Every finding on record at Creekside Healthcare Center

Based on interview and record review, the facility failed to protect one of three sampled residents (Resident 1), Resident 1's right to be free from neglect, when Resident 1 did not receive the ordered treatment and care to maintain good foot health due to failure of staff to follow-up and arrange routine Podiatry (foot specialty) services to Resident 1.These failures resulted in Resident 1:Developing long, severely curved, thick, discolored toenails digging into the adjacent skin for not having podiatry services for almost six months following initial admission that resulted in Resident 1 experiencing prolonged foot pain and discomfort.Potential to result in worsening skin breakdown and/or injury and fungal infection (disease caused by fungi) of toes and/or feet.A review of Resident 1's Face Sheet, undated, indicated Resident 1 was initially admitted to the facility in January 2026 with diagnoses of chronic respiratory failure (a long-term condition of underlying lung damage with persistent shortness of breath [SOB], fatigue, and bluish tint to the skin), acute embolism and thrombosis of left femoral vein (a blood clot formed in or traveled to the large, deep blood vessel in the left thigh blocking normal blood flow), muscle wasting (loss or thinning of muscle mass), atrophy (complete wasting away of a body part, cell, tissue or organ), and a need for assistance with personal care.A review of Resident 1's Minimum Data Set (MDS, a resident assessment tool used to provide care), dated 5/5/26, indicated Resident 1 required supervision or touching assistance (Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently) with personal hygiene and grooming including nail care.A review of Resident 1's Physician Order Report, start date 1/28/26, indicated, Refer to Podiatry services for treatment of hypertrophied toenails (abnormal thickening and/or severely curved nails) and/or other foot problems as needed.A review of Resident 1's Physician Order Report, start date 3/31/26, indicated, MAY HAVE PODIATRY REFERRAL DUE TO (D/T) FUNGAL TOENAILS AND BILATERAL FEET PAIN.A review of Resident 1's Physician Order Report, start date 5/1/26, indicated, NAIL CARE AND BED BATH EVERY SUNDAY Special instructions: TRIM FINGERS AND TOENAILS TODAY.A review of the facility's Residents List for Podiatry Service Referral forms dated 3/31/26, 5/21/26, and 6/11/26, indicated on each of the forms was Resident 1's name listed as one of the residents requested to be seen by the facility's in-house Podiatry Service Provider.During concurrent interview and record review on 7/29/26, at 10:50 a.m., with Social Services Director (SSD), SSD was unable to present any Podiatry Visit Notes from Resident 1's medical records. SSD stated Resident 1 has not been seen by in-house Podiatrist (a doctor specializing in treatment of the foot) since initial admission in January 2026 due to Resident 1's health insurance limited coverage. Further review of Resident 1's clinical record revealed no documentation of an arranged outpatient Podiatry Appointment nor a follow-up with the in-house Podiatrist. During a follow-up interview on 7/29/26, at 12:08 p.m., with the SSD, SSD confirmed it was only until a recent encounter (per SSD, sometime between 7/5/26-7/17/26, when Resident 1 was sent out to the hospital first time since initial admission) with Resident 1's family member (FM) that SSD was prompted to contact and/or refer Resident 1 to the same in-house Podiatry Service Provider. SSD stated, after realizing in-house Podiatrist was not going to see Resident 1 due to health insurance noncoverage, FM 1 agreed to pay out of pocket just to have Resident 1's toenails clipped by a Podiatrist.During a telephone interview on 8/3/26, at 11:33 a.m., with Certified Nursing Assistant 1 (CNA 1), CNA 1 stated Resident 1's toenails were very long, abnormally thick, discolored, severely curved, digging into the adjacent skin and with fungal-like appearance. CNA 1 stated resident toenails, with or without diagnosis of diabetes (high blood sugar), need to be clipped by a Podiatrist because thick toenails could lead to ingrown nails and increased pain. CNA 1 stated Resident 1's toenails had been like this since admission and CNA 1 had not followed up on this because she knew this had been reported in the past to the Charge Nurses and SSD. CNA 1 stated CNA 1 had not seen a Podiatrist visit Resident 1 on any of the days CNA 1 worked at the facility. During a telephone interview on 8/6/26, at 3:25 p.m., with FM 1, FM 1 stated Resident 1's toenails were extremely long, thick, discolored, severely curved, and going into Resident 1's feet. FM 1 stated she raised this concern to the Physician and the nurses on multiple occasions. FM 1 further stated Resident 1 suffered from prolonged foot pain and discomfort due to absence of podiatry services since Resident 1's initial admission to the facility in January of 2026.A review of the facility's policy and procedure (P&P) titled, Abuse and Neglect Prohibition, revision date May 2013, indicated, Each resident has the right to be free from mistreatment, neglect, abuse.Neglect means failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness.A review of the facility's P&P titled, Abuse and Neglect Prohibition California Facility Addendum, released date 7/1/2017, indicated, .Neglect means.failure to assist in personal hygiene.failure to provide medical care for physical and mental health needs.A review of the facility's document titled, SOCIAL SERVICES DIRECTOR - HOURLY, undated, indicated, .ESSENTIAL DUTIES AND RESPONSIBILITIES include the following.Implements social service interventions that achieve treatment goals, address resident needs, link social supports, physical care and physical environment to enhance quality of life.A review of the facility's P&P titled, Podiatry Services, undated, indicated, It is the policy of this facility to provide timely, appropriate, and high-quality podiatric services to all residents in need, in accordance with federal and state regulations, as well as best practice guidelines.The primary goal is to ensure residents receive comprehensive foot care aimed at preventing, identifying, and treating foot-related conditions, thereby promoting mobility, comfort, and overall health.Residents identified as at risk or presenting with podiatric concerns will be referred to a facility-approved podiatrist for evaluation.Podiatry services will be scheduled regularly (e.g., every 61 days routinely or as clinically indicated), or on an as-needed basis for acute issues.Effective communication will be maintained among the podiatrist, nursing staff, primary care providers, residents, and resident representative regarding podiatric findings, interventions, and ongoing care needs.Podiatrist will provide written or electronic progress notes for each encounter, which will be integrated into the resident's health record.A review of the facility's P&P titled, Activities of Daily Living (ADLs), Supporting, undated, indicated, .Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. hygiene (bathing, dressing, grooming, and oral care.Use STOP AND WATCH form (an early warning communication tool used by caregivers to spot and report early signs of physical or behavioral decline in a resident) for any change of condition observation.

Based on interview and record review, for one of three sampled residents (Resident 1), the facility failed to ensure Family Member 1 (FM 1) was informed of Resident 1's change of condition (COC, any sudden or gradual shift in a patient's physical, mental, or behavioral, or functional decline) on a timely manner. This failure resulted in FM 1 not being notified timely of Resident 1's change in health status and new physician order, placing Resident 1 at risk for delayed medical decisions, lack of advocacy, unmet care needs, and compromised health and safety. A review of Resident 1's Face Sheet, undated, indicated Resident 1 was initially admitted to the facility in January 2026 with diagnoses of chronic respiratory failure (a long-term condition of underlying lung damage with persistent shortness of breath [SOB], fatigue, and bluish tint to the skin), presence of tracheostomy (artificial opening in the airway to facilitate breathing), depression, and anxiety disorder. Further review of the Face Sheet indicated Resident 1 was his own responsible party (RP) and emergency contact call order showed, FM 1 as first contact, FM 2 as second contact, and Resident 1 himself listed as contact number 3. A review of Resident 1's Minimum Data Set (MDS, a resident assessment tool used to provide care), dated 5/5/26, indicated Resident 1's Brief Interview of Mental Status (BIMS, an assessment tool for a resident's orientation to time, and capacity to remember. The BIMS score ranges from 0-15, with 15 as an indication of intact skills) score was 15. 1. A review of Resident 1's Situation Background Appearance Review and Notify (SBAR, a communication tool used to transfer critical patient information between members of the team), dated 6/27/26, authored by Registered Nurse 1 (RN 1), indicated antibiotic for Pneumonia (inflammation of the lungs). Documented Resident Representative (RR) who was notified had a different name entry which was none of Resident 1's emergency contact list. A review of Resident 1's Chest x-ray, date of service 6/26/26, result indicated, The moderately increased interstitial markings may represent interstitial edema (abnormal build-up of fluid in the lungs), a viral pneumonitis (inflammation of lung tissue caused by viral infection), or atypical pneumonia (mild lung infection). A review of Resident 1's Physician Order Report, start date 6/27/26, indicated Amoxicillin (used to treat bacterial infections) capsule 500 milligram (mg) twice a day for Pneumonia. A review of Resident 1's Care Plan, problem start date 6/29/26, indicated a category: Antibiotic use, on antibiotic for Pneumonia. None of the Care Plan approaches listed showed informing RP/RR/FM of the COC and/or new Physician Order. During concurrent interview and record review on 7/29/26 at 1:55 p.m., with the Director of Nursing (DON), DON stated it was her expectation that FM be notified timely and documented accurately regarding new changes in resident's condition, as well as new orders. DON stated it was the responsibility of the Licensed Nurse (LN) who was on duty during the resident's COC episode to notify the family, and either the DON and/or the ADM ensured that notification was completed. When DON reviewed Resident 1's Progress Notes, dated 6/27/26, authored by RN 1, regarding resident's chest x-ray result, new Physician Order, and resident and FM notification, DON verified RN 1 did not indicate FM 1 was notified of Resident 1's COC. DON further stated there was no documentation that Resident 1 refused to tell FM 1 and neither was there documentation of notification, even to at least the resident. During an interview on 8/426, at 4:11 p.m., with RN 1, RN 1 stated facility received Resident 1's chest x-ray results on 6/27/26, during RN 1's night shift. RN 1 stated Physician was called and notified of the critical lab result and gave a new order. RN 1 stated she went back to notify Resident 1 of his chest x-ray result but failed to notify Resident 1's FM 1 in a timely manner. 2. A review of Resident 1's Physician Order Report, start date 1/29/26, through end date 4/23/26, indicated Skilled Physical Therapy (PT) Services 5x/week x 12 weeks. A review of Resident 1's Physician Order, start date 4/24/26, through end date 7/16/26, indicated continue Skilled PT services 2x/week x 12 weeks. A review of Resident 1's PT Treatment Encounter Notes, indicated date of service: 3/5/26, showed Resident 1 preferred to be seen in the afternoon, increased agitation noted when asked to get up at edge of bed and transfer to wheelchair (w/c). Resident 1 would rather try it next day. Another PT Treatment Encounter Notes indicated date of service: 4/7/26, showed Resident 1 encouraged to sit at edge of bed during mealtimes to improve mobility, to increase overall endurance. Further review of PT Treatment Encounter Notes indicated date of service: 6/16/26, showed Resident 1 refused chair/bed-to-chair transfer. A review of Resident 1's Interdisciplinary Team (IDT, a group of health care professionals with various areas of expertise who work together toward the goals of their residents) Care Conference Notes, completed dated 2/14/26, indicated Resident 1 spent time watching television (TV) and received family visits. Review of another IDT Care Conference Notes, completed date 5/19/26, indicated Resident 1's rehabilitation (rehab) order changed to 2x/week due to (d/2) resident not fully participating, not showing progress. Additional notes indicated Resident 1 encouraged to do more for himself, participate more, Resident 1 can sit at the edge of bed with rehabilitation, encouraged to try and sit up in reclining chair. During an interview on 7/29/26, at 3:38 p.m., with the Director of Rehab (DOR), DOR mentioned Resident 1 needed a lot of encouragement to follow through with rehab participation. DOR also stated Resident 1 had a BIMS score of 15, with intact cognition, and was listed as self-responsible. Facility did not notify Resident 1's FM whenever Resident 1 had occasions of refusals or noncompliance with rehab participation. However, DOR stated FM 1 was only made aware of Resident 1's poor rehab responses during Care Conferences and IDT Meetings held with FM 1. A review of the facility's policy and procedure (P&P), titled, Changes in Resident's Condition, undated, indicated, .The resident and/or resident representative (if resident has no capacity to make health care decisions or resident may have requested the Licensed Nurse to contact a family member during a change of condition), attending Physician, resident representative are notified by the Licensed Nurse/Company Designee when there is.b). A significant change in the resident's physical, mental or psychosocial status: c. a need to alter treatment significantly (i.e., a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); d. a decision to transfer the resident from the facility.

Based on interview and record review, for one of four sampled residents (Resident 1), the facility failed to provide Resident 1's Responsible Party (RP) copies of requested medical records within the required timeframe when she requested Resident 1's medical records by mail on [DATE] and sent the same request with documents via fax on [DATE]. The requested medical records were not released until [DATE] after the RP got a lawyer to make the same request on her behalf.This failure resulted in a delay in obtaining Resident 1's medical records, causing RP undue concern pertaining to obtaining the requested medical records.Findings:During a record review of Resident 1's admission Record (AR), undated, the AR indicated Resident 1 was admitted to the facility on [DATE] and discharged on [DATE], with discharge reason: Expired.During a phone interview on [DATE] at 11:15 a.m. with the RP, RP stated there was no response from the facility regarding Resident 1's medical records request sent in [DATE]. RP stated she sent an email to the facility's social worker, made multiple calls, sent a mail to the facility, but there was no response from the facility. RP stated she then sent the request and documents to the facility via fax in [DATE].During a phone interview on [DATE] at 3:56 p.m. with the RP, RP stated when she filed a medical records request initially in [DATE], she emailed the facility's social worker but never got a response from her. RP stated she sent a certified mail to the facility requesting Resident 1's medical records and the tracking information indicated it was delivered. RP stated she never got a response from the facility. RP stated she called again on [DATE] and sent the request with attached documents through fax addressed to Medical Records and she received fax confirmation that it went through, but the facility still did not respond. RP stated she then got in touch with a lawyer who contacted the facility in [DATE] and the records were then released.During a review of a copy of the six pages document titled, Fax Confirmation Report dated [DATE], the documents that were faxed to the facility indicated a medical records request for Resident 1 from the RP addressed to the name of the Medical Records person, the facility's Medical Record Department and the facility's address. The fax included a cover letter that indicated follow up on medical records for Resident 1, and indicated original certified request was mailed on [DATE] and delivered on [DATE] and indicated facility to confirm receipt. The fax document also indicated the request with attached supporting documents - a copy of completed form for Authorization for Release of Information dated [DATE], copy of Resident 1's death certificate, and a copy of RP's government issued ID.During an interview on [DATE] at 2:57 p.m. with Medical Records Director (MRD), MRD stated that when the facility receives a medical records request, the request is submitted to [NAME] (Electronic Risk Management Assistant), which is the facility's record request site. MRD stated when she checked the site, there was a request for Resident 1's records that was released in [DATE]. During a follow up interview on [DATE] at 3:30 p.m. with the MRD, MRD stated she was not aware there was a request by RP in [DATE] and [DATE]. MRD stated the only request found for Resident 1 that had RP's signature, was the one in [DATE] and requested by a law firm, and the records were released. MRD also stated the Administrator (ADM) stated she was not aware of the request made by the RP in [DATE] and [DATE]. When asked how they missed the fax request sent in [DATE] by the RP that had a fax confirmation report completed, MRD stated they receive a lot of faxes on the two fax machines at the facility and it could have been mixed with other faxed documents.During a concurrent interview and record review on [DATE] at 9:41 a.m. with the SSD, SSD read the content of the email dated [DATE], that stated that the RP was trying to request Resident 1's medical records and had called multiple times but had not been able to connect with the staff who handles the records. Further, the email indicated that the RP had asked if the SSD could assist her in getting the request started and wanted to know what documents to submit and where to send them. When asked, SSD stated the date on the email from the RP was [DATE]. SSD stated she must have overlooked the RP's email. SSD stated, It seems this one slipped by. During an interview on [DATE] at 10:54 a.m. with MRD, MRD acknowledged that in this case of the RP's medical records request for Resident 1, the RP did not get the requested medical records in a timely manner.During a follow-up interview on [DATE] at 12:08 p.m. with the MRD, MRD confirmed the medical records request should be released within 24 hours per the facility's policy. MRD acknowledged the RP did not get the medical records as requested on [DATE] via certified mail and via a fax follow up on [DATE]. MRD stated RP's request for medical records [of Resident 1] were released on [DATE] after the law firm requested the records from the facility.During a review of the facility's policy and procedure (P&P) titled, Resident Access to Protected Health Information, undated, the P&P indicated, .Medicare regulations for nursing facilities provide that current residents or their legal representatives may access the resident's designated record set upon written or oral request within 24 hours (excluding holidays and weekends). After receipt of the records for inspection, residents may purchase copies of the records, or any portion of them, at a cost not to exceed the community standard, upon 2 working days' notice.The company will provide the resident with access.in the form or format requested. If . not accessible in the format requested, a readable hard copy or a format to which the Company and the resident agree is acceptable.

Based on interview and record review, the facility failed to ensure three of four sampled residents (Resident 3, Resident 18, and Resident 45) Preadmission Screening and Resident Review (PASRR) were screened and referred to the appropriate state mental authority for Level II PASRR evaluation and determination.(PASRR is a federal requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are appropriately placed in nursing homes for long term care). This failure had the potential to prevent residents from receiving appropriate required mental health services. During a review of Resident 3's Minimum Data Set (MDS-an assessment screening tool used to guide care), dated 6/19/25 the MDS indicated Resident 3 was admitted to the facility on [DATE] with diagnosis that included post-traumatic stress disorder (PTSD a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event), anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), and depression. During a concurrent interview and record review on 8/7/25 at 9:32 a.m. with Director of Nursing (DON), Resident 3's PASRR Level I screen dated 6/13/25 was reviewed. PASRR Level I indicated Resident 3 did not had a diagnosis of serious mental illness. DON stated Resident 3's Level I PASRR was initiated from hospital before admission to facility. DON stated facility's process was for the Interdisciplinary Team (IDT) to review residents PASRR upon admission from the hospital and determine if there is required follow up. DON stated Resident 3's PASRR Level I was not accurately screened or referred to the appropriate state mental authority for Level II PASRR evaluation and determination.(IDT-an interdisciplinary team is a group of professionals from different fields who collaborate to address complex needs, often in healthcare or other specialized settings). During a review of Resident 18's Minimum Data Set (MDS-an assessment screening tool used to guide care), dated 5/26/25 the MDS indicated Resident 18 was admitted to the facility on [DATE] with diagnosis that included psychotic disorder ( a mental disorder characterized by a disconnection from reality) and anxiety a mental health disorder characterized by feeling of worry, anxiety, or fear that are strong enough to interfere with one's daily activities) and depression. During a concurrent interview and record review on 8/6/25 at 8:43 a.m. with DON, Resident 18's PASRR Level I screen dated 9/16/24 was reviewed. PASRR Level I indicated Resident 18 did not have a serious mental illness or a diagnosis of serious mental illness. DON stated Resident 18's Level I PASRR was not accurately screened. DON stated it was important to make sure PASRRs accurately reflect residents' mental health conditions in order for Resident 18 to receive necessary supporting care.During a review of Resident 45's MDS, dated [DATE], the MDS indicated Resident 45 was admitted to the facility on [DATE] with diagnosis that included depression and schizophrenia (a mental disorder that affects a person's ability to think, feel, and behave clearly). During a concurrent interview and record review on 8/7/25 at 9:49 a.m. with DON, Resident 45's PASRR Level I screen dated 8/16/21 was reviewed. PASRR Level I indicated Resident 45 required a Level II mental health evaluation and referral. DON stated Resident 45 was not rescreened and referred to the appropriate state mental authority for Level II PASRR evaluation and determination.During a review of the facility's policy and procedure (P&P) titled, PASSR, undated, the P&P indicated, The facility's designated staff will review the PASSR from the acute hospital and determine if there is a required follow-up i.e., Level II referral, etc.

Based on observation, interview and record review, the facility failed to ensure infection control practices were observed by one of one sampled laundry staff (LS) when the LS was not wearing a gown while moving soiled linen from the soiled linen hamper in to the washer.This failure had the potential for cross contamination and spread of infections among 72 residents at the facility.During a concurrent observation and interview on 8/7/25 at 10:09 a.m. with the LS and Certified Nursing Assistant (CNA) 1 in the laundry room, the LS was observed grasping soiled linen from the hamper in to the washer only with gloved hands. The LS stated she had never used a gown or was told to use a gown when putting the dirty linen in to the machine. The LS stated wearing the gown could protect staff and other residents from the spread of infection.During a concurrent observation and interview on 8/7/25 at 10:15 a.m. with the Laundry Staff Supervisor (LSS) in the laundry room, the LS continued to move the soiled linen from the hamper in to the washer with only gloved hands. The LSS stated gown should be worn all the time when picking dirty linen from the hamper. The LSS stated some laundry staff would wear a gown and some would not. The LSS stated wearing a gown made other laundry staff feeling hot. During a review of facility's policy and procedure (P&P) titled, Soiled Linen Collection and Transfer, undated, the P&P indicated, Soiled linen should not be carried against clothing when transporting . Put on personal protective equipment (PPE - refers to protective items or garments worn to protect the body or clothing from hazards that can cause injury and to protect residents from cross-transmission) before handling soiled linen or clothing.

Based on observation, interview and record review, the facility failed to provide routine medications to meet the needs of one of two sampled residents (Resident 62) and ensured controlled medications (those with high potential for abuse and addiction) were accurately reconciled for two of three sampled residents (Resident 3 and 39) when:1.Resident 62's basaglar insulin (medication used to help manage blood sugar levels) and epogen (medication used to treat anemia, a condition where the blood doesn't carry enough oxygen to the rest of the body) were not available for administration. These failures resulted in Resident 62 to not receive medications as ordered by the physician.2.Resident 3 and 39's controlled drug records were documented illegibly. These failures resulted in inaccurate accountability of controlled medications and potential for misuse or diversion (illegal distribution or abuse of prescription drugs or their use for purpose not intended by the prescriber) of controlled medications.1. During a review of Resident 62's Face Sheet, printed on 8/6/25, the Face Sheet indicated Resident 62 was admitted in the facility on 12/6/24 with a diagnosis of diabetes mellitus (a condition where blood sugar levels are too high) and anemia (a condition where the blood doesn't carry enough oxygen to the rest of the body).During a concurrent medication administration observation and interview on 8/5/25 at 9:00 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 was observed preparing and administering 12 out of 14 scheduled medications for Resident 62. LVN 1 stated Resident 62's basaglar insulin and epogen medications were not available. LVN 1 stated basaglar insulin and epogen medications were usually stored in the medication room refrigerator.During a concurrent observation and interview on 8/5/25 at 9:30 a.m. with LVN 1 in the medication room, LVN 1 unlocked the medication room refrigerator and searched for Resident 62's basaglar insulin and epogen medication. LVN 1 stated Resident 62's basaglar insulin and epogen were not in the refrigerator.During a review of Resident 62's Physician Order Report, dated 8/4/25, the Physician Order Report indicated Resident 62 had an order to receive seven units of basaglar insulin once a day at 9:00 a.m. for diabetes mellitus.During a review of Resident 62's Medication Administration History dated 8/5/25, the Medication Administration History indicated, Resident 62's basaglar insulin was not available and not administered.During a concurrent interview and record review on 8/6/25 at 11:48 a.m. with Registered Nurse (RN) 1, Resident 62's Progress Notes, dated 8/5/25 was reviewed. The Progress Notes indicated, Resident 62's epogen medication was denied by the insurance and RN 1 requested for a STAT delivery (medication to be delivered within a specific timeframe) from the pharmacy at 11:26 a.m. RN 1 stated STAT medication delivery were expected to be delivered within four hours from the time it was requested.During a review of Resident 62's Progress Notes, dated 8/5/25, the Progress Notes indicated, Resident 62's epogen medication delivery was followed up by RN 1 from the pharmacy at 5:51 p.m.During a review of Resident 62's Medication Administration History dated 7/8/25, 7/10/25, 7/12/15, 7/17/25, 7/19/25, 7/24/25, 7/26/25, 7/31/25, the Medication Administration History indicated, Resident 62's epogen medication were scheduled to be administered at 9:00 a.m. but were not available and were not administered.During a review of the facility's policy and procedure (P&P) titled, Medication Pass Guidelines, undated, the P&P indicated, To assure the most complete and accurate implementation of physicians' medication orders and to optimize drug therapy for each resident by providing for administration of drugs in an accurate, safe, timely manner . Medications are administered in accordance with written orders of the attending physician . 6. Administer medications within 60 minutes of the scheduled time. Unless otherwise specified by the physician, routine medications are administered according to the established medication administration schedule for the company.2a. During a review of Resident 3's Face Sheet, printed on 8/6/25, the Face Sheet indicated Resident 3 was admitted in the facility on 6/13/25 with a diagnosis of chronic pain syndrome (pain that lasts for over three months).During a concurrent interview and record review on 8/6/25 at 10:43 a.m. with Licensed Vocational Nurse (LVN) 2, Resident 3's undated Norco (controlled medication to relieve pain) Controlled Drug Record (an inventory sheet that keeps record of the usage of controlled medications) was reviewed. The Controlled Drug Record indicated, the documented date, time and signature of the 12th dose of Norco had multiple black lines across the numbers and letters. LVN 2 stated one line across the date, time and signature should have been made for documentation error. LVN 2 stated the nurse who made the documentation error should have written their initials next to the line.2b. During a review of Resident 39's Face Sheet, printed on 8/6/25, the Face Sheet indicated Resident 39 was admitted in the facility on 7/11/25 with a diagnosis of diverticulitis (condition where pouches in the lining of the colon become inflamed or infected) of large intestine.During a concurrent interview and record review on 8/6/25 at 2:12 p.m. with the Director of Nursing (DON), Resident 39's undated Norco Controlled Drug Record was reviewed. The Controlled Drug Record indicated, multiple documented date, time, and signatures had one line across the numbers and letters and multiple dose numbers were erased with a scribbled vertical line from dose 13 down to dose 1. The DON stated the nurses should have continued documenting dose 13 to dose 1 instead of crossing it out. The DON stated the documentation were confusing. The DON stated documentation should be clear and accurate.During a review of facility's policy and procedure (P&P) titled, Medical Record Management, undated, the P&P indicated, Medical records must be complete, accurately documented . During a review of facility's policy and procedure (P&P) titled, Controlled Medication Storage, dated 2007, the P&P indicated, Discrepancy in controlled substance medication counts is reported to the director of nursing immediately. The director of nursing or designee investigates and makes every reasonable effort to reconcile all reported discrepancies while the nurses remain on duty.

Based on observation, interview, and record review, the facility failed to maintain an effective pest control program for flies and gnats in three of three units designated for resident care. A dead kitten was found outside Resident 24's window for more than 22 hours. The failure to effectively treat flies and gnats and leaving the dead kitten outside Resident 24's room resulted in Resident 24 feeling ugly and grossed out and had the potential to result in infection for all residents residing at the facility. Findings: During an observation on [DATE] at 10:05 a.m., three flies were observed in Resident 322's room. During a concurrent observation and interview on [DATE] at 10:24 a.m., three flies were observed in Resident 42's room. Resident 42 stated that the facility has numerous flies and that the flies made him feel unsanitary. During a concurrent observation and interview on [DATE] at 11:20 a.m., in Resident 34's room, there were five flies in Resident 34's room on the overbed table, the wall, the curtain, and the ceiling. Resident 34 stated that there are flies all over and they drive me crazy. Resident 34 stated that staff often came in to use a chemical spray on Resident 34's room to kill any flies around, and that despite Resident 34 asking, nothing had been done to address the source of the flies. During an observation on [DATE] at 12:43 p.m., a fly was observed on Resident 42's lunch plate, directly on the food being served, when Resident 42 was about to eat his lunch. During a concurrent observation and interview on [DATE] at 11:50 a.m. with Certified Nursing Assistant (CNA) 1, outside of Resident 24's room on Unit 2, CNA 1 pointed out a dead kitten, outside in the bushes next to Resident 24's window. The cat had only its head, paws, spine, and tail left, and the rest of its organs were open and exposed. CNA 1 stated she noticed that another cat had been coming repeatedly to eat the deceased kitten. During a concurrent observation and interview on [DATE] at 9:26 a.m. with Resident 24, the dead kitten was still observed outside Resident 24's window, with further decomposition noted and more of the kitten's head missing. The dead kitten's remains were closer to the window than they were the previous day. A notable foul smell was coming through the window into Resident 24's room. Two flies were observed on the wall to the right of Resident 24's bed. Resident 24 stated, there were gnats all over the room . they get into [Resident 24]'s food and land in my [briefs] and bite my buttocks.' Resident 24 stated it made her feel ugly and grossed out. During a concurrent observation and interview on [DATE] at 9:34 a.m. with Housekeeper (HSK) 1, multiple flies were observed on Resident 34's doorframe in Unit 1. HSK 1 stated she had been noticing flies around the building coming in and out. HSK 1 stated that housekeeping staff attempt to kill the flies with a spray, and that sometimes the spray works, but does not work at other times. HSK 1 stated the housekeeping staff typically let the Maintenance Director know about the issue. When asked what the risks are to uncontrolled pests like flies, HSK 1 sated that the flies could land in residents' food and get them sick. During an observation on [DATE] at 9:38 a.m., one fly was observed on Resident 45's door in Unit 3. During an interview on [DATE] at 9:44 a.m. with the Maintenance Director (MND), the MND stated that there were lots of gnats in some rooms, and facility used fly traps and sprays to keep the pest levels down. The MND stated he was not aware of any dead animals on facility grounds. During a concurrent observation and interview on [DATE] at 9:46 a.m., with MND, outside Resident 24's room window, the dead kitten was still there. MND stated the risks from having dead animals on facility grounds and close to resident care areas was that the remains could create more flies and create greater risk for residents becoming sick. During an interview on [DATE] at 10:18 a.m. with the Director of Nursing (DON), DON stated that pests like flies posed a risk to residents and that the pests could get into resident food and cause infection. DON stated facility's Administrator (ADM) was responsible for pest control services. During a concurrent interview and record review on [DATE] at 10:21 a.m., with ADM and MND, the facility's Maintenance Request Log for February, March, April, and May of 2024 was reviewed. The ADM stated facility staff reported issues related to maintenance in the maintenance log. The ADM stated she was also unable to locate any reports of dead animals from [DATE]. The ADM stated facility was aware of gnats and flies being an issue since February 2024. However, ADM was unable to find any record in the maintenance log. ADM stated the facility hired an outside vendor to perform cleaning to control the gnat issue on [DATE] and [DATE], however the pest issue was not effectively resolved. A review of facility's policy and procedure titled Pest Control, undated, indicated that the facility staff should report the following insect or pest related information: type of problem, location, person reporting, and time reported . and that the facility should maintain a written report of pest sightings and remedial actions.

Based on observation, interview, and record review, the facility failed to maintain a medication error rate of less than 5 %. During the medication pass, three medication errors were observed out of 32 opportunities for three of six residents, resulting in an error rate of 9.38%. 1. Amlodipine (medication for management of high blood pressure) for Resident 1 was unavailable and not administered as ordered. This failure had the potential to result in uncontrolled high blood pressure. 2. Semglee pen U-100 insulin (Insulin Glargine, a long acting insulin) subcutaneous injection was administered to Resident 45 without following manufacturer's recommendation. This failure had the potential to affect the insulin dose's effectiveness and the resident's blood sugar. 3. Humulin R Regular U-100 insulin (a short acting insulin) subcutaneous injection was administered to Resident 19 without following the manufacturer's recommendation. This failure had the potential to affect the insulin dose's effectiveness and the resident's blood sugar. Findings: 1. During a review of Resident 1's Admission Record, undated, the Admission Record indicated Resident 1 was admitted in December 2019 with diagnoses that included high blood pressure, chronic kidney disease, and dementia. During a concurrent medication pass observation and interview on 5/22/24 at 9:18 p.m. with Licensed Vocational Nurse (LVN) 2, LVN 2 checked Resident 1's blood pressure (BP) and stated Resident's BP was 125/58. LVN stated the order indicated to hold if Systolic BP is less than 100. LVN 2 prepared medications for Resident 1 for the 9 a.m. administration time. LVN 2 was unable to find the amlodipine. Its bubble pack was empty. LVN 2 stated it was supposed to be supplied by pharmacy. During a concurrent interview and record review on 5/22/24 at 11:38 a. m. with LVN 2, the physician order indicated Amlodipine 10 mg tablet Amount to administer; amount to administer: 1 tab oral once a day for hypertension. Hold for systolic blood pressure less than 100, LVN 2 stated Amlodipine was not yet available. During a review of Resident 1's Electronic Medication Administration (EMAR), the EMAR for amlodipine was not signed off on 5/22/24. During an interview on 5/23/24 at 8:48 a.m. with LVN 2, LVN 2 stated the amlodipine for Resident 1 was delivered by pharmacy later in the day yesterday but was not administered. 2. During a review of Resident 45's Admission Record, undated, the Admission Record indicated Resident 45 was admitted in January 2023 with diagnoses that included diabetes and chronic kidney disease. During a medication pass observation on 5/22/24 at 10.27 a.m. with Registered nurse (RN) 1, RN 1 administered 18 units of Semglee U-100 insulin to resident 45 via subcutaneous injection. RN 1 immediately removed the needle from the skin after delivering the injection. The manufacturer's recommendation is to hold the needle in place for 10 seconds after administering. During a concurrent record review interview on 5/22/24 at 11:55 a.m. with RN 1, the Physician Order was reviewed. The Physician Order indicated Semglee Pen U-100 Insulin (Insulin glargine); 100 unit/ml (3ml) Amount to Administer: 18 units; subcutaneous once a day for DM (diabetes) at 7:30 am. RN 1 confirmed it was not administered within the time frame. RN 1 stated she was supposed to hold the needle in place for 10 seconds before removing it, so the resident may not be getting the full dose. During a review of the manufacturer's insert for Semglee, the insert indicated once injected, continue to depress the button until the dial has returned to 0 and for an additional 10 seconds. 3. During a review of Resident 19's Admission Record, undated, the Admission Record indicated Resident 19 was admitted in February 2024 with diagnoses that included diabetes and polyneuropathy. During a medication pass observation on 5/22/24 at 11:31 a.m. with LVN 2, LVN 2 administered 12 units of Humulin R insulin to Resident 19 via subcutaneous injection. LVN 2 immediately removed the needle from the skin after delivering the injection, instead of holding it in place for at least five seconds as recommended by the manufacturer's insert and standard injection protocol. During a concurrent interview and record review on 5/22/24 at 11:38 a.m. with LVN 2, the Physician Order was reviewed. The Physician Order indicated Humulin R Regular U-100 Insulin (Insulin Regular human) solution; 100/unit/ml; Amount to Administer: 12 units injection Before meals for DM. During an interview on 5/22/24 at 1:40 pm with LVN 2, LVN 2 confirmed that he did not hold the insulin syringe in place for the recommended five seconds during the subcutaneous injection. He admitted to immediately withdrawing the needle from the resident's skin after administering the insulin; he stated the resident may not get the full dose. During a review of the manufacturer's insert for Humulin R insulin, the insert indicated once injected, continue to depress the button until the dial has returned to 0 and for an additional 5 seconds. During a review of the facility's policy and procedure (P&P) titled, Medication Pass Guidelines, undated, the P&P indicated, To assure the most complete and accurate implementation of physician's medication orders and to optimize drug therapy for each resident by providing for administration of drugs in an accurate, safe, ant timely, .manner.

Based on observation, interview, and record review, the facility failed to store medications and biologicals (a class of medications which are grown and then purified from large-scale cell cultures of bacteria or yeast, or plant or animal cells) in a safe condition when the temperature in one of two medication refrigerators was out of range in accordance with Federal, State, and CDC storage and handling guidelines. This failure had the potential to compromise the integrity and effectiveness of medications and biologicals and could potentially cause harm to the resident. During a concurrent interview and observation of medication refrigerator 2 (med fridge 2) on 5/21/24 at 11:55 a.m. with RN2, in medication storage room [ROOM NUMBER], the thermometer inside med fridge 2 indicated 32 degrees ( ) Fahrenheit (F). Inside med fridge 2, were two E kits (Emergency medication kits) with the same contents in each kit with a yellow sticker indicating Refrigerate. The label on the kit indicated the unopened contents included one Lantus insulin, Levemir insulin, one Novolin N insulin, one Novolin R insulin, one Novolog insulin, and two Lorazepam (medication to relieve anxiety) injection vials. There were multiple Lorazepam vials in small plastic bags labeled with a Resident's name (Resident 55). There was an intravenous reconstituted vancomycin (Antibiotics) one gram injection labeled with a Resident's name (Resident 59), and other medications. During an interview with RN 2 at 12 p. m. with RN 2, RN 2 stated that the temperature was 32 F. RN 2 stated she did not know what the normal range for the medication refrigerator temperature was supposed to be. During another observation of the med fridge 2 on 5/21/24 at 2:30 p.m. with RN 4, med fridge 2 thermometer indicated temperature of 29 F. RN 4 acknowledged it was 29 F. RN 4 provided a recorded temperature log from 1st to AM of 21st. However, there was no month and year indicated on it. The log titled, Medication Refrigerator Temperature Log- Done Twice Daily Normal Temperature: 36-46 /Normal Freezer Temperature: 0-32 F. Notify DON if Temperature is out of range. The undated log had records and initials as of 21st and indicated 36 F recorded for AM (morning of the 21st) ref. RN 4 stated the normal range for the med fridge temperature was indicated on the log. During a review of the temperature log, the log indicated the temperatures were 34 F on the 14th, 32 F on the 15th, and 34 F on the 17th of May 2024. During two observations on 5/22.24 at 12:32 pm and at 3:20 pm, with LVN 3 medication room [ROOM NUMBER], med fridge 2 temperature was 32 F. LVN 3 stated the temperature of med fridge 2 was 32 F. The multiple medications were still in med fridge 2. During an interview on 5/23/24 at 10:40 am with RN 4 and RN 3, RN 3 stated she checked the thermometer yesterday and it was okay and recorded the temperature in the log. When asked why the temperature was below the normal range during multiple observations, RN 3 stated sometimes it is okay, sometimes it is not okay, but most of the time, it is okay. When asked what effect that would have on the medications inside med fridge 2, especially the insulin and lorazepam injections, RN 3, and RN 4 were unable to answer. During an interview on 5/23/24 at 3p.m. with Director of Nursing (DON), DON stated the temperature for the fridge should be within range, and they must follow the manufacturer's recommendations for efficacy of the medications. DON stated if the temperature is below the range, medication could freeze. A review on 5/23/24 of the manufacturer's inserts for the insulin vials in med fridge 2: The manufacture's insert for Lantus (Insulin glargine-medication used for diabetes) indicated, Lantus .should not be allowed to freeze .Not-in-use (unopened Refrigerated (36 F-46 ). The manufacturer's insert for Levemir insulin (for diabetes) indicated, Not-in-use (unopened) Refrigerated (36 F to 46 F). The manufacturer's insert for Novolin N (for diabetes) indicated, Not-in-use (unopened) Refrigerated (36 F to 46 F). The manufacturer's insert for Novolin R (for diabetes) indicated, Not-in-use (unopened) Refrigerated (36 F to 46 F). The manufacturer's insert for Novolog (for diabetes) indicated, Do not freeze Novolog .All unopened vials: store unopened NovoLog vials in the refrigerator at 36 F to 46 F. During a review of the carton label for Lorazepam injection indicated to store in refrigerator 2 C to 8 C (36 F - 46 F). During a review of the manufacturer's insert for gabapentin oral solution indicated to store gabapentin oral solution refrigerated at 36 F to 46 F. During a review of the facility's policy and procedure (P&P) titled, Medication Storage, Storage of Medication, dated 2007, the P&P indicated: medications and biologicals are stored properly, following manufacturer's or provider pharmacy recommendations, to main integrity and to support safe effective drug administration .Medications requiring, refrigeration or temperatures between 2 C (36 F), and 8 C (46 F) are kept in a refrigerator with a thermometer to allow temperature monitoring .

Based on interview and record review, for three of three sampled residents (Resident 49, Resident 65 and Resident 68) reviewed for arbitration (a private process where disputing parties agree that one or several other individuals can make a decision about the dispute [disagreement or claim among parties where one party claims to have been harmed] after receiving evidence and hearing arguments) agreement, the facility failed to ensure the arbitration agreement was explained in a manner they understood. This failure had the potential to result in violation of the residents' right to make informed decisions and choices about important aspects of healthcare and welfare. Findings: 1. During a review of Resident 49's Resident Face Sheet, the Resident Face Sheet indicated Resident 49 was readmitted to the facility in April 2024, Resident Representative (RR) 1 was listed as Resident 49's Representative. During a review of Resident 49's Minimum Data Set Assessment (MDS, a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan), dated 4/7/24, the MDS indicated a Brief Interview for Mental Status (BIMS, a scoring system used to determine the resident's cognitive status in regard to attention, orientation, and ability to register and recall information) score of nine. (A BIMS score of 8-12 is an indication of moderate cognitive impairment). During an interview on 5/23/24 at 10:05 a.m. with RR 1, RR 1 stated he/she asked to sign Resident 49's admission documents/admission packet a few days after Resident 49 was readmitted from the hospital. RR 1 stated he/she was not aware that an arbitration agreement was one of the documents that was signed. RR 1 stated he/she did not know what the arbitration agreement was about and was not told he/she could rescind the agreement within 30 days of signing. RR 1 stated even if he/she knew what it was now, It would be too late [to rescind]. During a review of Resident 49's ARBITRATION AND DISPUTE RESOLUTION AGREEMENT (arbitration agreement), the arbitration agreement indicated it was signed by RR 1 and Admissions Director (AD) on 4/3/24. 2. During a record review of Resident 65's Resident Face Sheet, the Resident Face Sheet indicated Resident 65 was admitted to the facility in April 2024, Resident 65 was listed as Responsible Party. During a review of Resident 65's MDS, dated [DATE], the MDS indicated a BIMS score of nine. During a review of Resident 65's ARBITRATION AND DISPUTE RESOLUTION AGREEMENT, the arbitration agreement indicated, while it was signed by Resident 65, there was no signed acknowledgment that a copy of the Dispute Resolution Program information and Frequently Asked Questions handout were received by Resident 65. The arbitration agreement indicated Admissions Assistant (AA) as the Facility Representative who also signed the agreement. During an interview on 5/23/24 at 9:33 a.m. with Resident 65, Resident 65 stated she did not understand what an arbitration agreement was and what it was for. During an interview on 5/23/24 at 11:44 a.m. with AA, AA stated she asked the resident or the resident representative to sign the admission packet upon admission or return from the hospital. AA stated the arbitration agreement would be included in the admission packet for the resident or resident representative to sign. AA was not able to answer what the arbitration agreement was about and was not able to provide what information was given to the residents or their representative before signing. During a telephone interview on 5/23/24 at 11:46 a.m. with Admissions Director (AD), AD stated during the admission process, the resident or the resident representative would sign the admission packet as soon as possible or within 72 hours of admission. AD stated the admission packet included bed-hold notice, primary insurance information, standard admission agreement, personal funds, and arbitration agreement. AD stated her role was making sure the residents had signed the admission packet and that every document was completed but AA was the assigned Coordinator for the facility, who would oversee the signing of the admission documents in AD's absence. 3. During a review of Resident 68's Resident Face Sheet, the Resident Face Sheet indicated Resident 68 was admitted to the facility in March 2024. RR 2 was listed as Resident 68's representative. During a review of Resident 68's MDS, dated [DATE], the MDS indicated a BIMS score of four (severe cognitive impairment). During a review of Resident 68's ARBITRATION AND DISPUTE RESOLUTION AGREEMENT, the arbitration agreement indicated the arbitration agreement was signed by both RR 2 and AD on 4/1/24. During a telephone interview on 5/23/24 at 10:37 a.m. with RR 2, RR 2 stated she was made to sit in the conference room to sign for Resident 68's admission to the facility. RR 2 stated she heard about the arbitration agreement for the first time during the interview and stated she did not know the implications of such an agreement and would not have given up Resident 68's right to litigation in a court proceeding if she had known.

Based on observation, interview, and record review, the facility failed to accurately assess one of four sampled residents (Resident 322) for right forearm swelling. This failure resulted in Resident 322 experiencing pain and limited range of motion of the right arm, and placed Resident 322 at risk of untreated edema, further pain skin damage, and fluid overload. Findings: During a review of Resident 322's Face Sheet (a document used to communicate important information about a resident), undated, the record indicated Resident 322 was admitted to the facility in May 2024. During a review of Resident 322s Data Collection (a document used to collect data upon admission for a resident), dated 5/13/24, the record indicated Resident 322 had [right upper extremity] swelling present upon admission to the facility. During a concurrent observation and interview with Resident 322 on 5/20/24 at 10:05 a.m., Resident 322 stated his right arm was swollen and painful to the touch. Resident 322 was laying in bed with the head of the bed elevated, with a pillow under his head. Resident 322's right forearm and hand were noticeably swollen, and Resident 322 was not able to effectively make a fist with his right hand due to the swelling. Resident 322 stated it had been like this for weeks now. Resident 322 stated the facility had not done anything to decrease the swelling or pain in his right arm. Resident 322 stated it made him feel like I want to jump off a bridge. During a concurrent observation and interview with Certified Nursing Assistant (CNA) 1 on 5/22/24 at 11:50 a.m., CNA 1 stated Resident 322's right arm definitely looks swollen. CNA 1 stated Resident 322 complained of pain in the right arm the day prior, and that was reported to Registered Nurse (RN) 1. CNA 1 stated the risks of untreated pain were further pain and discomfort for the affected resident. During an observation and interview with RN 1 on 5/22/24 at 12:27 p.m., in Resident 322's room, RN 1 stated Resident 322 had edema (a result of excess fluid buildup in the body, causing swelling; when pressure is applied to the swollen area, a pit, or indentation, will remain) in the right arm. RN 1 stated Resident 322's right arm edema had increased as it was 1+ (a scoring system for edema; 1+ means the edema formed a pit at least 2 millimeters deep) the day before, however the edema was at least a 2+ (a score indicating the edema formed a pit at least 4 millimeters deep) that day. RN 1 stated Resident 322 also complained of some pain in the right arm the day before. RN 1 stated she did not inform Resident 322's physician for pain and/or edema she noted on 5/21/24. During a concurrent interview and record review with RN 1 on 5/22/24 at 12:41 p.m., Resident 322's Treatment Administration Record (TAR, a document used to log treatments and observations for a specific resident) and Nursing Progress Notes, dated 5/21/24, were reviewed. RN 1 stated the documents indicated Resident 322 did not have any swelling and/or pain in the right arm on 5/21/24. RN 1 stated not completing an accurate assessment for edema placed Resident 322 at risk for untreated edema leading to further pain, increased limited range of motion, and complications such as fluid overload. During a review of the Care Plan (a document used to indicate problems a resident is facing along with goals and measures to achieve them) for Resident 322, dated 5/13/24, the record indicated Resident 322 had impaired skin integrity . RFA (right forearm) and that approaches to this included monitor daily for pain, skin breakdown, or signs of worsening condition. Notify MD/NP Once a Day.

Based on observation, interview, and record review, the facility failed to provide an environment and a safe transfer to prevent accident for one of eight sampled (Resident 2) when Resident 2 fell from the Hoyer lift during transfer from bed to chair by a Certified Nurse Assistant (CNA) and a Licensed Vocational Nurse (LVN). This deficient practice resulted in Resident 2 sustaining a superficial scalp laceration and hematoma due to the witnessed fall from the Hoyer lift. Findings: During a review of Resident 2's Admission Record, undated, the Admission Record indicated medical diagnoses that included Alzheimer's disease (a type of dementia that affects memory, thinking, and behavior), dementia (a general term for memory loss and other cognitive abilities serious enough to interfere with daily life), aphasia (a language disorder caused by damage to parts of the brain that control speech and understanding of language), chronic kidney disease, sensorineural hearing loss (happens when there is damage in the inner ear), and high blood pressure. During a review of Resident 2's Minimum Data Set (MDS, a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan), dated 3/18/24, the MDS indicated no score for Resident 2's Brief Interview for Mental Status (BIMS, a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan), indicative of severe cognitive impairment. During a review of the MDS for functional activities of daily living (ADL, the activities needed for self-care and mobility and include activities such as bathing, dressing, grooming, oral care, ambulation, toileting, eating, transferring, and communicating), the MDS indicated Resident 2 was dependent indicating a helper does all of the effort. Resident 2 required the assistance of two or more helpers to complete ADLs. During a review of Resident 2's Interdisciplinary Team (IDT) Summary of Investigation, dated 5/1/24, the IDT Summary indicated, On 4/30/24, 11 am, resident was being assisted by an LVN and a CNA to transfer from bed to wheelchair. While the resident was already up on the sling, the LVN was adjusting the wheelchair to prepare for the next step to transfer, while the CNA was steadily holding the Hoyer lift machine, when the resident accidentally slid down to the floor. Both staff were unable to break the fall. Resident sustained a laceration and a bump on the back of her head and was transferred to the hospital via 911 . During a review of Resident 2's hospital x-ray report, dated 4/30/24, the report indicated moderate left parietal scalp hematoma is seen . During a review of Resident 2's Post Fall Risk Observation (FRO), dated 5/22/24, the FRO indicated Resident 2 received a fall risk score of 20; a fall risk score of ten or higher, represents a high risk for fall. During a review of Resident 2's Comprehensive Care Plan. dated 9/13/13, reviewed/revised 5/22/24, the comprehensive care plan included approaches to provide assistance as identified in transfer and mobility . During an interview on 5/21/24, at 2:52 p.m. with CNA 3, CNA 3, stated Resident 2 fell from the Hoyer lift and had a bump in the middle of her head. CNA3 stated she was the one operating the Hoyer lift. During an interview on 5/22/24 at 2:17 p.m. with LVN 2, LVN 2 stated CNA 3 was operating the Hoyer lift, while he was fixing Resident's wheelchair. LVN 2 stated he was looking down as he tried to release the WC brakes and he did not witness the fall. LVN 2 stated he did not get a training for the Hoyer lift prior to the incident. During an interview on 5/23/24 at 1:10 p.m. with the Director of Staff Development (DSD), DSD stated the incident was reported to her. DSD stated she has trained staff on how to use a Hoyer lift properly and safely, and the chair must be placed in the right position. During a concurrent interview and record review on 5/23/24 at 1:20 p.m. with DSD, DSD stated all staff are trained, including licensed nurses (LNs), on use of the Hoyer lift upon hire, but not a requirement for LNs. DSD could not find a training record for the Hoyer lift for LVN 2. During an observation and interview on 5/24/24 at 9 a.m. with Resident 2, Resident 2 was nonverbal. Resident 2 was able to communicate using the basic communication chart. A bump with a scar was observed on the crown of Resident 2's head. After the bump was touched, Resident 2 nodded to pain when showed on the communication chart. During a review of the facility's policy and procedure (P&P) titled Resident Transfer: Mechanical Lift, undated, the P&P indicated, .Manufacturer's instructions and recommendation should always be followed, including the number of staff needed for a safe transfer. Mechanical lifts require at least a 2- person assist, or as per manufacturer's instructions . Both care givers will steady the resident as the lift is being moved. The second caregiver will guide the resident's body while the first caregiver moves the lift .

Based on observation, interview, and record review, the facility failed to provide adequate pharmaceutical services when Resident 1's medication, amlodipine (medication used to treat high blood pressure) was not available and not administered as ordered. This failure had the potential to result in uncontrolled high blood pressure for Resident 1 During a review of Resident 1's Admission Record, undated, the Admission Record indicated Resident 1 was admitted in December 2019 with diagnoses that included hypertension, chronic kidney disease, and dementia. During a concurrent medication pass observation and interview on 5/22/24 at 9:18 a.m. with Licensed Vocational Nurse (LVN) 2, LVN 2 checked Resident 1's blood pressure and stated Resident's BP was 125/58. LVN stated order indicated to hold if Systolic BP is less than 100. LVN 2 prepared medications for Resident 1 for the 9 am administration time. LVN 2 unable to find amlodipine, the bubble pack was empty. LVN 2 stated it was supposed to be supplied by pharmacy and doesn't why they do not have it. LVN 2 stated they usually request in advance when there are just few remaining in the pack. During a concurrent interview and record review on 5/22/24 at 11:38 a. m. with LVN 2, the Physician Order was reviewed. The Physician Order indicated amlodipine 10 mg tablet. Amount to administer: 1 tab oral once a day for hypertension. Hold for systolic blood pressure less than 100. LVN 2 stated the amlodipine was not available. During a review of Resident 1's Electronic Medication Administration Record (EMAR) on 5/23/24, the EMAR for amlodipine was not signed off on 5/22/24. During an interview on 5/23/24 at 8:48 a.m. with LVN 2, LVN 2 stated the amlodipine for Resident 1 was delivered by pharmacy later during the day yesterday but was not administered. During a concurrent interview and record review on 5/24/24 with DON at 10:30 a.m., DON stated the licensed nurse would notify the doctor if not delivered on time by pharmacy. During a review of the facility's policy and procedure (P&P) titled, Medication Pass Guidelines, undated, the P&P indicated, To ensure the most complete and accurate implementation of physician's medication orders and to optimize drug therapy for each resident by providing for administration of drugs in an accurate, safe, ant timely, .manner. To systematically distribute medications to residents in accordance with state and federal guidelines .If the medication is not available during the medication pass, the Licensed Nurse (LN) will check the medication room if available. If the medication is still not available in the medication room/medication storage area, the LN will notify the pharmacy for delivery. If the medication will be administered later than the original schedule as a result of the pharmacy delivery time, the LN will notify the physician for further orders or recommendations . During a review of the P&P titled, Pharmaceutical Services, undated, the P&P indicated, Medications shall be administered in a safe and timely manner, and as prescribed .All medication orders will be supported by appropriate care processes and practices.

Based on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 68) received quetiapine (an antipsychotic medication, a class of medication that affects brain activities associated with mental processes and behavior) without an appropriate indication for use or appropriate behavior monitoring. This failure resulted in Resident 68's behavior not being appropriately monitored for the use of quetiapine and placed Resident 68 at risk of experiencing untreated psychosocial distress. Findings: During a review of Resident 68's Resident Face Sheet, the record indicated Resident 68 was admitted to the facility in March 2024 with a diagnoses to include unspecified dementia (a loss of brain function that occurs with certain diseases, affecting one or more brain functions such as memory, thinking, language, judgment, or behavior) without behavioral disturbance (a condition where a person behaves in a manner that may put themselves or others at risk), psychotic disturbance (a condition where a person's thinking is disconnected from reality), mood disturbance (a condition where a person's mood is negatively impacted), and anxiety (a feeling of fear or dread). During a review of Resident 68's Minimum Data Set (MDS, a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan), dated 4/25/24, the record indicated Resident 68 did not have any unsafe behaviors or mood disturbances during the seven days look back period. During a review of Resident 68's Brief Interview for Mental Status (BIMS, is a scoring system used to determine the resident's cognitive status in regard to attention, orientation, and ability to register and recall information), Resident 68 had a BIMS score of 5, indicating cognitive impairment. During an observation on 5/20/24 at 11:32 a.m., Resident 68 was observed sitting on the edge of the bed with feet dangling over the floor. Resident 68 was eating a piece of bread and stated she was here in a rental home. Resident 68 showed no signs of agitation or distress. During an interview with Certified Nursing Assistant (CNA) 2 on 5/22/24 at 9:58 a.m., CNA 2 stated Resident 68 wandered (walking aimlessly) at times but did not try to leave the facility. CNA 2 stated Resident 68 did not have any other behavioral issues. During a concurrent interview and record review with Licensed Vocational Nurse (LVN) 1 on 5/22/24 at 10:01 a.m., Resident 68's Physician's Orders and Treatment Administration Record (TAR), dated 5/2024 were reviewed. LVN 1 stated Resident 68 received quetiapine 12.5 milligrams (mg) every night for psychosis (A mental disorder characterized by a disconnection from reality) [manifested by] noncompliant to [plan of care] since 4/30/24. LVN 1 stated she was unable to find any record of attempting to refuse or deny care documented in Resident 68's TAR. During a concurrent interview and record review with the Director of Nursing (DON) on 5/22/24 at 10:08 a.m., Resident 68's Medication Regimen Review (MRR), dated 5/10/24, was reviewed. DON stated noncompliance with plan of care was not an appropriate diagnosis or indication for use of quetiapine for Resident 68. The MRR indicated to request clarification on use of quetiapine for refusal of care . as it is not an appropriate indication for use. DON stated the risks of not having an appropriate indication to use quetiapine included not accurately capturing the behaviors or symptoms Resident 68 was experiencing and could result in making it hard to determine the actual need for the psychotropic medication's usage for Resident 68. During a phone interview with Resident Representative (RR) 1 on 5/23/24 at 10:38 a.m., RR 1 stated Resident 68 experienced auditory hallucinations (a condition where a person hears sounds that do not exist) and wanders around frequently, attempting to leave home without reason in the past. These symptoms led to the resident being prescribed quetiapine prior to the admission to the facility. RR 1 stated DON had called her on 5/22/24 to discuss the reason Resident 68 was prescribed quetiapine, and that this was the first time anyone from the facility had asked for this information. During a review of the policy and procedure (P&P) titled Psychotropic Medication Assessment & Monitoring, undated, the P&P indicated the behavior of residents receiving antipsychotic medication will be monitored by the licensed nurse every shift.

Based on interview and record review, the facility failed to follow its policy and procedure to report the fall incident of Resident 2 to the California Department of Public Health (CDPH) and other appropriate agencies, as required by the federal or state regulations. This failure had the potential in delay of investigation and affects the health, safety, or welfare of residents. Findings: During a review of Resident 2's Admission Record, undated, the Admission Record indicated medical diagnoses that included Alzheimer's disease (a type of dementia that affects memory, thinking, and behavior), dementia (a general term for memory loss and other cognitive abilities serious enough to interfere with daily life), aphasia (a language disorder caused by damage to parts of the brain that control speech and understanding of language), chronic kidney disease, sensorineural hearing loss (happens when there is damage in the inner ear), and high blood pressure. During a review of Resident 2's Interdisciplinary Team (IDT) Summary of Investigation, dated 5/1/24, the IDT summary indicated, On 4/30/24, 11 am, resident was being assisted by an LVN and a CNA to transfer from bed to wheelchair. While the resident was already up on the sling, the LVN was adjusting the wheelchair to prepare for the next step of transfer, while the CNA was steadily holding the Hoyer lift machine, when the resident accidentally slid down to the floor, both staff were unable to break the fall. Resident sustained a laceration and a bump on the back of her head and was transferred to the hospital via 911 . During a review of the facility's policy and procedure (P&P), titled Unusual Occurrence Reporting, undated, the P&P indicated, As required by federal or state regulations, our facility reports unusual occurrences or other reportable events .other occurrences that interfere with facility operations and affect the welfare, safety, or health of residents, employees, or visitors.

Based on interview and record review, the facility failed to ensure the care plan was reviewed and revised by the interdisciplinary team after an identified concern for one of three sample selected residents (Resident 1) when Resident 1 informed the staff of the facility about his sensitivity to the scents. The facility did not make a care plan and follow up with Resident 1's concern. This failure resulted in frustration for Resident 1 and having to inform each of the staff himself about his issue with scents. Findings: A review of Resident 1's Face Sheet indicated Resident 1 was admitted to the facility with multiple diagnoses including acute bronchospasm (happens when the muscles that line your airways in your lungs tighten) and Chronic Obstructive Pulmonary Disease (COPD, a condition involving constriction of the airways and difficulty or discomfort in breathing). During an interview on 4/10/24 at 10:25 a.m. with Resident 1, Resident 1 stated that he had high sensitivity to fragrances and scents and when he was admitted to the facility, he told every staff and administrator about his issue and none of the staff listened to him. He stated he is still receiving care from staff with the smell of cologne or smoke. Furthermore, Resident 1 stated that he had an accident that he had a respiratory issue and had to go through a lot of treatment because of smell of cologne before. During a concurrent interview and record review on 4/11/24 at 9:00 a.m. with the Administrator (ADM), ADM stated Resident 1 complained to her about staff wearing fragrances and ADM became aware of Resident 1's sensitivity to scents. ADM stated because she did not find any allergy history on Resident 1's medical records, ADM did not take the complaint seriously. Furthermore, ADM reviewed the care plan and confirmed there was no care plan for Resident 1's issue with scents. A review of Resident Progress Note indicated on 3/29/24 . he (Resident 1) said I told you people do not wear perfume . and on 3/16/24 . sensitive to smell . A review of Grievance/complaint Report, dated 3/19/24, indicated Resident 1 complained to the ADM about his sensitivity to scents. A review of Resident 1's Care Plan indicated the facility did not make a care plan for Resident 1's sensitivity to scents. A review of Employee Handbook Union, dated 2018, indicated .Employee should exercise personal hygiene including the absence of body odors and limit the use of strong perfumes and colognes . A review of the facility's policy and procedure Comprehensive Plan of Care, undated, indicated . Re-evaluate and modify care plans: as necessary to reflect changes in care, services and treatment .

Based on observation, interview and record review, the facility failed to ensure residents' right to receive visitors were honored when visits were restricted to 30 minutes for two of five sampled residents (Residents 1 and Resident 6). This failure had the potential to result in emotional distress in residents. Findings: During an interview with the Administrator (ADM), on 5/24/22 at 10:40 a.m., ADM stated for in-room visitation where a resident's roommate is present and does not agree to be out of the room, the lobby could be utilized or outdoor visits were offered. During an interview with the Receptionist (REC), on 5/24/22 at 11:30 a.m., REC stated the facility's policy was for families to call first for an appointment. REC also stated on the day of the scheduled visit, after the families were screened, they would be allowed to do indoor or outdoor visits for 30 minutes but would be allowed extension up to 45 minutes. REC stated, for in-room visits, the resident's roommate should be out of the room during the visit, and would have to be re-scheduled if the roommate refuses to be out of the room. Review of the facility's policy and procedure (P&P) titled, Visitation During COVID-19, last revised 4/20/21, the P&P indicated, Visits will be scheduled by appointment with the facility's receptionist, with the schedule of 30 minutes per visit, however, visits can be extended to 45 minutes under some circumstances, if the facility can accommodate the visit, in a designated location (indoor or outdoor). The facility's P&P also indicated, The facility will follow the local district, local public health's directives if differs from this protocol. During a follow-up interview and concurrent review of the facility's P&P with ADM on 5/24/22, at 11:51 a.m., ADM stated, while the facility has its own policy on visitation which was last revised in 2021, All Facilities Letter (AFL, a letter from the State Health Agency to the facility that contains information that may include changes in requirements in healthcare, enforcement, or general information that affects the facility) will be followed. The AFL 22-07 dated 2/7/22 with the subject, Guidance for Limiting the Transmission of COVID-19 in Skilled Nursing Facilities, did not indicate any time limit on visitation. The AFL also indicated, Visits for residents who share a room should be conducted in a separate indoor space or with the roommate not present in the room (if possible), regardless of the roommate's vaccination status. When asked what the facility's policy was for instances when residents who share a room both refuse to be out of the room, or when it was not possible to visit without the roommate being in the shared room, ADM did not answer. During an interview with Certified Nursing Assistant (CNA) 1, on 5/24/22 at 12:40 p.m., CNA 1 stated, if both residents who share a room refused to be out of the room during visits with family, the visit would have to be re-scheduled. During an observation and concurrent interview with Resident 1, on 5/24/22 at 12:45 p.m., Resident 1 stated in-room visits were only limited to 30 minutes even when a roommate was out of the room longer than the allowed time. Resident 1 stated time was not enough and it discouraged families to visit, especially when they had to drive for many hours just to have a 30-minute time with residents. Resident 1's roommate was not in the room. Resident 1 stated roommate was at the dining room from before lunch until way after lunch hour (2-3 hours) so it did not make sense that visits were not allowed beyond 30 minutes while roommate was out of the room. Review of Resident 1's Minimum Data Set (MDS, an assessment tool used to direct resident care) dated 4/3/22 indicated Resident 1 had a Brief Interview for Mental Status (BIMS, an assessment tool for resident's orientation to time and capacity to remember) score of 15. The BIMS score range is from 0-15, with zero as the most impaired. During an interview with Family Member (FM) 1 (Resident 6's family) on 5/24/22 at 1:25 p.m., FM 1 stated she was never allowed in-room visits since facility re-opened for visitations. FM 1 also stated how she was told that her 30 minutes was up while visiting with Resident 6 outdoors or in the lobby.

Based on interview and record review, the facility failed to develop and implement policies and procedure to ensure that all staff are fully vaccinated for COVID-19 (a respiratory infection caused by coronavirus that could result in mild to severe complications) when hospice (compassionate care focusing on the quality of life so that the person's last days may be spent with dignity and quality) personnel, x-ray and laboratory technicians' vaccination status were not documented and tracked. This failure had the potential to result in unvaccinated employees providing resident care. Findings: During an interview and concurrent review of Staff Vaccination Matrix with the Infection Preventionist (IP), on 5/24/22 at 10:50 a.m., IP stated, all employees who did not receive their booster doses were required to get tested twice weekly. IP stated hospice staff were not included in the facility's matrix. IP stated she did not know the names of the hospice staff or their vaccination status. IP stated, the hospice staff were screened at the reception as they entered the facility. During an interview with the Receptionist (REC), on 5/24/22 at 11:25 a.m., REC stated she screened hospice staff and x-ray technicians the same way all visitors were screened. REC stated, before being allowed entry, all visitors were asked to present proof of their COVID-19 vaccination. REC stated, most of the time, visitors had their vaccination records on their phone and were allowed entry. REC stated hospice staff came to visit once or twice weekly. REC stated copies of the vaccination records for all visitors would be kept in a binder at the reception area. REC stated she does not remember if the hospice staff and x-ray technicians' vaccination records were kept in the facility log book for visitors. REC stated if the x-ray technician or hospice staff did not have proof of getting COVID-19 booster dose, they would still be allowed entry but would be required to wear an N95 while inside the facility. During an interview and review of facility's vaccination information binder for visitors with the Central Supply Staff (CSS) on 5/24/22 at 12:35 p.m., CSS stated she only stayed at the reception area for 30 minutes. CSS stated she did not know the names of the x-ray technicians and could not find their vaccination records in the binder. During a joint interview and concurrent review of the employee vaccination roster with the Administrator (ADM) and IP, on 5/24/22 at 12:53 p.m., IP stated she did not have the names of the hospice staff, x-ray and laboratory technicians or documentation of their vaccination records. IP stated, the hospice, x-ray and laboratory technicians were screened at the reception area and were required to show negative test result to be allowed entry. During a follow-up interview with REC and CSS on 5/24/22 at 12:57 p.m., both stated copies of the vaccination record of the hospice, x-ray and laboratory technicians were not in the visitor vaccination binder. REC stated she did not know if they were requested to show negative COVID-19 tests or if they were tested on -site. Review of the facility's policy and procedure (P&P) titled, COVID-19 Vaccination -Staff, last released on November 2021, indicated, all staff are required to be fully vaccinated for COVID-19. It also indicated, staff means all individuals who provide any care, treatment, or other services for the facility and its residents including individuals under contract or other arrangements, for example, hospice personnel and portable x-ray suppliers/x-ray technicians. The policy also indicated, The Infection Preventionist maintains a tracking worksheet of staff members and their vaccination status. that would provide most current vaccination status of all staff that includes; the staff name, initial start date of employment or service and vaccination status.

Based on observation, interview and record review, the facility failed to ensure safe medication storage when the eye drops and ear drops were stored next to each other in green and white boxes and there was an expired 1000 ml (milliliter) bag of 10% Dextrose (sugar water solution given intravenously or into the vein) in the medication storage room. These failures had the potential for medication errors to occur (for example, administering ear medication into the eye which could cause [CONDITION(S)]) or or the resident to receive expired intravenous (IV) fluids. Findings: 1. During an observation on [DATE] at 11:15 a.m., there were eye drops and ear drops kept next to each other on a shelf. Both were in green and white boxes. During an interview with the Registered Nurse (RN) 2 on [DATE] at 11:15 a.m., RN 2 stated they should not be stored next to each other because it would be easy to grab the wrong one. 2. During an observation of the Medication Storage Room on [DATE] at 11:15 a.m., there was a bag of 10% Dextrose in a drawer with a pharmacy label indicating a room temperature expiration date of [DATE]. The prescription filled date was [DATE]. During an interview with Registered Nurse 2 (RN) on [DATE] at 11:15 a.m., RN 2 stated the 10% Dextrose was to hang when a Resident was not getting his TPN (total [MEDICATION(S)] nutrition, a special formula given through a vein). RN 2 stated the expiration date from the manufacturer was ,d+[DATE]. During a telephone interview with the Pharmacist (Ph) on [DATE] at 11:49 a.m., Ph stated once the bag of fluids is removed from the moisture bag (a protective overwrap), it expires in 30 days. Ph stated this bag was opened on [DATE], so the expiration date is [DATE]. During a review of the Drug & Biological Storage policy, dated ,d+[DATE], the policy indicated that no discontinued, outdated or deteriorated drugs or biologicals may be retained for use.

Based on observation, interviews, and record review, the facility failed to follow a current seasonal menu and meal plan when the facility used the Fall/Winter 2021 menu to prepare the residents' meals. This deficient practice did not ensure seasonal foods which offer variety, palatability, and nutritional value were made available to residents. Findings: During an interview on 5/2/22 at 11:11a.m., the Certified Dietary Manager (DS) provided a copy of the menu titled, Fall/Winter 2021. DS stated the facility currently uses the Fall/Winter 2021 menu to prepare the residents' meal. During an interview on 5/2/22 at 12:42 p.m., the Registered Dietician (RD) stated the spring menu cycle began in April 2022. RD stated the facility had contacted the menu provider in order to initiate the new menu cycle. During an interview on 5/3/22 at 10:06 a.m., the Administrator (Admin) stated the facility had been in contact with the menu provider for updated seasonal menus and continued to wait. During the tray line observation on 5/3/22 at 11:33 a.m., the facility used the Fall/Winter 2021 menu for food preparation and served the following for lunch: Fish, carrot and rice pillar, gravy, tomato soup, chicken and rice soup, baked chickens , mashed potato, beef parties, broccoli, puree fish, or chicken ravioli as an alternative. The facility's policy and procedure titled, Menu revised 7/1/2017, indicated the menus incorporate regional tastes, seasonal changes, and dietary modification.

Based on observation, staff interviews, review of facility documents including logs, policies and procedures and manufacturer's recommendations, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety when: 1. The facility stored food in a freezer (Freezer #1) that was not functioning properly. This had the potential to cause food borne illness for all residents in the facility that receive food from the kitchen. 2. The facility failed to demonstrate it was correctly monitoring the temperatures of the freezers and refrigerators from (MONTH) (YEAR) through (MONTH) (YEAR). The dietary staff had no knowledge base of correctly reading and logging the freezer and refrigerator temperatures therefore from (MONTH) (YEAR) through (MONTH) (YEAR) uncertainty of what the actual temperatures were and how long the freezer was not properly functioning could not be determined. This had the potential for significant harm and food borne illness to occur for all residents who received food from the kitchen. 3. The facility failed to realize and maintain the final cooking temperature of chicken was prior to and after meal service delivery. This had a significant potential for food borne illness to occur among residents who received food from the kitchen as well. 4. The facility failed to ensure its thermometers were properly calibrated. An uncalibrated thermometer was used to test the final cooking temperature of chicken. This resulted in the potential to serve undercooked chicken to residents who received chicken as their main meal course from the kitchen. 5. The facility policy for cool downing instructions posted in the kitchen were misleading and could also contribute to the potential for food borne illness for all residents who receive food from the kitchen. 6. The facility failed to maintain a kitchen/dietary services that minimized contamination concerns that may contribute to food borne illness, such as proper sanitization of kitchen equipment. Immediate jeopardy was declared on (MONTH) 11, (YEAR) at 11:29 a.m. The facility Administrator, Patient Advocate and Director of Nursing were present during the notification of the Immediate Jeopardy situation. Findings: 1. Freezer By observation, during the tour of the facility kitchen on 9/10/18 at 9:11 a.m., the temperature display on the three-door, reach-in freezer, (Freezer #1) showed a temperature reading of 54 degrees F. By further observation, the contents of the freezer showed an internal thermometer reading of 34 degrees F with a significant amount of frost on the exterior of sherbet and other food items which showed evidence of some thawing (soft to touch). In an interview on 9/10/18 at 9:12 a.m., Cook 1 stated that the freezer had been left open and the food items were taken out for about ½ an hour during Freezer #1's cleaning. Cook 1 stated that she cleans the freezer on Mondays before food delivery. Review of the facility's policy titled, Cleaning and Defrosting Freezers, dated (YEAR) showed that the dietary staff were to, move all items to another section within the same freezer or if available or move items to another freezer temporarily during the cleaning process .Verify that temperature is < 0 degrees F before placing food back into the freezer. By further observation on 9/10/18 at 9:11 a.m., there was no evidence that Freezer #1's temperature was < 0 degrees F after the Cook 1 cleaned Freezer #1 as was described in the facility policy. By observation and concurrent interview on 9/10/18 at 9:47 a.m., the temperature of the second two-door freezer (Freezer #2) was 25 degrees F. By further observation, the internal thermometer of Freezer #2 was difficult to access, it was in the back of the freezer facing sideways. Cook 1 lifted two boxes to access it the internal thermometer. Cook 1 did not respond when asked about her ability to read the thermometer. By observation on 9/10/18 at 11:12 a.m., the external temperature of Freezer #1 was 60.5 F and internal temperature was 32. 5 degrees F. By further observation on 9/10/18 at 11:18 a.m., the external thermometer displayed on Freezer #1 was 68 degrees F, and at 11:33 a.m., the external temperature increased to 70 degrees F and switched to the defrost cycle as evidenced by DEF on the thermometer display. By continued observation, the orange sherbet inside Freezer #1 showed continued evidence of frost on the container and was not frozen solid; it was soft and its temperature reading was 21.6 degrees F By continued observation on 9/10/18 at 3:45 p.m., the temperature of Freezer #1 was 78.5 degrees F and internal temperature was 24 degrees F; all food items remained stored in Freezer #1 and the temperature readings for Freezer #2 had returned to normal. By observation on 9/11/18 at 7:54 a.m., the external temperature of Freezer #1 was 135 degrees F and the internal temperature was 18 degrees F. In an interview on 9/11/18 at 8:02 a.m. with the DSS regarding the temperature of Freezer #1 and the condition of the contents of Freezer, (which included the sherbet and ice cream), the DSS stated that the external temperature display was inaccurate and did not know what was wrong with it. The DSS further stated that the internal freezer temperature should be between 0 and 32 degrees F, ideally 0 but less than the freezing point of water. In response to what temperature the DSS would be concerned about for the freezer, DSS stated, when it is significantly above 0. DSS added that there was no magic number at which she would be concerned about the functionality of the freezer and the she believed dietary staff would say something if it goes over 32 degrees F. The DSS stated Freezer #1, typically has problems and we have to service it often. The DSS added that the repair company provides a regular monthly service on the freezers and that the ice cream that was delivered on 9/10/18 was not frozen solid and was soft at 14.9 degrees F. Review of the facility's temperature logs for the freezers and refrigerator for the months of (MONTH) (YEAR) through (MONTH) (YEAR) showed that no temperature had been recorded for Freezer #2 on 9/11/18 and that the temperature for Freezer #1 was recorded as 10.1 degrees F. In an interview on 9/11/18 at 8:02 a.m., the DSS stated the cooks record the freezer and refrigerator temperatures. The DSS stated she was not concerned that the temperature for Freezer #2 had not been recorded at 8:00 a.m. The DSS further stated that based on her training and understanding, temperatures should be recorded ideally when the shifts starts, however as far as the for the log was concerned, AM temperatures could be recorded as late as 12 noon because it was still AM (morning) and for the PM temperatures they could be recorded before dietary staff leave for the day. The DSS stated the facility policy does not specify exactly what time freezer and refrigerator temperatures should be recorded. Continued review of the of the facility documents titled, Freezer and Refrigerator Temperature Record/Logs, dated (MONTH) (YEAR) through (MONTH) (YEAR), did not support DSS' statement that there was no time stipulations for the actual time the temperatures were to be taken. Further review of the records showed, Record temperature of freezers and refrigerators twice daily at approximately 6:00 AM and 7:00 PM. Review of the facility Policy and Procedure titled, Freezer Storage, dated (YEAR), showed, It is recommended temperatures be recorded in the AM immediately after opening the kitchen and the PM before closing. The same policy also stated, The freezer should be maintained at a temperature equal to or less than 0 degrees F. 2. Monitoring of Freezer and/or Refrigeration Temperatures In a concurrent record review and interview on 9/11/18 at 8:14 a.m., a review of the temperature log for Freezer #1 showed the temperature recorded as 0.4 degrees F. While in the presence of DSS, Cook 2 (who recorded the AM temperature), was asked how she could get 0.4, a decimal number when the internal thermometer was not digital. Cook 2 stated that she only records the external temperature displayed. Cook 2 further stated that she adds decimal points to the numbers she sees. Cook 2 stated the morning before, when the display read, 4, she wrote 0.4 on the log. The DSS then stated in response to Cook 2's explanation, that the external temperature should never have been recorded. Cook 2 further explained that she would write 13.6 degrees if 136 degrees F was displayed on the external thermometer. Cook 2 added that she always recorded the external never the internal temperature, something she has done since being hired by the facility approximately five years earlier. In an interview on 9/11/18 at 8:35 a.m. the DSS was asked again regarding the process used by Cook 2 to record temperatures; the DSS stated she did not know. In an interview on 9/11/18 at 10:18 a.m., the Maintenance Supervisor (MS) stated he was aware of the problems with Freezer #1 and that he had called the repair company. MS also stated the facility does not have a monthly service contract with the repair company, does not have a regular monthly service, and the repair company only comes when there is a problem. Review of the Work Orders from the contracted repair company dated 7/9/18 and 8/27/18, showed Freezer #1 had a similar problem of the freezer being warm and the evaporator (evapt) coil iced up, clean condenser. Further review of the Work Orders dated 9/11/18 and 9/12/18, showed Freezer #1's temperature was 143 degrees F when the technician arrived at the facility. 3. Cooked Chicken By observation on 9/10/18 at 11:45 AM, during trayline preparation, Cook 2 pulled out of the oven a stainless steel container with several pieces of chicken breast and placed them on the trayline for lunch meal service. By continued observation, the chicken breast was 150.6 degrees F using the surveyor thermometer and 115 degrees F using the facility thermometer. Continued observation the facility dietary staff returned the chicken to the oven. Further observation of dietary staff's chicken preparation for lunch indicated that one resident received ground chicken, however it was unclear and could not be determined where the chicken was obtained from in order to prepare the ground chicken for the one resident. By further observation of the trayline preparation, at the end of trayline, the chicken breast pulled out of the oven was 156.7 degrees F. In an interview on 9/10/18 at 12:38 p.m., Cook 1 stated that as long as the chicken was 140 degrees F, It is fine. In a separate interview with Cook 1 on 9/10/18 at 3:40 p.m., a discussion regarding the preparation of chicken salad took place with Cook 1. Cook 1 stated the chicken salad was prepared using raw chicken. Cook 1 further explained that she boils the chicken breast until the chicken reaches 140 degrees F, she drains the chicken, cuts it up and puts in an ice bath to cool. Review of the facility policy and procedure titled, Proper Temperature for Meal Preparation and Service, dated (YEAR), lists the final internal cooking temperature for poultry as 165 degrees F. 4. Thermometer Calibration By observation and concurrent interview on 9/10/18 at 11:27 a.m. at the beginning of the trayline preparation, simultaneous food temperatures were taken from the trayline. By continued observation, there was consistently a 30 degree F or more discrepancy between the temperatures of the surveyor and the facility staff; as a result of this observation, facility staff were asked to demonstrate how they calibrate their thermometers. Cook 1 stated she had calibrated the thermometer earlier that morning. By observation on 9/10/18 at 12:42 p.m., Cook 1 was unable to demonstrate proper thermometer calibration using the ice water method (50:50 ice and water mixture). Cook 3 was also asked to demonstrate thermometer calibration at 12:43 p.m., and Cook 3 was also unable to demonstrate proper thermometer calibration. The DSS who was present during the observation, acknowledged the thermometers were not calibrated. 5. Proper Cooling Method During an interview with Cook 1 on 9/10/18 at 3:40 p.m. regarding cool down procedures of cooked food, it was difficult to determine that Cook 1 was following proper cool down procedures. Cook 1 stated that she followed procedures outlined on a green colored poster observed to be above the food preparation sink. A review of the facility policy (green colored poster above the food preparation sink) showed that it had information contrary to the current food safety guidelines. By further review the information on the poster, indicated that if food does not cool down from 135 degrees F to 41 degrees F in 6 hours, then the item should be reheated to 165 degrees F for 15 seconds. Review of another facility policy and procedure titled, Cool Down, also indicated, although not advisable, if food does not reach 41 degrees F within six hours, reheat until the inner temperature reaches 165 degrees for at least 15 seconds. Review of the Center for Medicare and Medicaid State Operations Manual indicated that Foods held in the danger zone for more than .6 hours (if cooked and cooled) may cause a food bourne illness if consumed. Further review of the (YEAR) Food Code Annex provision for cooling provides for cooling from 135ºF to 41°F or 45°F in 6 hours, with cooling from 135ºF to 70°F in 2 hours. The (YEAR) Food Code Annex also indicates that, the initial 2-hour cool is a critical element of this cooling process and that cooked hot food should be discarded immediately if the food is above 70 ºF and more than two hours into the cooling process; or above 41 ºF and more than six hours into the cooling process. In an interview on 9/11/18 at 8:34 a.m. Registered Dietician (RD 1) stated she believed the food should be tossed. 6. Other Identified Kitchen Concerns During a tour of the kitchen and concurrent interview on 9/10/18 at 9:12 a.m., a brown colored oily residue (resembling a lubricant/engine oil) was observed in the food mixer bowl stored away as clean. Cook 1 who was present during the observation, explained the oil was from the mixer because the lever to raise the bowl for mixing had malfunctioned. By observation on 9/10/18 at 9:54 a.m., two scoops stored away as clean were found visibly soiled. A blue colored handled scooper was found with a brown dried substance on it resembling cake batter. The interior handle of a second scooper which was ivory colored, had a greasy, oily residue on it. The DSS who was present during the observation, acknowledged the presence of dirt and oily residue on the scoopers. Review of the (YEAR) Food Code; Section 4-601.11 (A), Equipment, food contact surfaces and utensils shall be clean to sight and touch. By observation and concurrent interview on 9/12/18 at 8:00 a.m., the Dietary Aide (DA 2) demonstrated the testing of the quat sanitizer used to clean food contact surfaces. By continued observation, DA 2 using the test strips, found that the concentration of the sanitizer was between 400 and 500 parts per million (ppm). During the testing process, DA 2 stated the water was hot and quickly withdrew his hands from the testing solution. By continued observation, a temperature check indicated that the water was 122.2 degrees F. DA 2 explained the facility practice is to add water if the reading was too high and that he had added water; hot water. DA 2 stated that the technician responsible for the chemicals directed the dietary staff to do this. DA 2 did not indicate that there was a specific amount of water instructed to add. Review of the Manufacturer's Instructions, located on a nearby poster, the sanitizing solution should be between 65 - 75 degrees F. Review of the Manufacturer's Recommendation, the concentration of the sanitizing solution needed to be 150 - 400 ppm. with an immersion of the testing strips for 10 seconds in the solution. Review of the (YEAR) Food Code Section 4-302.14, indicated that, too much sanitizer . could be toxic. The facility Administrator, Patient Advocate and Director of Nursing were notified of the Immediate Jeopardy situation on 9/11/18 at 11:29 a.m The facility Administrator and other staff present were informed of the following: 1. Freezer that was not working, and the continued storage of food in the freezer resulting in the defrosting of the stored food with no corrective action. 2. The use of uncalibrated food thermometer to check the final cooking temperature of chicken, a Time -Temperature control for safety (TTS) Food (formerly potentially hazardous food). 3. The failure of the Dietary Services Supervisor (DSS) to monitor the freezers and refrigerators as evidenced by inaccurate documentation of temperature logs by food service staff from (MONTH) (YEAR) through (MONTH) (YEAR) and possibly for over this three month period. 4. The inaccurate and misleading policy on cooling down cooked foods that could result in food borne illness. 5. Inadequate staff knowledge of the final cooking temperature for chicken, proper cool down procedures and thermometer calibration. 6. There were other contamination concerns in the kitchen that could also contribute to the development of food bourne illness, such as dirty surfaces and equipment and the sanitization methods of these critical kitchen elements. The survey team accepted the facility's plan of action on (MONTH) 11, (YEAR) at 4:20 p.m. The corrective action included discarding all items stored in Freezer #1 and freezer tagged for non-use. An outside contractor was called in to assess the freezer for repairs. The posted policy on cool-down was removed off the wall for revision. All thermometers were replaced and checked for calibration. The facility Registered Dietitian and Administrator conducted in-service education for all food and nutrition staff on thermometer calibration, final cooking temperature, reading and recording of refrigerator and freezer temperatures, proper cool down process. The Immediate Jeopardy situation was abated (removed) on (MONTH) 13, (YEAR) at 8:38 am, when the freezer was repaired and able to maintain internal temperature of - 6 degrees F; stored food was frozen solid. Food and nutrition staff were able to demonstrate proper thermometer calibration, explain final cooking temperature for chicken and proper cooling procedures. In addition, the facility policy was revised and amended to match the guidelines described in the (YEAR) Food Code.