Resident 24's brief while she was standing on the left side of the bed, she pulled the sheet towards her side, tried to pull the brief out from under Resident 24 towards the right side, and the resident slipped and fell out of the bed on the left side; and-CNA 1 stated she was informed Resident 24 required two-person assist for brief changes. On July 22, 2025, at 11:07 a.m., during an interview with Licensed Vocational Nurse (LVN) 1, she stated Resident 24 was bed bound and a fall risk due to weakness. LVN 1 stated CNA 1 was performing brief change on Resident 24 when the resident rolled on the left side when CNA 1 was pulling the brief. LVN 1 stated Resident 24 was on the floor on the left side of the bed and was holding onto the roommate's bed rail. On July 22, 2025, at 2 p.m. during an interview with Registered Nurse (RN) 1, RN 1 stated Resident 24 was immobile in bed and required total assistance for care. RN 1 further stated Resident 24 was on a low air loss mattress, which required two-person assist for brief changes and CNA 1 should have had a second staff member present while providing care to Resident 24.On July 23, 2025, at 9 a.m., during an interview with the Director of Nursing (DON), the DON stated Resident 24 was considered substantial/maximal assist for rolling from left to right. The DON stated substantial/maximum assistance indicated two-person assistance was required. The DON stated the cause of the fall was mechanical due to the air fluctuating in the low air mattress along with the mattress' slippery surface and the lack of follow-through from CNA 1 regarding requiring two-person assistance. The DON further stated the cause of the fracture was from the fall and CNA 1 should have called for assistance during the brief change.On July 23, 2025, at 4:06 p.m., during a follow up interview with CNA 1, CNA 1 stated she was not aware Resident 24 required two person assist for bed mobility, including brief changes, prior to the fall. CNA 1 further stated she should have called a second person for assistance when providing care to Resident 24. A review of the facility's policy and procedure titled, Falls and Fall Risk, Managing, dated March 2018, indicated, .staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling.will identify and implement relevant interventions.to try to minimize serious consequences of falling.A review of the facility's policy and procedure titled, Activities of Daily Living (ADLs), Supporting, dated March 2018, indicated, .Residents who are unable to carry out activities of daily living independently will receive the services necessary.including appropriate support and assistance with.Mobility.Elimination (the removal of substances through bodily fluids such as urine, sweat, and feces). 2. On July 21, 2025 at 11:43 a.m., during an interview with Resident 57, Resident 57 stated she smokes and her cigarettes and lighter were being kept inside her bedside table drawer, unlocked.A review of Resident 57's admission Record, indicated Resident 57 was admitted on [DATE].A review of Resident 57's History and Physical, dated October 28, 2024, indicated Resident 57 had the capacity to understand and make decisions.A review of Resident 57's Minimum Data Set (MDS - an assessment tool), dated May 2, 2025, indicated a BIMS score of 15 (cognitively intact).On July 24, 2025 at 8:52 a.m., during a concurrent interview and record review with the Director of Nursing (DON), Resident 57's Smoking Assessment, dated January 30, 2025, indicated the facility needed to store lighter and cigarettes and resident required supervision for safety. The DON stated cigarettes and lighter should not have been stored at the resident's bedside based on the Smoking Assessment. The DON stated this was important because it was a safety concern for all residents and staff.A review of the facility's policy and procedures titled, Smoking Policy - Residents, dated July 2017, indicated, .Residents without independent smoking privileges may not have or keep smoking articles, including cigarettes, tobacco, etc.

Based on observation, interview, and record review, the facility failed to ensure sanitary conditions were maintained in the food and nutrition services and food were stored in accordance with professional standards for food service safety when: 1.Outside food items were not stored past the store by date and properly labeled according to the facility's policy and procedure; and2.The [NAME] did not disinfect the food thermometer in between use.These failures had the potential to cause food borne illness and food poisoning within their resident population.Findings:1.On July 24, 2025, at 3:50 p.m., an observation with a concurrent interview was conducted with the Dietary Supervisor (DS). The designated shared residents' refrigerator located in the conference room was inspected. The DS stated residents were allowed to store personal food in the designated shared refrigerator. The DS stated food was allowed to stay for three days in the refrigerator and the food item should be dated and labeled with the resident's name and room number upon storage.Signage was observed posted on the refrigerator door indicating, .Don't leave food for more than 48hrs (48 hours).The refrigerator is emptied out and cleaned every Friday.Stored inside the refrigerator were several mislabeled food items including:- One undated and unlabeled glassware container with food; the food item appeared frozen upon inspection;- One undated (name of restaurant) bag of food; the bag of food was labeled with resident's name and room number;- One undated bag of chips;. the bag of food was labeled with the resident's name;- One undated bag with leftover chicken; the bag of food was labeled with the resident's name;- One undated bag of leftover chicken; the bag of food was labeled with a room number;- One undated (name of restaurant) bowl of leftovers; the bowl of food was labeled with the resident's name;- One undated white glassware with rice;- One unlabeled and undated blue container with food;- One undated white and blue THANK YOU bag of food; the bag of food was labeled with the resident's name and room number;- One unlabeled and undated tub of dark chocolate peanut butter cups;- One undated and unlabeled bottle of (brand of milk) reduced fat milk;- One undated (name of drink) bottle;- One unlabeled and undated tub of sour cream with an expiration date of 7/7/25 (July 7, 2025); and- One undated bottle of (brand of drink); the bottle was labeled with the resident's first name; the bottle was opened and appeared to be frozen.The DS stated these outside personal food items should have been discarded. The DS stated the staff should have labeled the residents' food items with their name, room number, and the date.The DS stated there was a potential for the residents to get sick from the expired food. The DS stated it was a food safety concern due to the potential for food-borne illness and poisoning. The DS further stated she should have checked the refrigerator.A review of the facility's policy and procedure titled, Foods Brought by Family/Visitors, revised October 2017, indicated, .Food brought by family/visitors that is left with the resident to consume later will be labeled and stored in a manner that is clearly distinguishable from the facility-prepared food.Perishable foods must be stored in re-sealable containers with tightly fitting lids in a refrigerator. Containers will be labeled with the resident's name, the item and the use by date.The nursing staff will discard perishable food on or before the use by date.The nursing and/or food service staff will discard any foods prepared for the resident that show obvious signs of potential foodborne danger (for example, mold growth, foul odor, past due package expiration dates).2. On July 23, 2025, at 12 p.m., an observation with [NAME] 1 was conducted. [NAME] 1 was observed measuring the food cooking temperatures of each individual food item on the steam table prior to the tray line assembly.Cook 1 was observed to not consistently wipe the thermometer with a paper towel and/or alcohol swab between the measuring of temperatures between food items. [NAME] 1 was observed to be inconsistently using the same paper towel and/or alcohol swab to wipe off the food residue from the thermometer prior to taking the temperature of the food item.On July 24, 2025, at 11:15 a.m., [NAME] 1 was interviewed. [NAME] 1 stated that when taking temperature of foods prior to tray line, she must clean with tissue and then with an alcohol swab each time between foods.On July 24, 2025, at 11:40 a.m., the Dietary Supervisor (DS) was interviewed. The DS stated the food thermometer should be wiped with a paper towel and disinfected with an alcohol swab after a temperature is taken and before moving onto the next food.The DS stated that she saw [NAME] 1 only wipe the thermometer with a paper towel and did not disinfect it each time she proceeded to take the food temperature of the next food item. The DS stated not disinfecting the food thermometer prior to using it on the next food item can result in cross contamination of food, food allergies complications, and may alter the taste of the food.The facility's policy titled, THERMOMETER USE AND CALIBRATION, dated 2023, was reviewed. It indicated, .when using the same thermometer on different foods during one meal, wipe the thermometer with an alcohol swab, clean cloth, or paper towel between different food items.

Based on observation, interview, and record review, the facility failed to ensure provision of safe and effective pharmaceutical services to meet the needs of the residents when:1. For Resident 39, cholestyramine (medication used to lower cholesterol and treat itching or diarrhea caused by a buildup of bile acids [substances made by the liver that help digest fats]) was administered without appropriate separation from other oral medications, not in accordance with the manufacturer's instructions and the facility's consultant pharmacist's recommendation to separate administrations.This failure had the potential to result in reduced drug absorption, and inadequate medication treatment, compromising the effectiveness of other administered medications; and 2. The documentation on Controlled Drug Record (CDR, accountability records, an inventory sheet that keeps records of the usage of controlled medications) and Medication Administration Record (MAR) did not reconcile for two randomly selected residents (Residents 78 and 106).These failures resulted in inaccurate accountability of controlled substances (medication with high potential for abuse and addiction), which had the potential for misuse or diversion (medication taken by someone other than for whom it is prescribed) of controlled substances. Findings:1. On July 21, 2025, at 8:58 a.m., during a medication pass observation with Licensed Vocational Nurse (LVN) 3, LVN 3 was observed preparing a total of four oral medications for Resident 39. Included in the medications were 2 (two) tablets of acetaminophen (pain medication) 500 mg (milligram - unit of measurement), 1 (one) tablet of Eliquis (blood thinner) 5 mg, 1 (one) capsule of stool softener (docusate sodium, active ingredient) 100 mg, and UTI-Stat oral liquid (supplement) 30 ml (milliliter - unit of measurement). LVN 3 stated cholestyramine 4 gm (gram - unit of measurement) also needed to be administered but would first administer the four prepared medications and then obtain a graduated measuring cup from the supply room to dilute the cholestyramine powder in 8 oz (ounces - unit of liquid measurement) of liquid, as the cups available in the medication cart were too small to accurately measure the required 8 oz of liquid.On July 21, 2025, at 9:18 a.m., LVN 3 was observed administering the four prepared medications to Resident 39.On July 21, 2025, at 9:26 a.m., LVN 3 was observed preparing and administering the diluted cholestyramine to Resident 39.During a review of Resident 39's medical record, the following physician orders were noted:- Cholestyramine Light Packet 4 GM, Give 1 packet by mouth two times a day for Generalized body itching, Mix in 8 oz Liquid, dated December 1, 2024. The scheduled administration times were 8 a.m. and 5 p.m.;- Acetaminophen 500 MG, Give 2 tablets by mouth two times a day for Pain Management/chronic headache, dated July 24, 2024;- Apixaban (generic name for Eliquis) Oral Tablet 5 MG, Give 5 mg by mouth two times a day for PPX (prophylaxis, preventive) blood clots, Monitor for sign of bleeding/discolorations, dated June 21, 2025;- Stool Softener Oral Capsule 100 MG (Docusate Sodium), Give 1 capsule by mouth two times a day for constipation, hold for loose stool, dated December 25, 2024; and- UTI-Stat oral liquid (Cranberry-Vitamin C-Inulin), Give 30 ml by mouth one time a day for management, dated July 9, 2025.During a review of Resident 39's medical record, the MAR, dated June 2025 and July 2025, indicated the cholestyramine was administered at 8 a.m. and 5 p.m. through July 9, 2025, then at 10 a.m. and 6 p.m. beginning July 10, 2025.On July 21, 2025, at 3:08 p.m., during a concurrent interview and record review with LVN 3, LVN 3 reviewed the physician's order and stated the Director of Nursing (DON) had updated the administration time for cholestyramine from 8 a.m. and 5 p.m. to 10 a.m. and 6 p.m., as reflected in the revised physician's order dated July 9, 2025.On July 22, 2025, at 2:45 p.m., during a concurrent interview and record review with the Director of Nursing (DON), the DON confirmed the administration times for cholestyramine had been updated from 8 a.m. and 5 p.m. to 10 a.m. and 6 p.m. on July 9, 2025, following the recommendation from the Consultant Pharmacist (CP)'s Medication Regimen Review (MRR). The DON explained the facility's medication pass time window allows for medications scheduled at 9 a.m. to be administered between 8 a.m. and 10 a.m., and those scheduled at 5 p.m. to be administered between 4 p.m. and 6 p.m. The DON acknowledged the CP's recommended administration times needed clarification, as they overlapped with other scheduled oral medications given daily at 9 a.m., and twice daily at 9 a.m. and 5 p.m., according to the facility's medication pass schedule.A review of the facility's CP's MRR, dated June 27, 2025, the MRR for Resident 39 indicated: .Cholestyramine (Questran) significantly interacts with other medications by preventing their absorption. The manufacturer indicates it should be given 1 hour after other meds in order to avoid these potential interactions. Please consider giving at 10am (1000) & 6pm (1800) instead.On July 22, 2025, at 2:45 p.m., during a concurrent interview with the CP, the CP acknowledged the recommended administration times of 10 a.m. and 6 p.m. overlapped with the facility's medication pass windows for the scheduled 9 a.m. and 5 p.m. doses. During a concurrent interview with the DON, the DON acknowledged the recommended administration times by the CP should have been clarified since they still overlapped with the administration times of other oral medications.A review of a nationally recognized drug information resource from Micromedex, dated on March 19, 2025, the resource indicated, .Administer other oral medications at least 1 hour before or 4 to 6 hours after cholestyramine, due to the potential to bind to orally administered drugs.A review of the facility's policy and procedure titled, Administering Medications, dated April 2019, indicated, .If.a medication has been identified as having potential adverse consequences for the resident or is suspected of being associated with adverse consequences, the person preparing or administering the medication will contact the prescriber, the resident's Attending Physician or the facility's Medical Director to discuss the concerns.2a. On July 22, 2025, at 11:22 a.m., during an inspection of Medication Cart 1 with LVN 3, blister cards containing controlled substance (CS) were randomly selected from the locked drawer of the Medication Cart 1 and reviewed to verify accurate documentation of administration and accountability. Resident 106's record was concurrently reviewed with LVN 3. Resident 106 had a physician's order, dated July 14, 2025, for tramadol (a controlled substance for pain) 50 mg (milligram, unit of measurement), one tablet by mouth every four hours as needed for moderate to severe pain.Resident 106's tramadol 50 mg CDR and July 2025 MAR were reviewed. LVN 3 confirmed the Resident 106'sCDR indicated the nursing staff removed and signed out one tablet of tramadol 50 mg on July 18, 2025, at 9 p.m., but it was not documented as administered on the MAR. 2b. On July 22, 2025, at 3:10 p.m., during an inspection of Medication Cart 3 with LVN 4, blister cards containing CS were randomly selected from the locked drawer of the Medication Cart 3 and reviewed to verify accurate documentation of administration and accountability. Resident 78 had a physician's order, dated May 7, 2025, for oxycodone (a controlled substance for pain) 10 mg, one tablet by mouth every four hours as needed for severe pain. Resident 78's oxycodone 10 mg CDR and July 2025 MAR were concurrently reviewed with LVN 4. LVN 4 confirmed the CDR indicated nursing staff removed and signed out one tablet of oxycodone 10 mg on July 21, 2025, at 12:48 p.m., but it was not documented as administered on the MAR. On July 24, 2025, at 3:40 p.m., during a concurrent interview and record review with the DON, the CDR and MAR were reviewed for Residents 78 and 106. The DON confirmed the findings and stated each resident's CDR and MAR should match. A review of the facility's policy and procedure titled, Documentation of Medication Administration, dated April 2007, indicated, .A Nurse or Certified Medication Aide.shall document all medications administered to each resident on the resident's medication administration record (MAR). Administration of medication must be documented immediately after (never before) it is given. Documentation must include, as a minimum: Name and strength of the drug, Dosage, Method of administration, Date and time of administration, Reason(s) why a medication was withheld, not administered, or refused (as applicable), Signature and title of the person administering the medication, and Resident response to the medication, if applicable (e.g., PRN, pain medication, etc.) .A review of the facility's policy and procedure titled, Controlled Substances, dated April 2019, indicated, .Controlled substances are reconciled upon receipt, administration, disposition, and at the end of each shift.The nurse administering the medication is responsible for recording. Controlled medications are counted at the end of each shift. The nurse coming on duty and the nurse going off duty determine the count together. Any discrepancies in the controlled substance count are documented and reported to the Director of Nursing Services immediately. The Director of Nursing Services investigates all discrepancies in controlled medication reconciliation to determine the cause and identify any responsible parties, and reports the findings to the Administrator. The Director of Nursing Services consults with the provider pharmacy and the Administrator to determine whether further legal action is indicated.A review of the facility's policy and procedure titled, Administering Medication, dated April 2019, indicated, .The individual administering the medication initials the resident's MAR on the appropriate line after giving each medication and before administering the next ones. As required or indicated for a medication, the individual administering the medication records in the resident's medical record: The date and time the medication was administered.The signature and title of the person administering the drug.

Based on observation, interview, and record review, the facility failed to ensure proper labeling and storage of medications in accordance with the facility's policies and procedures and/or manufacturer's instructions when:1. One discontinued and expired medication for Resident 107 was stored in Medication Refrigerator in Medication room [ROOM NUMBER] along with other active medications available for use;2. A total of four IV (intravenous, into a vein) Mini-Bag Plus containers, removed from manufacturer's overwrap, were stored without beyond use dates (BUD, date or time after which the product may not be used) in IV Emergency Kit (E-kit, a sealed container with various medications for use in emergencies) in Medication room [ROOM NUMBER]; and3. One expired inhaler for Resident 71 was stored in Medication Cart 1.These failures had the potential for residents to receive discontinued, expired, or ineffective medications, leading to medication errors and compromised treatment outcomes.Findings:1. On July 22, 2025, at 9:19 a.m., during an inspection of the Medication Refrigerator in the Medication room [ROOM NUMBER] with Registered Nurse (RN) 1, one bag of compounded Total Parenteral Nutrition (TPN - nutrition given through an IV) was observed to be expired. The pharmacy-applied label on the bag indicated Do Not Use After: 7/2/25 (July 2, 2025), 3 pm.During a concurrent interview, RN 1 confirmed the expiration date on the medication label and stated the TPN medication order for Resident 107 had been discontinued, and the resident had been discharged . RN 1 further stated the TPN bag should have been removed from the medication refrigerator and placed in the pharmaceutical bin for disposal.During a review of Resident 107's medical record, the physician's order, dated July 7, 2025, indicated the TPN medication order was discontinued on July 7, 2025, at 4:33 p.m.On July 22, 2025, at 10:15 a.m., during an interview with the Director of Nursing (DON), the DON stated the licensed nurse should have removed medication from the refrigerator for disposal when the order was discontinued. A review of the facility's policy and procedure titled, Discontinued Medication, dated April 2007, indicated: Staff shall destroy discontinued medications.in accordance with facility policy.Discontinued medications must be destroyed.in accordance with established policies.A review of the facility's policy and procedure titled, Discontinued Medications, dated January 9, 2025, indicated: .All discontinued medication must be labeled and stored in a secure location.Discontinued or on hold medications (accountable or not accountable) shall be given to the facility designate upon discontinuation (DON, etc.) and placed in a secured location.A review of the facility's policy and procedure titled, Storage of Medication, dated January 9, 2025, indicated: .All medications on hand for discharge or expired residents shall be immediately withdrawn from stock and either destroyed or locked away separately in conformance with medication destruction procedure.A review of the facility's policy and procedure titled, Destruction of Non-Accountable Medications, dated January 9, 2025, indicated: .A licensed nurse will remove discontinued non-controlled medication from stock, Attach D/C date sticker to medication.with date, Discontinued medication will be stored in the designated locked area awaiting disposition/return. Routinely licensed personnel will list discontinued medications on the appropriate log and package the medication in preparation for disposal. 2. During an inspection of an IV E-kit labeled IV EKIT #13, stored in the Medication Room in Nursing Station 2 on July 22, 2025, at 9:38 a.m. with RN 2, two 50 mL (milliliter - unit of measurement) bags and two 100 mL [NAME]'s (name of manufacturer) 0.9% Sodium Chloride IV Mini-Bag Plus containers (sterile IV bags containing a solution of salt and water, designed for easy mixing and administration of IV medication) were observed removed from the manufacturer's original overwrap packaging. These bags did not have BUD labeled as recommended by the manufacturer once the overwrap is removed.During a concurrent interview with the RN 2, RN 2 acknowledged none of the IV Mini-Bag Plus containers were labeled with a use-by date or BUD.On July 22, 2025, at 3:05 p.m., during a concurrent interview and record review with the DON, the DON stated the pharmacy had informed the BUD of 15 days for 50 mL bags and 30 days for 100 mL bags of Mini-Bag Plus containers after being removed from the overwrap. The DON also provided a pharmacy-supplied document titled ASHP Guidelines on Compounding Sterile Preparations, published in 2022 by the American Society of Health-System Pharmacists (ASHP), a national professional organization representing pharmacists in hospitals and health systems. The document included Table 10, which indicated a BUD of 15 days from the date the diluent (bag containing solution) was removed from the overwrap, for [NAME] Mini-Bag Plus containers, both 50 mL and 100 mL bags, when stored at room temperature, unless otherwise specified by the manufacturer. The DON acknowledged the BUD information.A review of the facility's policy and procedure titled, Administering Medications, dated April 2019, indicated: .beyond use date.is checked.A review of the facility's policy and procedure titled, Storage of Medications, dated November 2020, indicated: Drug containers that have missing, incomplete, improper, or incorrect labels are returned to the pharmacy for proper labeling before storing.outdated or deteriorated drugs.are returned to the dispensing pharmacy or destroyed.3. On July 22, 2025, at 10:55 a.m., during an inspection of Medication Cart 1 in Nursing Station 1 with Licensed Vocational Nurse (LVN) 3, one expired inhaler, Fluticasone Propionate and Salmeterol (generic for Advair Diskus, used to treat long-term breathing problems such as wheezing, shortness of breath, or frequent coughing), inhalation powder 250 mcg/50 mcg (microgram - a unit of measurement) was observed stored outside of its foil pouch for Resident 71. The open date was written on the manufacturer's box as 5/24/25 (May 24, 2025). On July 22, 2025, at 10:55 a.m., during a concurrent interview and record review with LVN 3, the manufacturer's instruction on the box and the package inserts (PI - document included in the package of a medication that provides information about that drug and its use) were reviewed, and the PI indicated .Discard the inhaler 1 month after opening the foil pouch or when the dose counter reads 0 (after all blisters have been used), whichever comes first. LVN 3 confirmed the inhaler had been opened on May 24, 2025, and acknowledged it had been stored beyond its recommended use period and had not been removed from the medication cart.On July 24, 2025, at 3:40 p.m., during a concurrent interview and record review with the DON, the DON confirmed the finding and acknowledged the PI indicating the BUD of 1 month after opening the Advair Diskus. The DON stated any expired medications should have been removed from the medication cart and disposed of.A review of the manufacturer's instruction on the package insert (PI), dated December 2024, the PI indicated: .How supplied/Storage and Handling.Fluticasone propionate and salmeterol inhalation powder should be stored inside the unopened moisture-protective foil pouch and only removed from the pouch immediately before initial use. Discard fluticasone propionate and salmeterol inhalation powder 1 month after opening the foil pouch or when the counter reads 0 (after all blisters have been used), whichever comes first. The inhaler is not reusable.A review of the facility's policy and procedure titled, Administering Medications, dated April 2019, indicated: .the expiration/beyond use date on the medication label is checked prior to administering.A review of the facility's policy and procedure titled, Storage of Medication, dated January 9, 2025, indicated: .Medications shall not be kept on hand after the expiration date on the label.

Based on observation, interview, and record review, the facility failed to ensure the cook (Cook 1) followed the recipe for pureed (blend food into soft consistency) vegetables.This failure has the potential to affect the consistency, taste, and nutritive value of the pureed menu items, and further affect the resident's overall health condition.Findings:On July 23, 2025, at 11:00 a.m., a kitchen observation with a concurrent interview was conducted with [NAME] 1. [NAME] 1 stated there were 18 residents on a puree diet and that she had already prepared the pureed foods at 10:00 a.m.Cook 1 stated she followed the recipe book for pureed foods. [NAME] 1 stated when she prepared the pureed vegetables, she added two cups of water. Observed [NAME] 1 stirring the pureed vegetables, and noted the consistency of the pureed vegetables was more liquid than pudding consistency. [NAME] 1 was then observed pouring powder directly from a plastic clear container to the pureed vegetables without measuring. [NAME] 1 stated that she put 1.5 cups of thickener in the pureed vegetables (used to change the texture of food).On July 24, 2025, at 11:15 a.m., a concurrent interview and record review was conducted with [NAME] 1. [NAME] 1 stated that she followed the recipe book when pureeing food and when adding thickener to the food.The undated facility document titled, RECIPE: PUREED VEGETABLES, indicated that a serving of 6 (six) has a maximum of 1/3 cup (one third) of fluid and serving of 12 has a maximum of 3/4 (three fourths) cup of fluid. For commercial instant food thickener, it also indicated that a serving of 6 has a maximum of 6 tbsp (tablespoons - unit of measurement) and that a serving of 12 has a maximum of 12 tbsp.Cook 1 stated she did not follow recipe for pureed vegetables or food thickener use. [NAME] 1 stated that she exceeded the menu recipe's requirement for pureed food and thickener use.On July 24, 2025, at 11:40 a.m., the Dietary Supervisor (DS) was interviewed. The DS stated that [NAME] 1 should have followed the recipe for thickener and pureed foods. The DS stated the thickener added to the pureed food should have been measured. The DS stated not following the recipe for puree food and as well as not measuring thickener being added to the pureed food could affect the texture, taste, and nutritional value of food.A review of the facility's document titled, REGULAR PUREED DIET, dated 2023, indicated, .The pureed diet is a regular diet that has been designed for residents who have difficulty chewing and/or swallowing. The texture of food should be of a smooth and moist consistency and able to hold its shape .Detailed recipes and procedures for pureeing foods may be found in Binder #1 .

Based on observation, interview, and record review, the facility failed to ensure infection prevention and control practices were upheld when:1. One licensed nurse was observed wearing long, acrylic nails while providing direct patient care;2. One licensed nurse was observed not to follow enhanced barrier precautions (EBP- a type of isolation precaution) while providing direct patient care to Resident 45; and3. For Resident 44, the nebulizer tubing and mask, as well as the Yankauer suction tip (type of suction tip), were not stored appropriately when not in use.These failures had the potential to spread infection among the vulnerable residents of the facility. Findings: 1. On July 23, 2025, at 12:30 p.m., the medication cart was observed in front of room [ROOM NUMBER] and Licensed Vocational Nurse (LVN) 3 was observed coming out of the room after a few minutes. In a concurrent interview, LVN 3 stated she finished with her medication pass (administration) and the task entailed checking blood sugars and administering insulin for the 11 am med pass. LVN 3 was observed wearing long, red acrylic nails, approximately 1/3 inch from the tip of her fingers on all five fingers of the left hand, as well as the thumb, forefinger and third digit of the right hand. LVN 3 confirmed she was wearing acrylic nails, and the acrylic nails were placed on top of her natural nails since her natural nails were brittle. LVN 3 stated she was not sure what the facility policy was regarding acrylic nails, but acknowledged that nails should be kept short and clean. LVN 3 stated having long nails while providing direct patient care increased the risk of transmission of infection to the residents. LVN 3 stated she should not be wearing long, acrylic nails. On July 24, 2025, at 9:40 a.m., the Infection Preventionist (IP) was interviewed. The IP stated LVN 3 should not have worn long acrylic nails, since long and artificial nails were not allowed due to high risk of infection transmission to residents. The IP further stated long nails can also cause skin tears in the residents, which in turn, could also get infected. On July 24, 2025, at 2:15 p.m., the Director of Nursing (DON) was interviewed. The DON stated LVN 3 should not have had long acrylic nails. The DON further stated he expected direct patient care staff to have short clean nails and not have artificial nails, to avoid scratching the residents and potentially transmitting infection among the residents. A review of the facility’s “EMPLOYEE HANDBOOK,” dated November 1, 2014, indicated, “…Appearance Standards…Fingernails must be kept clean…” The facility did not have a policy specific to long, artificial nails in relation to infection control. According to the Centers for Disease Control and Prevention (CDC - a leading national public health institute in the United States) website, .Germs can live under artificial fingernails both before and after using an alcohol-based hand sanitizer and hand washing. It is recommended that healthcare providers do not wear artificial fingernails or extensions when having direct contact with patients at high risk .Keep natural nail tips less than 1/4 inch long. 2. On July 21, 2025, at 10:50 a.m., an observation was conducted with Resident 45. Resident 45 was in bed, alert, non-verbal, and appeared congested. Outside Resident 45’s room was a signage indicating EBP before entering. The EBP sign indicated, “EVERYONE MUST: Perform hand hygiene before entering the room…ANYONE PARTICIPATING IN ANY OF THESE SIX MOMENTS MUST ALSO: [NAME] (put on) gown and gloves…Device care or use…Change and discard gown and gloves and perform hand hygiene between each resident and before leaving room…” On July 21, 2025, at 10:55 a.m., LVN 3, was observed to enter Resident 45’s room. LVN 3 donned gloves and proceeded to suction (clear out airway) Resident 45’s airway. LVN 3 did not don a mask and/or gown prior to suctioning Resident 45’s airway. On July 21, 2025, at 11:55 a.m., LVN 3 was interviewed. LVN 3 stated Resident 45 was experiencing oxygen desaturation (decrease in oxygen concentration level in blood) and subsequently, required suctioning and breathing treatment. LVN 3 stated Resident 45 was on EBP due to her gastrostomy tube (tube inserted through abdomen to stomach for nourishment). LVN 3 stated EBP was indicated for residents with a gastrostomy tube to protect both the residents and staff from possible spread of infection. LVN 3 stated the facility staff should wear PPE (personal protective equipment) such as gown, gloves, and mask when providing direct care when providing direct care to a resident requiring EBP precaution. LVN 3 stated airway suctioning on a resident was considered direct care. LVN 3 stated she did not wear gown and mask when she conducted the airway suctioning on Resident 45. LVN 3 stated she did not follow the procedure on EBP precaution. On July 22, 2025, Resident 45’s record was reviewed. Resident 45 was admitted to the facility on [DATE], with diagnoses which included Alzheimer’s (memory loss), diabetes mellitus (abnormal blood sugar), and presence of gastrostomy tube. A review of Resident 45’s physician’s order, dated May 13, 2024, which indicated, “May have enhanced barrier precaution r/t (related to ) Gtube (gastrostomy tube) used to minimized risk of MDROs (Multi-Drug Resistant Organism - microorganisms, such as bacteria, that have become resistant to multiple antibiotics). A [NAME] of Resident 45’s care plan, dated May 13, 2024, indicated, “…May have enhanced barrier precaution…Follow enhance barrier precaution when doing high contact activities with resident…” The facility's policy and procedure titled, “Enhanced Barrier Precautions,” dated 2001, was reviewed. The policy indicated, “…Enhanced barrier precautions (EBPs) are utilized to prevent the spread of multi-drug resistant organisms (MDROs) to residents…EBPs employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply…Gloves and gown are applied prior to performing the high contact resident care activity…Face protection may be used if there is also a risk of splash or spray…EBPs are indicated (when contact precautions do not otherwise apply) for residents with wounds and/or indwelling medical devise regardless of MDRO colonization…” 3. On July 21, 2025, at 11:07 a.m., an observation with a concurrent interview was conducted with Resident 44. Resident 44 was in bed, alert, and able to be interviewed. Observed next to Resident 44’s bed was a bedside dresser with Resident 44’s personal belongings. Observed behind a bouquet of flowers and directly placed on top of the bedside dresser were the following: - A nebulizer tubing and mask with a date of “6/30/25 (June 30, 2025)”; and - A suction machine set-up with tubing and Yankauer (a type of suction tip used in medical procedures to remove fluids and debris from a patient's airway or surgical site). The suction canister contained a clear liquid and did not indicate a label date. Both nebulizer tubing and mask, and suction tubing and Yankauer were observed not stored in the appropriate container bag when not in use. In a concurrent interview, Resident 44 stated her last breathing treatment (respiratory medication given through nebulizer) was five days ago. On July 21, 2025, at 12:04 p.m., an observation with a concurrent interview was conducted with Licensed Vocational Nurse (LVN) 3. LVN 3 observed the nebulizer tubing and mask and suction tubing and Yankauer directly on top of Resident 44’s bedside dresser. LVN 3 stated the nebulizer tubing and suction supplies should be changed every week. LVN 3 stated the nebulizer tubing was dated June 30, 2025, and the suction supplies (tubing, canister, and Yankauer) were undated. LVN 3 stated the nebulizer tubing and bag should have been replaced on July 20, 2025. LVN 3 stated the nebulizer tubing and mask, and suction tubing and Yankauer should have been stored in a bag when not in use to prevent the spread of infection. LVN 3 stated she did not know when the suction machine was last used. On July 24, 2025, at 3:03 p.m., the Infection Preventionist (IP) was interviewed. The IP stated the nebulizer tubing and mask should be changed once a week. The IP stated it was the facility’s standard of practice to change tubing (e.g. oxygen tube, nebulizer tube) on Sundays. The IP stated a suction canister should be discarded after each use. The IP stated the suction canister and Yankauer next to Resident 44’s bedside dresser, should have been dated if not used and the suction canister and Yankauer should have been discarded after use during the shift. The IP further stated the nebulizer tubing and mask, and suction tubing and Yankauer should have been stored in a bag when not in use. A review of the facility’s document titled, “Suctioning the Upper Airway (Nasopharyngeal or Oropharyngeal Suctioning,” revised October 2023, indicated, “…After Suctioning…Turn off suction…Disconnect catheter from tubing. Wrap catheter around gloved hand. Pull the glove off and over the catheter. Discard in designated receptacle…”

Based on interview and record review the facility failed to ensure written information to formulate an Advance Directive (AD - written instruction for the provision of care and services when unable to make decisions for oneself) was provided to the resident or the resident representative, according to the facility's policy and procedure, for two of two residents (Resident 49 and Resident 88). This failure had the potential for the residents to receive unnecessary care/treatment and services.Findings: 1. On July 21, 2025, at 10:18 a.m., Resident 49’s record was reviewed. Resident 49 was admitted to the facility on [DATE], with diagnoses which included Alzheimer’s dementia (memory loss). A review of Resident 49’s “Physician Orders for Life-Sustaining Treatment (POLST - a document that outlines a seriously ill or frail patient's preferences for medical treatment, particularly at the end of life), dated July 4, 2025, indicated Resident 49 had no AD, with the checkbox for legally assigned decision maker marked with a check. The form was signed by a resident representative (RR). A review of Resident 49’s “History and Physical Examination,” dated July 7, 2025, indicated Resident 49 did not have the capacity to understand and make decisions. A review of Resident 49’s “Minimum Data Set (MDS – a resident assessment tool),” dated July 7, 2025, indicated Resident 49 had a BIMS (Brief Interview of Mental Status) score of 5 (severe cognitive impairment). There was no documented evidence formulation of an AD was offered to Resident 49 or Resident 49’s RR. On July 23, 2025, at 9:47 a.m., a concurrent interview and review of Resident 49’s record was conducted with the Medical Records Director (MRD). The MRD confirmed there was no documented evidence in Resident 49’s record that formulation of an AD was offered, and formulation of an AD should have been offered to Resident 49’s RR. The MDR further stated formulation of an AD should have been offered to the resident of resident representative upon admission and followed up within the first 14 days, during the period of baseline care planning. 2. On July 22, 2025, Resident 88’s record was reviewed. Resident 88 was admitted to the facility on [DATE], with diagnoses which included the right intertrochanteric femur fracture (broken upper thigh bone), status post cephalomedullary nailing (orthopedic implant for stabilization), and traumatic brain injury (injury to the brain). A review of Resident 88’s History and Physical Examination, completed by the physician on July 7, 2025, indicated Resident 88 had the capacity to understand and make decisions; A review of Resident 88’s SOCIAL SERVICES ASSESSMENT - INITIAL, dated July 7, 2025, indicated a check mark for POLST and a blank box for when and AD was offered. A review of Resident 88’s “POLST,” dated July 17, 2025, indicated a blank box for no AD, and the form was signed by Resident 88’s representative. On July 23, 2025, at 3:17 p.m., a concurrent interview and record review was conducted with the Case Manager (CM). The CM stated there was no documented evidence Resident 88 and/or Resident 88’s representative was offered education for AD or offered formulation of an AD. On July 23, 2025, at 3:39 p.m., a concurrent interview and record review was conducted with the MDS Coordinator (MDSC). The MDSC stated education for AD, and the formulation of an AD should have been offered to Resident 88 and/or Resident 88’s representative within 72 hours of admission. A review of the facility’s policy and procedure titled “Social Assessment,” revised July 2014, indicated, “…data obtained from social service assessment shall be used to develop…end-of-life care…wishes about medical treatment and care, including any advance directives…” A review of the facility’s policy and procedure titled, “Advance Directives,” dated December 2016, indicated, “…Upon admission, the resident will be provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive is he or she chooses to do so…If the resident is incapacitated and unable to information about his or her right to formulate an advanced directive, the information may be provided to the residents legal representative…Information about whether or not the resident has executed an advanced directive shall be displayed prominently in the medical record…If the resident indicates that he or she has not established advanced directives, the facility staff will offer assistance in establishing advanced directives. Nursing staff will document in the medical record the offer to assist in the resident’s decision to accept or decline assistance…”

Based on interview and record review, the facility failed to ensure the facility's policy and procedure on discharging a resident without a physician's approval was implemented, for one of three residents reviewed (Resident 102).This failure has the potential to place Resident 102 at risk for unsafe discharge.Findings:On July 24, 2025, Resident 102's record was reviewed. Resident 102 was admitted to the facility on [DATE], with diagnoses including diabetes mellitus (abnormal blood sugar), hypertension (high blood pressure), muscle weakness, abnormality of gait and mobility, and local infection of the skin and subcutaneous tissue. A review of Resident 102's History and Physical, dated March 31, 2025, indicated Resident 102 had the capacity to understand and make decisions.A review of Resident 102's Progress Notes, indicated the following :-On May 21, 2025, at 11:16 p.m., completed by licensed nurse, .Resident went out on pass during the AM shift to move his belongings from apartment to storage with movers. Resident is alert oriented X (times) 4 (four), and self responsible .Charge nurse reported to writer that resident is not back from OOP (Out On Pass) .Charge nurse had called resident phone number several times, resident was not taking his calls .MD (medical doctor), DON (Director of Nursing), Administrator and SSD (Social Service Director) notified .resident sent text message to RN (Registered Nurse) phone stating;i (sic.) think I'm going to stay out here ihave (sic.) my medical supplies that were sent to the house i (sic.) have some in storage followed up with another phone call from the resident @11:02PM (p.m.), which he confirmed he is not coming back to the facility this night, writer told the resident that, not coming back to the facility this night will be considered Against Medical Advice (AMA). Resident stated,i (sic) will be coming back to the facility in the morning to take my belongings, confirming AMA verbally, MD made aware .-On May 21, 2025, at 11:51 p.m., completed by the SSD, .Resident contacted SSD via phone call .SSD asked Resident if would like to return to the facility. Resident did not respond. SSD advised resident he needs to return due to need of medications and insulin. Per resident stated I wish to not return back to the facility I feel that I no longer need medical attention of any sort and I d o not need medications .resident(sic.) asked for belongings to be packed and he would pick up in 5 days or send someone to pick up belongings in the next days. SSD advised resident if he does not return it will considered against medical advice. SSD advising him of risks and benefits. Resident continued to state he does not want to return to the facility, and he verbalized understanding regarding leaving against medical advice .-On May 23, 2025, at 1:23 p.m., completed by the SSD, .Resident came to the facility with friend .resident took all personal belonging with him. Resident thanked SSD for safeguarding personal belongings. SSD will continue to assist as needed .There was no documented evidence Resident 102 signed the AMA acknowledgement form indicating he was leaving against medical advice from the physician and the facility administration. In addition, there was no documented evidence from the licensed nurses notified the physician Resident 102 returned to the facility from OOP on May 21, 2025, and was being discharged as AMA on May 23, 2025. On July 24, 2025, at 2:30 p.m., Licensed Vocational Nurse (LVN) 5 was interviewed. LVN 5 stated the physician was to be notified if a resident wanted to be discharged AMA from the facility, and the resident to sign the AMA release form, with risks and benefits explained to the resident.On July 24, 2025, at 2:48 p.m., the Director of Nursing (DON) was interviewed. The DON stated the following procedure should be followed when a resident verbalized wishes to go AMA:- The physician should be notified;- The risks and benefits of being discharged AMA would be discussed with the resident; and- The resident should sign the AMA form and the licensed nurses were to notify the physician and to document in the progress notes the AMA resident discharge.The DON stated this process was not done on Resident 102's AMA discharge. The DON stated the licensed nurses were not informed by the SSD Resident 102 returned from OOP on May 23, 2025, and wished to be discharged AMA. The DON stated there was no documentation the SSD provided the AMA form to Resident 102 to sign upon AMA discharge, nor refused to sign the AMA form. The DON stated the facility's process on discharging a resident without a physician's approval was not followed. The DON stated the process should have been followed by the SSD and the licensed nurses.A review of the facility's policy and procedure titled, Discharging a Resident without a Physician's Approval, dated October 2012, indicated, .If the resident or representative (sponsor) insist upon being discharged without the approval of the attending physician, the resident and/or representative (sponsor) must sign a release of responsibility form. Should either party refuse to sign the release, such refusal must be documented in the resident's medical record and witnessed by two staff members.

Based on observation, interview, and record review the facility failed to ensure, for two of 20 residents reviewed (Residents 85 and 10):1. For Resident 85, had a follow-up appointment with neurology (study of the brain after hospital discharge) as ordered on the general acute hospital (GACH) discharge summary; and2. For Resident 10, the facility identified, monitored, and notified the physician in a timely manner, multiple skin discolorations on both hands and the left upper extremity.These failures had the potential for Residents 85 and 10 to have a delay in the care and treatment and placed the resident at high risk for complications.Findings: 1.On July 23, 2025, Resident 85’s record was reviewed. Resident 85’s “admission Record,” indicated Resident 85 was admitted to the facility on [DATE], with diagnoses which included seizures (abnormal electrical activity in the brain), narcolepsy (brain’s inability to regulate sleep-wake cycle). The “History and Physical,” completed by the physician, dated February 24, 2025, indicated Resident 85 did not have the capacity to understand and make decisions. The GACH Discharge summary, dated [DATE], indicated, “…follow-up…neurology within 5 (five) to 7 (seven) days…for titration (adjusting the dose of a medication) of antiepileptic (medication to treat epilepsy) regimen . The “IDT (Interdisciplinary Team – a group of healthcare professionals) Care Plan Conference Summary,” dated February 25, 2025, did not indicate Resident 85’s follow- up appointment with neurology was discussed; The physician telephone order, dated March 1, 2025, at 2:51 p.m., indicated, “…May have follow up with Neurology consult within 5-7 days r/t (related to) titration of antiepileptic regimen . The “Progress Notes,” dated March 1, 2025, at 2:58 p.m., indicated, “…writer got a call from (name of acute hospital)…who called to confirm if resident have been scheduled for neurology consult…resident is supposed to see neurology within 5-7 days following hospital discharge…order was placed for May follow up…SSD/CM (Social Service Director/Case Manager) please follow up with scheduling resident appointment…” The telephone physician order, dated March 20, 2025, indicated, “…discharge back to (name of Assisted Living) on March 20, 2025…” The “admission Record,” indicated Resident 85 was admitted back to the facility on April 24, 2025. The medical appointment with Neurology, dated June 26, 2025, indicated, “ .recently hospitalized …discharge summary…follow-up with neurology for adjustment of antiseizure medication…at risk for seizures…continue Keppra (brand name for antiseizure medication) 1000 mg (milligram-unit of measurement) twice a day…return in 6 months or sooner if needed…” There was no documented evidence that a follow-up appointment with neurology was arranged by the facility staff as ordered in the acute hospital Discharge summary dated [DATE]. In addition, there was no documented evidence that a follow-up appointment with neurology was arranged by the facility staff as ordered by physician on March 1, 2025, not until June 26, 2025 (four months after the recommendation by the acute hospital February 21, 2025). On July 23, 2025, at 11:05 a.m., a concurrent interview and record review was conducted with the DON (Director of Nursing). The DON stated Resident 85 was admitted to the facility on [DATE], and was discharged to an Assisted Living Facility (ALF) on March 20, 2025. The DON stated the hospital Discharge summary, dated [DATE], indicated follow up with neurology within 5 to 7 days. The DON stated the physician order, dated March 1, 2025, indicated follow up with neurology within 5 to 7 days. The DON stated Resident 85 did not see the neurologist prior to his discharge to the ALF on March 20, 2025. The DON stated Resident 85’s did not see the neurologist until June 26, 2025. The DON further stated Resident 85 should have seen the neurologist within 5 to 7 days as indicated in the hospital Discharge summary dated [DATE], and physician orders dated March 1, 2025. The DON stated the facility did not have a policy pertaining to scheduling resident appointments. 2. On July 21, 2025, at 4:23 p.m., Resident 10 was observed in bed, alert, and was able to be interviewed. Resident 10 was observed to have multiple purplish blue skin discolorations in various sizes on the hands. On July 23, 2025, Resident 10’s record was reviewed. Resident 10 was admitted to the facility on [DATE], with diagnoses including chronic obstructive pulmonary disease (COPD – a progressive lung disease that makes it difficult to breathe), diabetes mellitus (abnormal blood sugar levels), and congestive heart failure (occurs when the heart doesn't pump enough blood to meet the body's needs). The “History and Physical,” dated June 6, 2025, indicated Resident 10 did not have the capacity to make decisions. The care plan, dated February 5, 2025, indicated, “…At risk for bleeding …At risk of alteration in skin integrity…Notify MD (medical doctor) of any bleeding episodes or any significant change in general condition, presence of bruises…” The facility document titled, “SHOWER SHEETS/BODY CHECK,” indicated the following: - On July 19, 2025, Resident 10 had “rashes” and “redness” on his forearms. The document did not indicate Resident 10 had multiple purplish blue skin discolorations on both hands; and - On July 23, 2025, Resident 10’s both forearms had “bruising, swelling,” and was “abnormal” in color. The document did not indicate the multiple purplish blue skin discolorations on both hands, which was identified since July 21, 2025. There was no documented evidence Resident 10’s multiple purplish blue skin discolorations on both hands, identified on July 21, 2025, were identified, addressed, and referred to the physician for treatment orders. On July 22, 2025, at 9:31 a.m., a record review was completed and noted that there was no documentation on the current skin discolorations within the care plan. On July 23, 2025, at 4 p.m., an observation was conducted on Resident 10. Resident 10 still observed to have the previously noted purplish blue discolorations on both hands and a pink skin discoloration on his left upper arm. On July 23, 2025, at 4:06 p.m., a concurrent interview and record review was conducted with Licensed Vocational Nurse (LVN) 1. LVN 1 stated Resident 10 had a history of anticoagulant (blood thinner) use, combative behavior, and fragile skin, which made him a high risk for skin injury. LVN 1 stated Resident 10’s discolorations were “on and off.” LVN 1 stated new skin discolorations should be identified and monitored. LVN 1 stated she last saw Resident 10 on July 22, 2025, but did not notice purplish blue discolorations on both hands or redness on his left upper extremity. On July 23, 2025, at 4:20 p.m., an observation with a concurrent interview was conducted with LVN 1. LVN 1 measured the multiple skin discolorations on Resident 10’s both hands and left upper arm. The measurement were as follows: - “Left upper extremity ecchymosis (discoloration due to bleeding) that is red in color, 9 cm (unit of measurement) x 11 cm”; - “Left second digit with grayish purple discoloration, 6 cm x 3 cm”; and - “Right fourth knuckle with purple discoloration, 3.5 cm x 2 cm” In a concurrent interview, LVN 1 stated there was no care plan initiated regarding the multiple skin discolorations she just measured. LVN 1 stated for new skin issues, the licensed nurse should complete a change of condition report, incident report, and inform the resident’s physician and family. LVN 1 stated this process was not done for Resident 10 since the skin issues were identified on July 21, 2025. LVN 1 stated the lack of reporting and monitoring of identified new skin problems had the potential to delay in the care or identification of underlying issues. LVN 1 stated this can also cause skin problems to worsen, including bruising and pain. On July 24, 2025, at 3:15 p.m., the DON was interviewed. The DON stated any new skin discoloration should be investigated for cause and potential abuse. The DON stated a change of condition report and care plan should be completed. The DON stated licensed nurses should have reported, assessed, and notified the physician and family of Resident 10. The DON stated all these components should have been done at the point of discovery. The DON stated the staff did not identify the new skin discolorations on Resident 10, and this should have been reported as soon as possible. The DON stated the delay in identification could result in a delay in treatment. The DON stated staff should have identified it early so the appropriate interventions could be “instituted” and communicated to family, the physician, and the staff. A review of the facility's document titled, Skin Tears - Abrasions and Minor Breaks, Care of, revised September 2013, indicated, .When an abrasion/skin tear/bruise is discovered, complete a Report of Incident/ Accident .Notify the responsible family member .Notify the physician of any abnormalities .

Based on observation, interview, and record review, the facility failed to accurately conduct pain assessment, for one of one resident (Resident 24).This failure had the potential for Resident 24's pain to be unmanaged appropriately.Findings:On July 23, 2025 at 12:24 p.m., during a concurrent observation of Resident 24 and interview with Licensed Vocational Nurse (LVN) 6 in Resident 24's room, Resident 24 was assessed for pain in English and Spanish by LVN 6. Resident 24 did not verbally respond and did not gesture with any head nodding up and down or side to side. LVN 6 stated Resident 24 was in pain if she would grimace or moan.A review of Resident 24's admission Record, indicated Resident 24 was admitted on [DATE], with diagnoses which included bilateral osteoarthritis (a chronic joint disease characterized by the breakdown of cartilage, the protective tissue that cushions the ends of bones in joints) of knee, right knee contracture (a permanent shortening of muscles, tendons, or other tissues that restricts movement), and dementia (memory loss).A review of Resident 24's History and Physical, dated February 18, 2025, indicated Resident 24 did not have the capacity to understand and make decisions.A review of Resident 24's Minimum Data Set (MDS - an assessment tool), dated April 16, 2025, indicated a Brief Interview for Mental Status (BIMS) score of 00 (severe cognitive impairment).A review of Resident 24's Medication Administration Record (MAR), for the month of July 2025, included a physician's order, dated November 5, 2024, which indicated, Monitor Level of Pain Q (every) Shift (Scale 0-10): (0 = No Pain, 1-3 = Mild Pain, 4-5 = Moderate Pain, 6-9 = Severe Pain, 10 = Excruciating Pain). The MAR a pain scale of 4 on July 19, 2025.The July 2025 MAR also included pain medication hydrocodone administered to Resident 24 on July 14, and 16, 2025 with a pain scale of 7 and 8 respectively.On July 23, 2025 at 12:25 p.m., during a concurrent interview and record review with LVN 6, Resident 24's July 2025 Medication Administration Record (MAR), indicated a pain level of eight (8) on July 22, 2025 at 8 a.m. LVN 6 stated she assessed Resident 24's pain on this date and time and should have implemented the PAINAD (a tool used to assess pain in individuals with advanced dementia who cannot verbally express their pain) assessment scale because Resident 24 was not able to verbally rate her pain using the numeric pain scale. LVN 6 stated it was important to implement the appropriate pain scale to accurately assess how much pain the resident was experiencing.On July 24, 2025, at 8:52 a.m., during an interview with the Director of Nursing (DON), the DON stated the licensed nurse should have used the PAINAD scale to accurately assess Resident 24's pain since the resident was nonverbal at the time. The DON stated it was important to utilize the appropriate pain scale to ensure the assessment was accurate.A review of the facility's policy and procedures titled, Pain - Clinical Protocol, dated March 2018, indicated, .Staff will use a consistent approach and a standardized pain assessment instrument appropriate to the resident's cognitive level.

Based on observation, interview and record review, the facility failed to ensure, for one of one resident (Resident 7):- Post dialysis (a medical procedure that acts as an artificial kidney, used when a person's kidneys fail to remove waste and excess fluid from the blood) complications were appropriately monitored on July 21, 2025;- The physician was notified of Resident 7's low blood pressure after dialysis treatment; and- Resident 7 ‘s low blood pressure was not monitored. These failures had the potential to result in the untimely reporting of adverse effects and symptoms post dialysis, which could also result in a decline in health condition.Findings: On July 22, 2025, at 1:45 p.m., a concurrent interview and record review was conducted with Licensed Vocational Nurse (LVN 2). LVN 2 stated a progress note were to be written when a resident would go out for dialysis treatment and another progress note to be documented when the resident would get back from the dialysis treatment. LVN 2 further stated upon a resident's return from dialysis treatment, the licensed nurse should conduct a complete physical assessment, check vital signs, weigh the resident, and assess the dialysis site. LVN 2 stated this assessment should be documented in the resident's medical record. LVN 2 stated Resident 7 went out for dialysis treatment on July 21, 2025, and there was no documentation of a complete assessment when the resident returned from the dialysis treatment.On July 22, 2025, Resident 7's record was reviewed. Resident 7 was admitted to the facility on [DATE], with diagnoses which included end stage renal disease (a chronic condition where the kidneys have permanently lost most of their function and can no longer effectively filter waste products from the blood) and dependence on renal dialysis.The care plan dated June 3, 2024, indicated, . Monitor VITAL SIGNS. Notify MD of significant abnormalities.Monitor/document/report PRN (as needed) for any s/sx (signs or symptoms) of renal insufficiency.The History and Physical Examination, dated February 20, 2025, indicated Resident 7 did not have the capacity to understand and make decisions.The physician's order, dated May 15, 2025, indicated, .Dialysis: Monitor for post dialysis treatment symptoms. Hypotension (low blood pressure), dizziness, nausea, vomiting, fatigue, fever, headache muscle weakness or cramps, itching, diarrhea or hypertension (high blood pressure), any symptoms Notify MD (medical doctor).There was no documented evidence Resident 7 was monitored for post dialysis treatment symptoms such as hypotension, dizziness, nausea, vomiting, fatigue, fever, headache, muscle weakness or cramps, itching, diarrhea and hypertension when she returned from the dialysis appointment on July 21, 2025.The Progress Notes, dated July 21, 2025, at 8 a.m., indicated, .was picked up at this time by (name of transport company) for dialysis this morning. There was no documented evidence that Resident 7 came back from dialysis.The document titled, HEMODIALYSIS COMMUNICATION RECORD, dated July 21, 2025, indicated Resident 7's vital signs prior to going for dialysis treatment. The lower portion of the document where vital signs and status of the resident post dialysis treatment should be documented was blank.The document titled, Blood Pressure Summary, indicated Resident 7 had the following blood pressure (BP):- On July 21, 2025, at 6:34 p.m., blood pressure was 104/50 mmHg (millimeters of mercury - unit of measurement); and- On July 21, 2025, at 6:34 p.m., warning was triggered for Diastolic (bottom number of blood pressure reading) Low of 60 exceededThere was no documented evidence Resident 7's post dialysis treatment BP reading of 104/50 was referred to the physician. In addition, there was no documented evidence Resident 7 was monitored and assessed for the low blood pressure reading after it was identified on July 21, 2025, at 6:34 p.m.On July 23, 2025, at 3:32 p.m., a concurrent interview and record review was conducted with the Director of Nursing (DON). The DON stated the following regarding the facility's process when a resident would go out for dialysis treatment:- A binder would be sent with the resident which includes the pre/post dialysis communication record (Hemodialysis Communication Record) and the licensed nurse to complete the pre dialysis information;- The receiving licensed nurse must take vital signs and ensure the dialysis communication record was filled out by the dialysis center staff when the resident comes back from dialysis; and- The receiving licensed nurse should write a progress note and monitor the resident for post dialysis treatment symptoms.The DON stated Resident 7's Hemodialysis Communication Record, was not filled out by the receiving LVN and the LVN did not write a progress note on July 21, 2025, when Resident 7 came back from dialysis treatment. The DON stated Resident 7's blood pressure reading of 104/50, on July 21, 2025, at 6:34 p.m., was considered an abnormal value and it should have been reported to the physician. The DON stated there was no documentation that this was done. The DON further stated a low blood pressure reading that was not reported to the physician in a timely manner could cause a delay in treatment for the resident.The DON stated there was no documented evidence Resident 7 was monitored for post dialysis treatment symptoms such as hypotension, dizziness, nausea, vomiting, fatigue, fever, headache, muscle weakness or cramps, itching, diarrhea and hypertension when she returned from the dialysis appointment on July 21, 2025. The DON stated these post dialysis treatment monitoring should have been done by the licensed nurse.A review of the facility's policy and procedure titled, End-Stage Renal Disease, Care of a Resident with, dated September 2010, indicated, .Residents with end-stage renal disease (ESRD) will be cared for according to currently recognized standards of care.Staff caring for resident with ESRD, including residents receiving dialysis care outside the facility, shall be trained in the care and special needs of these residents.Education and training of staff includes.the type of assessment data that is to be gathered about the resident's condition on a daily or per shift basis.signs and symptoms of worsening condition and/or complications of ESRD.

Based on interview and record review, the facility failed to ensure residents were free from unnecessary medications for one of five residents (Resident 69), when the nursing staff failed to clarify Resident 69's physician's order for lidocaine (medication for pain) 4% (percent, a unit of measurement for concentration) transdermal (topical) patches that directed application twice daily and failed to apply and remove the patch in accordance with both the physician's order and the manufacturer's instructions.This deficient practice had the potential to result in ineffective pain management, medication administration errors and compromised treatment outcomes as well as excessive lidocaine exposure and avoidable side effects such as skin irritation.Findings:On July 23, 2025, during a review of Resident 69's medical record, the admission Record indicated Resident was admitted to the facility on [DATE], with diagnoses which included dementia (loss of memory), major depressive disorder (depression), anxiety, osteoporosis (bones become weak and likely to break), osteoarthritis (tissues in the joint break down over time), difficulty in walking, and history of falling.A review of Resident 69's physician's order, dated June 28, 2025, indicated lidocaine 4% patch, with directions to apply to lower back topically two times a day for pain. Apply on lower back at 9 a.m. for 12 hrs (hours) and off at 2100 (9 p.m.) for 12 hours.A review of Resident 69's Medication Administration Record (MAR), dated June 2025 and July 2025, the MAR indicated nursing staff removed the lidocaine 4% patch at 9 a.m. on the following dates:- June 30, 2025;- July 1, 4, 8, and 22, 2025.A review of Resident 69's MAR, dated June 2025 and July 2025, the MAR indicated nursing staff applied the lidocaine 4% patch at 9 p.m. on the following dates:- June 27, 2025;- July 2, 5, 6, 14, 15, 16, 17, 18, and 20, 2025.During a review of Resident 69's MAR, dated July 2025, the MAR indicated the lidocaine 4% patch was applied to Resident 69 twice a day at 9 a.m. and 9 p.m. on the following dates:- July 2, 5, 6, 14, 15, 16, 17, 18, and 20. 2025On July 24, 2025, at 3:40 p.m., during a review of Resident 69's medical record with the Director of Nursing (DON), Resident 69's physician's order and the MAR were reviewed. The DON confirmed the findings and stated the lidocaine 4% patch should have been administered once daily, applied at 9 a.m. and removed at 9 p.m., as ordered by the physician. The DON acknowledged nursing staff should have clarified the frequency of the order with the physician and followed the correct application and removal times.A review of the facility's policy and procedure titled, Administering Medications dated April 2019, indicated, .Medications are administered in accordance with prescriber orders.If a dosage is believed to be inappropriate or excessive for a resident, or a medication has been identified as having potential adverse consequences for the resident or is suspected of being associated with adverse consequences, the person preparing or administering the medication will contact the prescriber, the resident's Attending Physician or the facility's Medical Director to discuss the concerns.A review of a nationally recognized drug information resource from Micromedex, dated on July 23, 2025, the resource indicated, .Lidocaine.Dosing/Administration.(Patch 4%) Apply 1 patch topically to affected area up to 12 hours.

Based on interview and record review, the facility failed to ensure, for one of three resident (Resident 1) was free from misappropriation of property when the Social Service Designee (SSD) used Resident 1's bank card to purchase items for her personal use, without consent from Resident 1. This failure had the potential to affect Resident 1's psychosocial wellbeing. Findings:On June 19, 2025, at 1:45 p.m., an unannounced visit was conducted at the facility to conduct two complaints and one Facility Reported Incident regarding allegation of abuse.On June 19, 2025, at 2 p.m., during an interview with the Director of Nursing (DON) and the ADM (Administrator), the DON stated the following information gathered through their investigation:-A Certified Nursing Assistant (CNA) notified him that Resident 1 had a concern regarding his Social Security Income (SSI);-Resident 1 reported he checked his bank account and noticed that there was not much money as he expected to be in there;-Resident 1 informed the SSD about the charges indicated in the bank statements were not authorized by the resident;-The SSD admitted to Resident 1 that she purchased those items through the resident's account and she owed the resident about $2300 and the SSD made a deal with Resident 1 about how to pay the amount she owed; and-Resident 1 indicated the SSD had paid him about $900 and would pay the balance by June 25, 2025.The ADM and the DON stated they were not aware for about two weeks from the time the SSD identified the problem until Resident 1 reported it to the CNA. The DON stated the SSD should have set up individual account for the resident if the resident wanted to order online and not through the staff account. On June 19, 2025, at 4:20 p.m., during an interview with Resident 1, Resident 1 stated he had an account with direct express and saw the balance was too low, about $1000 short. Resident 1 stated he requested bank statements from January 2025 to May 2025, and he opened them in front of the SSD, and the SSD confirmed with Resident 1 that she made the purchases/charges, apologized to the resident, and agreed to pay the resident. Resident 1 stated he asked the SSD why she did it and the SSD responded to him I need it.On June 19, 2025, Resident 1's record was reviewed. Resident 1 was admitted to the facility on [DATE], with diagnoses which included hemiplegia (weakness) and depression (mood disorder). A review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated March 9, 2025, indicated Resident 1 had a BIMS (Brief Interview of Mental Status) score of 13 (cognitively intact).A review of Resident 1's Progress Notes, dated June 13, 2025, at 4:04 p.m., indicated, .Informed (name of physician) that resident verbalized that one of the staff conducted unauthorized transaction of his debit card. MD (medical doctor) ordered to monitor resident for emotional distress and do psychiatrist/psychological consult .A review of Resident 1's IDT (Interdisciplinary Team - a group of healthcare professionals), dated June 16, 2025, indicated, .IDT met with the resident in the conference room in regards to the allegedly unauthorized transaction on his debit card of one of the facility staff, resident verbalized to one of the staff on 6/13/25 (June 13, 2025) that he notice deduction on his debit card and he confronted the allegedly staff member about it. Initial investigation was conducted on that day .staff assisted Resident contacting the bank to suspend current debit card and replacement card was requested .During the IDT meeting, resident verbalized that she (sic) told the social service designee of discrepancy of his billing at around Month of May. The social service designee assisted her (sic) to get bank statement. Upon receiving the bank statement, when he reviewed it, he notice unauthorized transaction on his statement. when he told the social service designee about it, she hastily admitted that this is her transaction .she told the resident that she need it. they compromise of settling the total amount that was deducted on his card on a (sic) installment basis. The approximation of the amount at 2300 dollar. IDT ask the resident why he did not report it to the upper management his respond is he want to see if the social service designee will go through with it. he feel hurt and betrayed but resident said he understand the financial predicament of the social service designee and his (sic) not blaming her for that .Resident verbalized that he don't (do not) even want to file legal proceeding to the social service as long as the money is returned back to him .At this time resident feel secured and dont (do not) have any emotional distress of what happen .A review of the facility's policy and procedure titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, dated April 2021, indicated, .Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation Protect residents from abuse, neglect, exploitation or misappropriation of property by anyone including .facility staff .

Based on observation, interview, and record review, the facility failed to ensure the ice machine and its components were properly cleaned and sanitized, for 87 of 90 residents who received ice from the the facility's ice machine. This failure had the potential to result in contamination of the ice being served to all residents and could lead to waterborne illness. Findings: On April 18, 2025, at 9:45 a.m., an unannounced visit was conducted at the facility, for the investigation of a complaint regarding dietary services. On April 18, 2025, at 10:15 a.m., an observation and inspection of the facility's Food Service's ice machine was conducted. A dry and clean paper towels were swiped along the top inside bin of the ice machine. The paper towels were noted to have multiple black and brown flakes present on them. The outside, top and sides of the ice machine, were noted to have a layer of dust, brown stain marks, and various pest legs, accumulating on the equipment. A dry clean paper towel was run along the top and sides of the ice machine, to collect the observed items. Also observed was water leaking from the plastic pipes, the runoff from the ice machine, spilling onto the floor, further dust accumulation noted on the top of the hardware used to hold the water filters in place, for the ice machine, no dates were indicated when the water filters had been replaced. On April 18, 2025, at 10:20 a.m., an observation and concurrent interview was conducted with the Dietary Supervisor (DS). The DS observed the paper towels used on the inside and outside of the ice machine. The DS stated there should not be any type of brown or black flakes, in the ice machine. The DS stated the inside of the ice machine was cleaned monthly by our kitchen staff. The DS stated there should not be dust, dirt, or pests on the ice machine or around it, all surfaces should be cleaned. The DS stated the outside of the ice machine should be wiped down weekly or more often if needed. The DS stated the water runoff should not be leaking onto the floor, it should be going into a drain. The DS stated she does not know the last time the ice machine was serviced. On April 18, 2025, at 10:30 a.m., an observation and concurrent interview were conducted with the Director of Nursing. The DON entered the kitchen area, observed items on the paper towels from the ice machine, and surrounding area and stated there should not be any black or brown substance inside of the ice machine, it could fall onto the ice and contaminate it. The DON stated there should not be dust or pests on any of the kitchen equipment, and the water should not be spilling onto floor, this is a safety issue and could cause an injury. The DON pushed the plastic pipes with his foot and moved them, and the water was dripping into the drain and not onto the floor. The DON stated the pipes should be secured in place, to ensure the water was draining properly. On April 18, 2025, at 10:50 a.m., an interview was conducted with the DS. The DS stated she did not know how often the water filters are being changed, they were not dated, the maintenance department usually takes care of that, and the ice machine had been serviced this year. The DS stated she will have to check with maintenance when the water filters were last changed. On April 18, 2025, at 12:50 p.m., an interview was conducted with the maintenance supervisor (MS). The MS stated the kitchen staff clean the ice machine every month and the ice machine was serviced by an outside company twice a year. The MS stated the outside company cleans the machine, replaces parts, and if needed will come out in between for maintenance. The MS stated it was serviced in January 2025 and there were no issues with the ice machine at that time. The MS stated the water filter for the ice machine were being changed every six (6) months per manufacturer's recommendations, he changes out the water filters himself, he does not date the filters, the filters have a button on them, to push and it will tell you how long it has been in use, he forgot to push the button on the current filter being used at [NAME] a monthly basis, a pest control company will inspect and service the Food & (and) Nutrition Services Department .is time. The MS stated the kitchen staff should be wiping down the ice machine and the areas around it daily. On April 18, 2025, at 4:50 p.m., an interview was conducted with the DON. The DON stated he inspected the ice machine, and the black/brown flecks are from the rubber aligning the ice dispenser, it is cracking and breaking down. The DON stated he would not want any rubber particles in his ice, it will need to be replaced, and it could affect the residents. A review of the facility's policy and procedure titled Ice Machine Cleaning Procedures, dated 2023, indicated, the ice machine needs to be cleaned and sanitized monthly. The internal components cleaned monthly or per manufacturer's recommendations .The maintenance supervisor can keep this record or .on the ice machine .be sure special attention is paid to cleaning the door molding . A review of the Manufacturer's Recommendations for the Ice Pro 800, water treatment system, indicated, .cartridge change out monitor label. Press the bubble firmly on the 'service filter' label to activate the 6 month timer .cartridge should be replaced every 6 months or when scale begins to form in the treated equipment . A review of the facility's policy and procedure titled Sanitation, dated 2023, indicated, .all equipment shall be maintained as necessary and kept in working order .each employee shall know how to operate and clean all equipment in his specific work area .the FNS (Food and Nutrition Services) director will write the cleaning schedule .on a monthly basis, a pest control company will inspect and service the Food & Nutrition Services Department .all .equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seam, cracks, and chipped areas .Ice which is used in connection with food and drink shall be from a sanitary source and shall be handled and dispensed in a sanitary manner .the kitchen staff is responsible for all cleaning . A review of the facility's document titled Pest Control, dated 2010, indicated, .common kitchen pests .cockroaches .carry and transmit disease, including salmonella, dysentery and diarrhea .ants .transport filth and waste .often enter facilities in search of water .deprive pests of food, water and shelter by following good cleaning procedures .

Based on observation, interview, and record review, the facility failed to ensure devices used for the residents, were sanitary, clean, and disinfected properly, when: 1. The pill crusher was observed with brown sticky substance, for 15 of 27 residents which required medications to be crushed; and 2. The stand lift machine (a non-electric standing aid designed to assist seniors in safely rising from a seated position in chairs, couches, or recliners) was observed to be dirty, for one of one resident who uses the stand lift machine. These failures had the potential to result in the residents being exposed to unsanitary shared devices which could lead to spread of infections. Findings: On April 18, 2025, at 9:45 a.m., an unannounced visit was conducted at the facility for the investigation of a complaint. On April 18, 2025, at 11:10 a.m., an observation of Nurse Station 3 (three) and hallway 300 was conducted. The Medication Cart 3 (three) was noted to have a pill crusher on top of the cart and was coated in a brown, semi soft, sticky substance, covering the area the pills were being placed inside to crush. The EZ-Up (brand of stand lift machine) transfer lifting equipment was observed to have crumbs, as well as white and beige colored flakes on the bottom of the device, where the resident's feet were being placed to stand up. On April 18, 2025, at 11:30 a.m., an observation and concurrent interview was conducted with the Licensed Vocational Nurse (LVN). The LVN looked at the EZ-Up transfer lifting equipment, the white flakes on the bottom portion where the resident's feet are to be supported looked like food crumbs, as well as feet flakes (flaky skin from the feet sheds off due to dry skin, fungal infections, and skin conditions). The LVN stated the EZ-UP were to be cleanse by the maintenance department. The LVN stated she would not want to be standing on the piece of equipment barefoot, it looked dirty, it needed to be cleaned. The LVN looked at the pill crusher and stated it might be apple sauce on the pill crusher, not sure, but has not been wiped down, it should be cleaned, and it needed to be cleaned before using the item. The LVN stated whatever the brown stuff was on the pill crusher could get on your hands or gloves, it's gross, it should not be used for the residents for infection control reasons. On April 18, 2025, at 11:40 a.m., an observation and concurrent interview was conducted with the Administrator (Admin). The Admin walked over to station 3 (three), observed the EZ-Up transfer lifting equipment and the pill crusher. The Admin stated the pill crusher should be cleaned down by the nurses, and the EZ-Up transfer equipment should be cleaned by housekeeping. The Admin stated we should know who would be responsible in cleaning the equipment between uses, and it should not be left sitting in the hallway without being cleaned. A review of the facility's policy titled Cleaning and Disinfection of Environmental Surfaces, dated August 2019, indicated, .Environmental surfaces will be cleaned and disinfected according to current CDC (Centers Disease Control and Prevention) recommendations for disinfection .levels of sterilization/disinfection necessary for items used in resident care and those in the resident's environment .non-critical environmental surfaces .decontaminate where they are used .will be disinfected with an .intermediate or low-level hospital disinfectant .spills of blood and other potentially infectious materials will promptly be cleaned and decontaminated . A review of the facility's policy titled Infection Prevention and Control Program, dated October 2018, indicated, .An infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections .the program is based on accepted national infection prevention and control standards .is a facility-wide effort involving all disciplines and individuals .

Based on observation, interview, and record review, the facility failed to provide a safe and functional environment, for two of two residents who independently uses the smoking patio (Resident A and Resident B), when the fire door closed was dismantled. In addition, the ceiling above the fire door closer was observed to have water damage. These failures had the potential to cause injury to Residents A and B while entering or exiting through the fire door. In addition, the stained ceiling had the potential for it to collapse and could injure residents and staff. Findings: On April 18, 2025, at 9:45 a.m., an unannounced visit was conducted at the facility for the investigation of a complaint. On April 18, 2025, at 11:50 a.m., an observation and concurrent interview was conducted with Resident A. Resident A was observed to wheel himself to the smoking area. Resident A was observed to go outside through the exit door, at the end of hallway 100. The fire door closer was observed to be dismantled, and the door did not close properly. Resident A was observed to push on the bar inside of the door with his left hand, at the same time lifted up on the outside door handle with his right hand while pulling up the door to close it, and moved his left hand out of the door before it closed on his fingers. In a concurrent interview with Resident A, he stated they do this all the time and they have not got their hands caught yet. On April 18, 2025, at 12:50 p.m., an observation and concurrent interview was conducted with the Maintenance Supervisor (MS). The MS observed the fire door at the back of hallway 100, the door closer hinge was noted to be dismantled. The MS stated he dismantled the closer to keep the door from slamming shut on any of the residents going outside to smoke on the patio. The MS demonstrated by opening the fire door and as the door closed, it would catch on the concrete and not close completely. The MS stated he need to reattach the mechanism to have the fire door close properly again, it is not safe, if there is a fire and it does not close correctly it can potentially harm the residents. The ceiling tile above the fire door exit sign was observed to have dark brown stain, was splitting, and deteriorating. The MS stated he had not noticed the ceiling tile looking like that. The MS stated there might have a leak as there was plumbing above the ceiling. The MS stated one of the pipes might need repair and the ceiling tile needed to be changed to prevent from it breaking and could fall on one of the residents, it is not safe. On April 18, 2025, a review of Resident A's medical record was conducted. Resident A was admitted to the facility on [DATE], with diagnoses which included paraplegia (a type of paralysis that affects the lower half of the body, resulting in the inability to move the feet, legs, and sometimes to abdomen), and Diabetes Mellitus (high levels of sugar in the blood). A review of Resident A's care plan, dated June 8, 2023, indicated, .Resident A is alert and oriented, he may go outside to the patio to smoke . On April 18, 2025, at 3:20 p.m., an observation and concurrent interview was conducted with Resident B. Resident B was observed out on the smoking patio, he went to close the fire door by pushing the inside bar with his left hand, while lifting up on the outside door handle, and pushing the door closed, and almost getting his fingers pinched in the door. Resident B stated it was the only way to close it as it would not close on its own. On April 18, 2025, a review of Resident B's medical record was conducted. Resident B was admitted to the facility on [DATE], with diagnoses which included cirrhosis of the liver (liver damage from different causes leading to scarring and liver failure) and ascites (excess abdominal fluid, swelling caused by an accumulation of fluid, related to liver disease). A review of Resident B's care plan, dated October 2, 2024, indicated, .A smoker with potential for smoking-related injuries, interventions included: resident may smoke with supervision, will use protective clothing (smoking apron) for safety . A review of the facility's policy titled Smoking Policy Residents, dated October 2023, indicated, .This facility has established and maintains safe resident and smoking practices .ability to smoke safely with or without supervision .Any smoking-related privileges, restrictions, and concerns .are noted on the care plan . A review of the facility's policy titled Fire and Smoke Barrier Doors, dated 2023, indicated, .Fire and smoke barrier doors are strategically located throughout the facility and such doors remain operable at all times .This facility has automatic fire and smoke barrier doors to contain fire and smoke .Fire and smoke barrier doors are not to be .held open by any means other than the automatic holding device built into the door .Staff are to report fire and smoke doors that are partially open or do not close properly .to the maintenance supervisor. Staff shall also notify the safety coordinator .

Based on observation, interview, and record review, the facility failed to implement the system of identifying and monitoring fall risk residents for one of three sampled residents (Resident 1). This failure has the potential for the staff not to provide interventions to residents, resulting to recurrent falls. Findings: On August 12, 2024, at 9:30 a.m., during observation with Resident 1 sitting in a wheelchair in the activity room. He was observed wearing a neck brace (neck support), with black purplish discoloration on the right periorbital (surrounding the eye) area and a band aid on the right eyebrow. Resident 1 ' s record was reviewed. Resident 1 was admitted to facility on July 7, 2024, with diagnoses which included muscle weakness, difficulty in walking, dementia (forgetful). A review of the History and Physical Examination, dated July 9, 2024, indicated, Resident 1 did not have the capacity to understand and make decisions. A review of the Fall Risk Assessment, dated July 7, 2024, indicated a score of 70 (score of 45 and higher indicates resident as high risk for fall) .High Risk for Falling . A review of the care plan, dated July 8, 2024, indicated, .resident is at risk for falls due to weakness .impaired balance .anticipate needs and meet resident ' s needs .follow facility fall protocol . A review of the Minimum Data Set (MDS- an assessment tool), dated August 4, 2024, indicated Resident 1 required maximal assistance on sit to stand, chair/bed to chair transfer. The MDS indicated Resident 1 needed some help in mobility. On August 12, 2024, at 10:25 a.m., an interview was conducted with the Activity Director (AD). The AD stated Resident 1 fell and hit his face to the ground while he was in the activity room. She further stated, activity staff did not identify Resident 1 as a high risk for fall. On August 12, 2024, at 10:51 a.m., a concurrent interview and record interview was conducted with Licensed Vocational Nurse (LVN 1) in nurse's station 3. LVN 1 stated she was not able to identify residents who were considered high risk to fall. She further stated there was no lists of documents for them to use as a tool for communication to all staff. On August 12, 2024, at 11:25 a.m., a concurrent interview and record review was conducted with the Registered Nurse Supervisor (RN 1). She stated there was no updated and no files of lists of residents with high risks for fall for nurses ' station 1, 2, and 3. She further stated the listed summary of residents ' high risk for fall should had been use as a tool to communicate to nursing and non-nursing personnel to enhanced awareness of fall. On August 12, 2024, at 11:45 a.m., an interview was conducted with the Director of Nursing (DON). He stated that his expectation to nursing staff was to have an everyday master list of residents of high risks to fall, give copy to non-nursing staff such as activity department, and could focus on residents who may fall. The DON further stated fall prevention policy should had been followed to prevent potential repeated fall. On August 12, 2024, at 12:41 p.m., an interview was conducted with the Activity Assistant (AA). He stated he was conducting bingo activity in the dining room with residents and did not know that Resident 1 was high risk for fall. The AA further stated if Resident 1 had an identifier or listed as high risks for fall, he will put Resident 1 beside him and will look after him. A review of facility policy and procedure titled, Fall Risks Assessment, dated March 2028, indicated, .The nursing staff, in conjunction with attending physician .therapy staff and others, will seek to identify and document risk factors for falls and establish a resident resident-centered falls prevention plan based on relevant assessment information .

Based on interview and record review, the facility failed to ensure a consistent and accurate reconciliation of controlled medications (drugs or medications that possess the potential for being misused) for two sampled residents (Resident 1 and Resident 2). This failure resulted in loss of medications and the potential for Resident 1 and Resident 2 to experience preventable suffering and inadequate pain management. In addition, this failure increased the risk for drug diversion (unauthorized/illicit use). Findings: A review of Resident 1 ' s clinical records, the face sheet (contains demographic information) indicated Resident 1 was admitted to the facility on [DATE], with diagnoses which included acute respiratory failure with hypoxia, difficulty walking, and idiopathic peripheral neuropathy. A review of Resident 1 ' s physician ' s orders, dated February 1, 2024, indicated a physician order for, Norco 5/325 mg (Hydrocodone acetaminophen) 1 tablet by mouth every 6 hours as needed for moderate to severe pain. A review of Resident 2 ' s clinical records, the face sheet (contains demographic information) indicated Resident 2 was admitted to the facility on [DATE], with diagnoses that Osteoarthritis (breakdown of joint tissues) and age-related Osteoporosis (weak and brittle bones). A review of Resident 2 ' s physician ' s orders, dated February 14, 2024, the following medication were ordered: Tramadol HCL Oral tablet 50 mg (Tramadol HCL) give 1 tablet by mouth every 8 hours for pain management. On August 12, 2024, at 3:35 PM, during an interview, LVN 2 stated on August 6, 2024, after receiving a call from the pharmacy, she realized that the second bubble pack that contained 30 Norco tablets and the narcotic count sheet that came along with it, was missing. On August 12, 2024, at 4:40 PM, during an interview, LVN 4 stated she does not accept the cart key completely until everything is ok. LVN 4 stated the nurse that she would be relieving, and the witness nurse would count the bubble pack, count the medication, and would make sure current number matches the count sheet and the bubble pack. LVN 4 stated the narcotics with multiple bubble packs would indicate in the bubble pack and the count sheet, 1 out of 3 cards 2 out of 3 cards, 3 out of 3 cards, that is how the nurse would know if a bubble pack and count sheet are missing. On August 12, 2024, at 4:53 PM, during an interview with the Director of Nursing (DON), the DON stated, the Norco bubble pack with 30 tablets and the paper count sheet were reported missing the afternoon of August 6, 2024. He started his investigation right away and could not find the Norco bubble pack that contained 30 tablets. In addition, the DON stated, while investigating he noticed Resident 2 ' s Tramadol q 8 hour, were missing two bubble packs of 30 tablets each, (total of 60 tablets) along with the two narcotic count sheets. On August 12, 2024, at 5:28 p.m. during an interview, LVN 5 stated, she has been working full time at the facility. She stated she would not accept the key for the cart until everything matches. LVN 5 stated the pharmacy would write on the buble pack, 1 out of 3, 2 out of 3. She stated the count sheet would indicate, 30 of 90 and 60 of 90, while pointing at the bubble pack and the count sheet. A review of the facility ' s Charge Nurse job position, Medication Administration Functions., dated October 2020, indicated, .Review the controlled substance and drug disposal records for accuracy and notify the Director of Nursing and pharmacy of discrepancies ' . A review of the facility ' s policy and procedure titled, Controlled Substances, dated April 2019 indicated, .controlled substances are reconciled upon receipt, administration, disposition and at the end of the shift .controlled medications are counted at the end of each shift. The nurse coming on duty and the nurse going off duty determine the count together .

Based on interview and record review, for three of eight residents reviewed for Advance Directive (AD - written instruction related to the provision of health care when the resident is no longer able to make decisions), the facility failed to ensure: 1. For Resident 38 and 76, a copy of their formulated AD was available for review in the resident's medical records. This failure had the potential for Residents 38 and 76's treatment wishes to not be honored; and 2. For Resident 37, the POLST (Physician Orders for Life-Sustaining Treatment - a portable medical order form that records the resident's treatment wishes for emergency personnel reference) was completed by the resident's representative to indicate the resident's care treatment. This failure had the potential for the facility staff to be not aware of Resident 37's treatment wishes and unable to implement the plan of care for the resident's medical condition. Findings: 1a. On June 27, 2024, Resident 38's record was reviewed. Resident 38 was admitted on [DATE], with diagnoses which included atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow) and malignant neoplasm of esophagus (cancer of the throat). A review of Resident 38's Minimum Data Set (MDS - an assessment tool), dated March 13, 2024, indicated a BIMS (Brief Interview of Mental Status) score of 12 (cognitively intact). Further review of Resident 38's record indicated there was no AD Acknowledgement Form completed by the resident to indicate if the resident had a formulated AD or wish to formulate an AD. On June 28, 2024, at 9:25 a.m., an interview was conducted with the Social Service Director(SSD). The SSD stated Resident 38 did not have an AD Acknowledgement Form but had a formulated AD which Resident 38's family/POA (Power of Attorney) had provided the facility in January 2024. The SSD stated she could not find the copy of the formulated AD in Resident 38's record. The SSD stated a copy of Resident 38's formulated AD should be in the resident's medical record to ensure the resident's treatment wishes should be the same as the signed POLST. 1b. On June 27, 2024, Resident 76's record was reviewed. Resident 76 was admitted to the facility on [DATE], with diagnoses which included cerebral infarction (stroke) and sickle cell disease (a group of disorders that cause red blood cells to become misshapen and break down). A review of Resident 76's MDS, dated [DATE], indicated a BIMS score of 13 (cognitively intact). A review of Resident 76's undated Advance Directive Acknowledgement, indicated the resident formulated an AD. Further review of Resident 76's record did not indicate a copy of the resident's formulated AD was available in Resident 76's record for review. On June 27, 2024, at 4:25 p.m., a concurrent interview and record review was conducted with the SSD. She stated Resident 76's formulated AD was not available in the resident's medical record. She stated Resident 76's formulated AD should be in the resident's medical record easily accessible for review. A review of the facility's policy and procedure titled, Advance Directive, dated September 2022, indicated, .The resident has the right to formulate an advance directive, including the right to accept or refuse medical or surgical treatment. Advance directives are honored in accordance with the state law and facility policy .Prior to or upon admission of a resident, the social services director or designee inquires of the resident, his/her family members and/or his or her legal representative, about the existence of any written advance directives .If the resident or the residents (sic) representative has executed one or more advance directive(s), or executes one upon admission, copies of these documents are obtained and maintained in the same section of the residents (sic) medical record and are readily retrievable by any facility staff . 2. On June 27, 2024, Resident 37's record was reviewed. Resident 37 was admitted to the facility on [DATE], with diagnoses which included respiratory failure (lung failure with difficulty breathing). A review of Resident 37's MDS, dated [DATE], indicated Resident 37 had a BIMS score of 14 (cognitively intact). A review of Resident 37's POLST, indicated Resident 37's representative signed the POLST on June 22, 2024. Resident 37's signed POLST did not indicate the resident's treatment wishes the staff should follow in case of an emergency. On June 27, 2024, at 10:45 a.m., an concurrent interview and record review was conducted with the SSD. The SSD stated the Resident 37's POLST should have been completed by the resident representative to indicate what treatment wishes the resident wanted in case of an emergency. A review of the facility's undated policy titled, Physician Order for Life Sustaining Treatment (POLST), indicated, .The POLST form should be executed as part of the health care planning process .Completion of a POLST form should reflect a process of careful decision making by the resident, or if the resident lacks decision making capacity the resident's legally recognized health care decision maker .If a resident who has decision making capacity, or the legally recognized health care decision maker wishes to complete a POLST form during the resident's stay, they shouold discuss the POLST form with the physician and/or the resident then complete and sign .

Based on observation, interview, and record review, the facility failed to prepare, serve and distribute residents' food under sanitary conditions when: 1. The kitchen floor and all surfaces near and around and under three of three stoves/ovens (where resident food is cooked) was noted with approximately one to one and one half inch buildup of grease, grime, dust, trash, food crumbs, living roaches and three roach traps containing dead roaches. 2. Two staff working in the kitchen were unable to confirm proper sanitizing chemical levels in three of three red kitchen sanitizer pails. 3. The entire kitchen floor perimeter had an approximately one to one and a half inch thick build-up of a thick dark sticky substance, food crumbs and trash and all washable kitchen surfaces, such as walls, table legs, storage shelves, plate warmer lids and opening rim, tray carts, and range hoods were noted with a build-up of grime, grease, food splatters and food particles. 4. The table mounted can opener had a build-up of dried food and grime around the cutting blade, on the holder and under the base thick enough to be scratched off with the tip of an ink pen. These failures resulted in an Immediate Jeopardy situation. The Immediate Jeopardy was called on May 11, 2015, at 1:50 p.m., with the Administrator and the survey team present. On May 12, 2015, at 3:15 p.m., with the survey team and the ADM present, the Immediate Jeopardy situation was abated. These failures had the potential to result in food borne illness including nausea, vomiting, weakness, fever, abdominal pain and diarrhea to a medically vulnerable resident population of 79. Findings: 1. During initial observation in the kitchen on May 11, 2015, starting at 8:30 a.m., the kitchen floor and all surfaces near and around and under all three stoves/ovens (where resident food is cooked) was noted with an approximately one to one half inch thick buildup of grease, grime, dust, trash, food crumbs, and three roach traps containing dead roaches. During this initial kitchen observation, live roaches were observed running along the base of the wall near the walk in refrigerator. There was approximately one to one and one half inch accumulation of grease and food particles pooled under the burners of the main cooking stove. The gas and electric lines and the walls next to and behind all cooking areas had an approximately one inch thick layer of grease and spattered food particles with a build-up of fuzzy gray dust stuck to it. The entire kitchen floor perimeter had an approximately one to one and a half inch thick build-up of a thick dark sticky substance, food crumbs and trash and all washable kitchen surfaces, such as walls, table legs, storage shelves, plate warmer lids and opening rim, tray carts, and range hoods were noted with a build-up of grime, grease, food splatters and food particles. Concurrently Cook 1 verified the thick accumulation of grease, dust, food, trash and living and dead roaches around the stoves/ovens stating,That is a live roach running away, those are roaches in roach traps, that's pretty dirty. During a concurrent interview, both the Director of Food Services (DFS) and the Administrator (ADM) confirmed all three stove areas were covered in a very thick, approximately one inch to one and a half inch thick, dark layer of grease, dust, food splatters and food particles. The DFS verified she had not been checking behind the stoves and didn't know it had gotten that dirty. A concurrent review of the kitchen cleaning schedule sheet did not include a sign off space for stoves, ovens, areas behind, around and underneath the cooking areas. A review of the facility policy and procedure for sanitization of food service department dated, 2005, indicated, Policy, The food service staff shall maintain the sanitation of the food service department through compliance with a written, comprehensive cleaning schedule . 5. A cleaning schedule shall be posted weekly for all cleaning tasks, and employees will initial tasks as completed. On May 11, 2015, a review of the Food Safety and Sanitation Checklist completed by the Registered Dietician (RD) on February 25, 2015, indicated,6. Stoves, ovens, grill, range, clean.No.hood is sticky. The review of a second Food Safety and Sanitation Checklist completed by the Registered Dietician on April 29, 2015, indicated she had observed,1. Does the facility appear in sound condition, without filth or contamination?.YES . 24. Are utensils, surfaces, and equipment cleaned and sanitized after each use?.YES . 7. Is the range/oven clean?.YES, and 8. Is the hood professionally cleaned on a routine bases?.YES. The undated facility policy and procedure for Pest Control indicated .All storage and food preparation areas are to be kept clean. This includes walls, floors, shelving, cabinet tops, sinks, equipment, etc. Keep grounds free of trash and brush. Clean up food spills. Use pesticides only after all other channels of control are exhausted. Use pesticides only as a preventive measure and in conjunction with proper mechanical controls. Following the review of the Food Safety and Sanitation Checklists, the ADM was asked to produce the invoices for the last year of professional hood cleaning and he stated, We don't use a company, we clean it ourselves. On May 11, 2015, at 1:50 p.m., following telephone consultation with Health Facilities Evaluator Supervisor (HFES) and California Department of Public Health (CDPH) consulting Registered Dietician, an Immediate Jeopardy situation was called in the presence of the ADM and the CDPH survey team. At approximately 3:00 p.m. on May 11, 2015, the ADM was observed in the kitchen cleaning behind and underneath the grill/stove area using an approximate four inch putty spatula taped to a broom handle to shovel heaping scoops of grease and debris into an already half full five gallon bucket. The maintenance staff was also observed hand cleaning the same area. The degreaser solution half filled a five gallon bucket. The solution in the bucket was black. (solution starts as a white, cloudy appearance) During an interview on May 11, 2015, at 5:45 p.m., the Registered Dietician verified she had not been looking under and behind the stoves/ovens and visually checking all washable surfaces in the kitchen, prior to checking them off as clean. A review of the pest control report dated November 5, 2014, at 9:59 p.m., indicated, Light oriental roach activity noted. This same report also identified the following areas of concern, Insect light trap-(ILT) inoperative. This fly light has been altered and will not attract flies. An incandescent light bulb has been installed in place of florescent bulb. Replace fly light with a newer model. Wall covering loose. Stainless steel wall covering 4 feet above the floor around the entire perimeter of the dishwashing area. Repair loose wall coverings. Insect light trap -inoperative. Plug ILT into electrical outlet or repair as necessary. A review of the pest control report dated May 6, 2015 at 10:00 p.m., indicated, Moderate large roach activity noted. At this visit 16 glue board style roach traps were distributed throughout the facility. A review of the pest control report dated May 12, 2015, at 12:59 a.m., recommended the following repairs to prevent further entry of pests, Insect light trap (ILT)-inoperative. This fly light has been altered and will not attract flies. An incandescent light bulb has been installed in place of florescent bulb. Replace fly light with a newer model. Wall covering loose. Stainless steel wall covering 4 feet above the floor around the entire perimeter of the dishwashing area. Repair loose wall coverings in order to eliminate pest harborage areas. Insect light trap -inoperative. Plug ILT into electrical outlet or repair as necessary. Pipe entry point needs sealing. Outside on exterior West kitchen wall two feet to the right of the sliding window. Seal pipe entry points in order to eliminate pest entry points. Pipe entry point needs sealing- in the food tray staging room behind the ice machine. Seal pipe entry points in order to eliminate pest entry points. Upon request, ADM was unable to produce documentation that the pest control company had continued to inspect the facility from November 5, 2014, through April 9, 2015. On May 12, 2015, at 3:15 p.m., with the survey team and the ADM present, the immediate Jeopardy situation was abated. 2. During initial observation in the kitchen on May 11, 2015, starting at 8:30 a.m., Cook 1 tested three of three red sanitizing pails. After dipping the testing paper into the solution, Cook 1 proceeded to check the wet quaternary ammonia testing paper color against the color comparison chart on the test paper holder noting the color was very light orange indicating the sanitization level at zero. Cook 1 confirmed the level was less than 200 ppm (parts per million describes the concentration of sanitizing solution in water) which is low. Cook 1 then retested the solution using the bleach test paper. The color on the chlorine bleach testing paper was very light blue indicating the level was 10 ppm, which is below the acceptable level of 100 ppm. Cook 1 and Dietary Aide 1 then proceeded to test the solution in the other two sanitizing pails which gave the same unacceptable results of 10 ppm bleach and 0 ppm quaternary ammonia. During concurrent interviews, Cook 1 stated she had not checked the sanitization solution in any of the three pails since starting to work that morning, May 11, 2015, at 4:30 a.m. Dietary aid 1 stated she had not tested any of the three sanitization solution pails since starting to work at 5:30 a.m. that morning, May 11, 2015. On May 11, 2015, a review of the facility policy and procedure dated, 8/09, titled, Cleaning Cloths, indicated, .Wet cloths will be rinsed under running water, and stored in a chemical sanitizer at a concentration of: 200 ppm for quaternary ammonium or 100 ppm for chlorine .Fresh sanitizing solution will be made each day, and the dietary will start each day with clean dry cloths. On May 12, 2015, a review of the kitchen inspection sign off sheet completed by the Registered Dietician (RD) on February 25, 2015, indicated,5. Cleaning cloths are kept in sanitizer bath . not ok .0 sanitizing solution. The review of a second kitchen inspection sign off sheet completed by the Registered Dietician on April 29, 2015, indicated she had observed, cleaning cloths lay over the place. 1 cleaning cloth is lying on hand washing sink, another one is lying on slice machine and another one is lying next to steam table. In a concurrent interview, the Director of Food Services (DFS) confirmed that chlorine bleach was used in the sanitizing pails and the solution should test at 100 ppm and changed each morning and as needed throughout the day. DFS also confirmed there was currently no sign off sheet for checking the sanitizer levels in the sanitization pails and cleaning cloths. A concurrent review of the DFS job description indicated, The primary purpose of your job position is to assist the Dietician in planning, organizing, developing and directing the overall operation of the Food Services Department in accordance with current federal, state and local standards, guidelines and regulations governing our facility, and as may be directed by the Administrator. To assure that quality nutritional services are provided on a daily basis and that the Food Services Department is maintained in a clean, safe, and sanitary manner. 3. During initial observation in the kitchen on May 11, 2015, starting at 8:30 a.m., the entire kitchen floor perimeter was noted with a build-up thick enough to be scrapped off with an ink pen lid, of a thick dark sticky substance, food crumbs and trash. Concurrently all washable kitchen surfaces, such as wall, table legs, storage shelves, plate warmer lids and opening rim, tray carts, and hood were noted with a build-up of grime, grease, food splatters and food particles. During a concurrent interview, Cook 1 verified the unsanitary condition of the kitchen stating, I don't know if anybody had been cleaning for a long time. A concurrent review of the kitchen cleaning schedule sign off sheet indicated the walls had not been signed off as cleaned 16 of the last 16 days reviewed, April 26, 2015, to May 11, 2015. The floors were signed off as cleaned 14 of the last 16 days reviewed April 26, 2015, to May 11, 2015. During a concurrent interview, the Director of Food Services (DFS) confirmed the kitchen was very dirty stating, I know it is dirty, I have hired new staff and we are cleaning it now. I am the one who is to be checking that the cleaning has been done. It has not been done. We will clean it now. A concurrent review of the undated facility cleaning schedule indicated a daily cleaning is required for the following areas: can opener, steam table counter, coffee urn table, food carts, milk refrigerator, washing cards, hand washing sink, maintain condiments, laundry, dish machine, dishwashing counters, spice condiment shelves, cook's refrigerator, preparation table, range. A concurrent review of the DFS job description indicated, The primary purpose of your job position is to assist the Dietician in planning, organizing, developing and directing the overall operation of the Food Services Department in accordance with current federal, state and local standards, guidelines and regulations governing our facility, and as may be directed by the Administrator. To assure that quality nutritional services are provided on a daily basis and that the Food Services Department is maintained in a clean, safe, and sanitary manner. 4. During initial observation in the kitchen on May 11, 2015 starting at 8:30 a.m., a table mounted can opener was noted to have a significant build-up, thick enough to be scrapped off with the tip of an ink pen lid, of dried food and grime around the cutting blade and around and under the base for the can opener. During a concurrent interview, Director of Food Services (DFS) stated that the can opener was not clean. She also stated the can opener should be cleaned after each use and confirmed it had not been cleaned. DFS stated,We will clean it now. A concurrent review of the kitchen cleaning schedule sign off sheet indicated the can opener was last cleaned the previous day, May 10, 2015. On May 12, 2015, at approximately 3:00 p.m., the kitchen table mounted can opener blade and base were again observed with an accumulation of grime and food particles on the blade and under the base. During a concurrent interview, the Administrator (ADM) stated, We just took it apart and cleaned it. Maintenance just put it back together. But I see that it is still dirty. We will clean it again. A concurrent review of the facility document dated,2005 titled, Cleaning Instructions Can Opener, indicated, Can opener will be cleaned after each use . Wash base thoroughly with hot detergent water. Be sure to remove all food particles from blade and base.

2. On May 13, 2015, beginning at 9:20 a.m., the environmental tour was conducted with the Maintenance Supervisor (MS) and Housekeeping Supervisor (HS). Thick cobwebs were observed extensively throughout the exterior. The cobwebs were on the patio covers, at windows and doors, and under the overhang of the roof. In addition, the main dining room was observed to have a fly strip hanging from the ceiling. The MS and HS verified the findings. Based on observation, interview, and record review, the facility failed to ensure an effective pest control program was implemented to eradicate roaches, ants, spiders and pests from the facility from November 5, 2014 through April 9, 2015. This failure had the potential to result in the spread of disease and injury to a medically vulnerable resident population of 85. Findings: 1. During the initial kitchen tour on May 11, 2015, at 8:30 a.m., a cockroach was observed running along the kitchen wall near the walk in refrigerator. Also in the kitchen, under the small prep counter next to the large stove/oven, three glue style insect traps were noted with roaches inside. During a concurrent interview, Cook 1 confirmed the living cockroach stating, That's a cockroach, we see them sometimes. When asked if a pest company comes to treat the kitchen Cook 1 stated, I haven't seen anyone come in a while. During the confidential group interview on May 12, 2015, at 10:00 a.m., four of 11 residents present voiced concerns about the continued sightings of live roaches, ants, and spiders in the living areas. A review of the pest control report dated November 5, 2014, at 9:59 p.m., indicated, Light oriental roach activity noted. This same report also identified the following areas of concern, Insect light trap-inoperative. This fly light has been altered and will not attract flies. An incandescent light bulb has been installed in place of florescent bulb. Replace fly light with a newer model. Wall covering loose. Stainless steel wall covering 4 feet above the floor around the entire perimeter of the dishwashing area. Repair loose wall coverings. Insect light trap -inoperative. Plug ILT into electrical outlet or repair as necessary. A review of the pest control report dated May 6, 2015, at 10:00 p.m., indicated, Moderate large roach activity noted. At this visit 16 glue board style roach traps were distributed throughout the facility. A review of the pest control report dated May 12, 2015, at 12:59 a.m., recommended the following repairs to prevent further entry of pests, Insect light trap-inoperative. This fly light has been altered and will not attract flies. An incandescent light bulb has been installed in place of florescent bulb. Replace fly light with a newer model. Wall covering loose. Stainless steel wall covering 4 feet above the floor around the entire perimeter of the dishwashing area. Repair loose wall coverings in order to eliminate pest harborage areas. Insect light trap -inoperative. Plug ILT into electrical outlet or repair as necessary. Pipe entry point needs sealing. Outside on exterior West kitchen wall two feet to the right of the sliding window. Seal pipe entry points in order to eliminate pest entry points. Pipe entry point needs sealing- in the food tray staging room behind the ice machine. Seal pipe entry points in order to eliminate pest entry points. On May 14, 2015, at 9:00 a.m., an opossum was observed on the roof of the facility climbing down into a bush located on a patio used by residents. The pest inspection company was called and performed an inspection. On May 14, 2015, at approximately 9:45 a.m., during an interview with the pest control worker, he stated he performs the exterior inspections of the facility only. He also stated he was aware that his company had a lapse in service due to lack of payment. On May 11, 2015, at 1:15 p.m., during an interview, the Administrator (ADM) stated he had not maintained a pest control contract since November 2014, due to the facility's bankruptcy situation. ADM stated he and his maintenance crew were, keeping an eye on the bugs and pests, we are taking care of it. When asked, the ADM was not able to provide any documentation to support pest inspection and prevention had been performed by the facility staff. Also, when asked, ADM stated that since November, 2014, none of the pest control company recommended repairs have been started.