Every finding on record at Elmwood Care Center

Based on observation, interview, and record review, for one of three sampled residents (Resident 1), the facility failed to ensure Resident 1, who required intermittent self-catheterization (inserting a thin, flexible tube called a catheter through the urethra into the bladder to drain urine, typically done several times a day to prevent urinary tract infections and kidney damage), was provided the necessary physician-ordered catheter supplies to support Resident 1's ability to perform activities of daily living.This failure had the potential to result in Resident 1's urinary retention (inability to completely or partially empty the bladder), infection and discomfort during procedure.Findings: During a review of Resident 1's admission Record (AR) dated 6/24/26 the AR indicated Resident 1 was admitted to the facility in June 2025 with diagnoses of obstructive and reflux uropathy (Obstructive uropathy occurs when a structural or functional blockage hinders the normal flow of urine. Reflux uropathy when urine flows backward from the bladder into the ureters and kidneys), benign prostatic hyperplasia (enlarged prostate), acute kidney failure (sudden and rapid loss of your kidneys' ability to filter waste from your blood), and severe sepsis (a life-threatening medical emergency defined by an infection that triggers the body's immune system to overreact, resulting in acute dysfunction or failure of one or more organs).During a review of Resident 1's Minimum Data Set (MDS, an assessment tool used to direct resident care), dated 6/10/26, the MDS indicated a 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.) score of 15 (A BIMS score of thirteen to fifteen is an indication of intact cognitive status).During an interview on 6/24/26 at 12:16 p.m., with Resident 1, Resident 1 stated needing to obtain straight catheter supplies himself. Resident 1 stated the using of new Central Supply Staff (CSS) began two months prior, the facility did not provide Coude (a type of urinary catheter with a curved tip used for intermitted catheterization) 16 Fr (French- It is the universal unit of measurement used to describe the outside diameter [gauge] of the catheter tube) catheter ordered by the urologist.During a review of Resident 's undated Orders, the Orders indicated that Resident 1 should self-catheterize using [NAME] (name of the factory) hydrophilic VaPro (ready-to-use, no-touch urinary catheter designed for sterile bladder drainage) coude 16 Fr straight catheter ( a thin, flexible tube inserted into bladder to drain urine, then removed immediately after use) six times daily, and the facility must provide the supplies.During an interview on 6/24/26 at 1:52 p.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated Resident 1 self-catheterized, but she did not know who supplied the catheters. LVN 1 stated she never gave the catheters herself because it was ordered via CSS and CSS usually supplied them.During a concurrent observation and interview on 6/24/26 at 2:20 p.m., with CSS, CSS stated she was not sure what catheter size was provided to Resident 1 or not as she had not provided one. CSS stated the nurses handled the supplies that Resident 1 needed. CSS went to the storage room in the facility's basement and, after 20 minutes, returned with an 18 Fr silicone-coated foley catheter (a flexible, sterile tube inserted through the urethra into the bladder to drain urine. Held in place by an inflated balloon, it allows for continuous bladder drainage in patients unable to urinate naturally), unaware it differed from a straight catheter. CSS stated being new to the facility. Shortly after, CSS provided a 14 Fr [NAME] brand straight catheter.During an interview on 6/24/26 at 3:30 p.m., with LVN 2, LVN 2 stated working the evening shift. LVN 2 stated Resident 1 must have received supplies from the Central Supply (CSS) rather than the nursing team. LVN 2 stated she has never provided Resident 1 with a catheter for use.During a follow-up observation and concurrent interview on 6/24/26 at 3:38 p.m., with Resident 1, at Resident 1's bedside, Residen1 showed multiple boxes that included Apogee IC (a straight catheter for intermittent use) 14 FR, 16 inches, a box of straight tip 16 Fr [NAME] catheters, but none were Coude catheters. Resident 1 stated he preferred the Coude type with a curved tip as they were easier to use for his obstruction. During an interview on 6/25/26 at 10:12 a.m., with Director of Nursing (DON), DON stated she was unaware Resident 1's lack of supplies for catheterization. DON stated only straight catheters with a straight tip were available in Central Supply not the Coude, DON stated she would review the physician's orders to find out what kind of catheter Resident 1 needed.According to an article from [NAME] Medical (a leading manufacturer of disposable medical products such as catheters), straight catheters are easy to use for those who do not have obstructed urinary tract, whereas Coude catheters have an angled, slightly curved tip, designed for patients with obstructive urinary tract for example those who have benign prostatic hyperplasia because the catheter easily bypasses the obstruction smoothly. Reference: Coude vs. Straight Catheters: Which One Is Right for You?-Hangzhou [NAME] Medical Devices Co., Ltd

Based on interviews and record review, the facility failed to administer medication as ordered by their physician for one of three sampled residents (Resident 1), when the facility did not administer Resident 1's physician ordered dose of insulin (a hormone needed to move sugar from blood into cells for energy). This failure had the potential to jeopardize Resident 1's health and safety.During a review of Resident 1's admission Record, printed 4/16/26, the Record indicated Resident 1 was admitted to the facility in February 2026 with a diagnosis of Type 1 Diabetes Mellitus (a chronic condition where the body's immune system attacks and destroys insulin producing cells in the pancreas, requiring daily insulin treatment to prevent high blood sugar) . During a review of Resident 1's Physician's Order, dated 2/1/26, the Order indicated, Insulin NPH (an intermediate-acting insulin used to manage blood sugar levels in people with diabetes). Subcutaneous Suspension 100 UNIT/ML (milliliter). Directions. Inject 8 unit subcutaneously one time a day for diabetes type 1 give 30 minutes before a meal. Start Date 2/2/26 06:30. During a concurrent interview and record review on 4/16/26, at 12:17 p.m., with Director of Nursing (DON), Resident 1's Medication Administration Record (MAR), dated February 2026 and Resident 1's Progress Notes, dated 2/2/26 were reviewed. DON stated the MAR indicated on 2/2/26, for the 6:30 a.m. administration time, Resident 1's Insulin NPH was held. The Progress Note, indicated, Insulin NPH. pending delivery. DON stated there was no documentation on the MAR or Progress Notes that indicated Resident 1 received their Insulin NPH on 2/2/26 at the 6:30 a.m. administration time, or the physician was notified after it was held. During an interview on 4/16/26, at 2:49 p.m., with DON, DON stated when insulin was not given as ordered by their physician, staff should have assessed the resident, taken their blood sugar, and notified the physician to get any new orders such as an order to hold the medication or for an alternative medication. DON stated this was important for patient safety and to prevent complications. During a review of the facility's policy and procedure (P&P) titled, Medication administration, dated 1/1/24, the P&P indicated, Medications shall be administered as ordered by a licensed nurse upon the order of a physician/ licensed independent practitioner. The P&P indicated, Holding medications. the responsible nurse shall notify the physician of any medications held and the reasons for holding as soon as possible. The P&P indicated, Medication Errors. The nurse shall notify the physician immediately after a medication error has been noted. if a medication error is the omission of a dose, the nurse shall notify the appropriate physician and observe the resident for any status change.

Based on observation, interview and record review, the facility failed to provide adequate supervision to one of three sampled residents (Resident 1), when Resident 1, with a history of repeated falls, sustained another fall while ambulating (walking) on his own in the facility's hallway.This failure resulted in Resident 1's falling on the ground, sustaining a fracture (broken bone) to the right hip, and transferring to the acute care hospital for right hip surgery.During a review of Resident 1's admission Record (a record with basic information) printed on 11/3/25, the record indicated Resident 1 was admitted on the facility on 04/07/25.During a review of Resident 1's Minimum Data Set (MDS, a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan), dated 10/12/25, indicated Resident 1'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), score was 10 out of 15, indicating moderate cognitive (mental status) impairment. The record indicated Resident 1 had a diagnosis of Schizophrenia, (a severe chronic mental disorder that results in disorganized thinking and behavior). Review of Functional Abilities section indicated Resident 1 required a manual wheelchair and was able to wheel at least 50 feet, was able to sit to stand, and walk at least 50 feet with supervision/touching assistance (where staff provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity). The assessment also indicated facility did not attempt to assess Resident 1 to walk 150 feet due to his medical conditions or safety concerns.During a review of Resident 1's Fall Risk Assessment, (an evaluation used to identify a resident's likelihood of falling and suffering injury), dated 10/12/25, the assessment indicated Resident 1's fall score as 50 related to Resident 1's history of falls, unsteady and weak gait (balance during walking), and the need to use wheelchair for mobility. During a review of Resident 1's undated Fall Care Plan, the care plan indicated Resident 1 was at risk for falls. The record indicated an intervention dated 9/10/25, stating, staff was to admit Resident 1 to high risk unit, anticipate and meet resident's needs, and to follow facility's fall protocol. During an observation on 02/18/26 at 09:30 a.m. in the facility hallway where Resident 1 was found on the floor on 11/01/25, it was noted that residents would make at least one turn to 2nd hallway to enter the patio, where Resident 1 was coming from on the day of his fall. During concurrent observation and interview of Resident 1's room, on 2/18/26 at 1:00 p.m., Resident 1 was in bed. Resident 1 stated he did not remember anything about the fall incident that occurred on 11/1/25.During an interview on 2/18/26 at 12:00 p.m., Certified Nursing Assistant (CNA 1) stated facility had a designated high fall risk unit for residents who were high fall risk for close monitoring. CNA 1 stated staff assigned in that area conducted every 15 mins rounds on high fall risk residents.During a telephone interview on 2/23/26 at 9:20 a.m., CNA 2, who worked in the facility on 11/1/25, stated she did not witness Resident 1 falling on that day. CNA 2 stated, however she knew that Resident 1 required one staff's assistance for mobility while he was in wheelchair and/or needed a ride to get to facility patio. CNA 2 stated Resident 1 was unstable while walking independently.During a telephone interview on 2/23/26 at 1:38 p.m., CNA 3, who worked in the facility on 11/1/25, stated she did not witness Resident 1 falling on that day. CNA 3 stated on 11/1/25 around 3:00 a.m., she saw Resident 1 was sitting on the ground near his room, next to his wheelchair. CNA 3 stated that she, along with Registered Nurse (RN 1) assisted Resident 1 from the ground to the wheelchair. During a phone interview on 2/20/26 at 2:06 p.m., RN 1 stated on 11/1/25 at around 2:50 a.m., he responded to a distress call from a staff stating Resident 1 was sitting on the ground in the hallway. RN 1 stated he could not recall which staff called his attention to Resident 1, however Resident 1 had an unwitnessed fall. RN 1 stated when he arrived Resident 1 was awake, alert, sitting on the ground. RN 1 stated he assessed Resident 1's neuro status (assessment of mental status), assessed for injury and pain. RN 1 stated Resident 1 complained of pain in the right hip area. RN 1 stated him and CNA 3 moved Resident 1 to the wheelchair. RN 1 stated he called Resident 1's Doctor, who ordered to complete an X-ray (imaging test primarily for bones and internal organs) of Resident 1's right lower extremity. RN 1 stated X-ray results came back and indicated Resident 1 had an acute hip fracture, so Resident 1 was sent to acute care for further evaluation.During a review of Resident 1's nursing progress notes dated 11/1/25, RN 1 documented [Resident 1] had an unwitnessed [not observed by anyone directly] fall in the hallway while returning from the patio after smoking, [him] landing on his right buttock .he complained of pain in his right leg groin, and near the hip joint 6/10 [moderate pain] especially with movement of the right leg .STAT [immediate] X-ray [completed] . During a review of Resident 1's X-Ray report dated 11/01/25, the report indicated acute comminuted fracture of the right intertrochanteric femur, (right upper thigh broken bone). During a review of Resident 1's Acute care hospital Discharge summary dated [DATE] indicated Resident 1 had surgery to right hip on 11/2/25 and was not discharged from acute care to the facility until 11/8/25.During a telephone interview on 2/23/26 at 3:00 p.m. with Acting Director of Nursing (ADON), the ADON stated Resident 1's fall could have been prevented if facility staff monitored Resident 1 closely and provided constant supervision while he was walking by himself on 11/1/25. During a concurrent phone interview and record review on 3/2/26 at 10:23 a.m., Director of Nursing (DON), Administrator (Adm) and ADON, Resident 1's post fall Interdisciplinary (IDT, a team that includes staff members from multiple disciplines such as nursing, therapy, physicians, and other advanced practitioners) progress note dated 11/4/25 was reviewed. The DON stated she was the one who documented the IDT note, while facility's Adm, DON, ADON, Resident 1's doctor was part of the IDT meeting. The IDT note indicated Resident 1 had falls on 5/3/25, 8/14/25, 9/3/25, 9/10/25 and 11/1/25 within a six-month period. The note indicated on 9/10/25, Resident 1 fell due to loss of balance while ambulating and the IDT recommended to admit Resident 1 to high risk unit. The DON stated Resident 1 was not admitted to high-risk unit until 11/8/25. The Adm stated facility decided not to move Resident 1 to high-risk unit because he did not have any injuries from 9/10/25 fall. The IDT note further indicated that Resident 1's fall on 11/1/25 was witnessed (directly observed by someone) fall. The DON stated she thought CNA 4 witnessed Resident 1's fall on 11/1/25. During a phone interview on 3/2/26 at 2:26 p.m., CNA 4 stated she was assigned to Resident 1 on 11/1/25. CNA 4 stated she was with another resident at the time Resident 1 had a fall. CNA 4 also stated she did not witness Resident 1 falling on that day and did not recall anything related to the fall.During the review of the facility's policy and procedure titled, Fall Prevention, dated 12/2015, indicated, all residents will receive adequate supervision and assistive devices to prevent accidents.

Based on interview, observation and record review, the facility failed to ensure the facility front entry door would lock.This failure had the potential to result in a significant security and safety issue potentially endangering the residents, staff and visitors.During an observation on 9/18/25 at 9:57 a.m. the front door of the facility was ajar and unlocked. The survey team was able to access the facility without staff being aware. There was no audible alarm to signify that someone had entered the facility, and the reception area was unattended.During a phone interview with the facility Administrator and Maintenance Supervisor on 9/19/25 at 12:20 p.m. the Maintenance Supervisor and Administrator both stated they did not know the entry door did not lock.During a concurrent observation and interview on 9/19/25 at 12:30 p.m. with the Maintenance Supervisor, the facility front entry door was observed unlocked and ajar. The Maintenance Supervisor was observed from the outside pushing the front entry door close. The Maintenance Supervisor stated once the entry door was closed the locking mechanism did not activate to secure the entry door. The Maintenance Supervisor stated the door did not have an alarm when the door was open to notify staff someone had opened the front door and was walking in the building. The Maintenance Supervisor stated he did not know how long the door lock had been malfunctioning. During the observation the Maintenance Supervisor made the Administrator aware the front door locking mechanism did not work and the entry door did not have an alarm when opened. During an interview and record review with the Maintenance Supervisor on 9/19/25 at 12:45 p.m., the Maintenance Supervisor presented a quote dated 6/12/25 for a commercial door repair. Maintenance Sup stated he had no knowledge of the door repair project start or completion date.During a review of the Maintenance logbook dated January 2025 through [DATE], the maintenance logbook did not indicate an entry or request to follow-up for the broken entry door lock. The Maintenance Supervisor stated he did not have access to the prior logbooks.

Based on observation, interview and record review, the facility failed to ensure that during a facility COVID outbreak:All staff wore a facemask. This failure had the potential to result in transmission of the respiratory COVID virus.Staff actively monitored visitors entering the facility for hand hygiene, temperature checks, and assessment of respiratory infections(fever, cough, shortness of breath and sore throat). This failure had the potential to result in transmission of the COVID -19 virus.1.During an observation and interview on 9/19/25 at 10:45 a.m. Maintenance Worker (MW)1 was observed walking through the facility not wearing a mask and exited down the stairwell on station 2. With an interpreter MW 1 stated he was not wearing a face mask and did not stop when surveyor wanted to interview him. MW1 stated he knew the facility had a COVID outbreak and he did not have a mask.During an observation and interview on 9/19/25 at 10:45 a.m. a Laundry Aide exited the stairwell onto station 2 and walked over to the time clock. The Laundry aide was not wearing a face mask or name badge. The Laundry aide with an interpreter stated she was not wearing a face mask, and she had the facility COVID education training.During an interview with the Maintenance Supervisor (MS) on 9/19/25 at 11:23 a.m. the MS stated the staff should always wear a mask upon entry and exit from the build during a COVIS outbreak. MS stated the laundry aide and MW 1 names are not on the general in-service record, as he discussed COVID prevention during a staff meeting. He stated he does not keep minutes of his meeting.During an interview and record review on 9/19/25 at 12:00 p.m. with the Infection Preventionist (IP), IP stated a review of the COVID isolation and PPE in-service training sheets dated 9/9/25 and 9/12/25 indicated the Center for Disease Control : Infection control Guidance :SARS-CoV-2 dated June 24, 2024 and the Californian Department of Public Health, Health Associated Infectious Program Recommendations for the prevention and control of COVID-19 .In California Skilled Nursing Facilities 2024-2025 dated 11/2/2024, was reviewed with Certified Nursing Assistance, Registered Nurses and all departments. Review of the in-service training report does not include names or signature for the laundry aide and housekeeping staff. The IP stated staff not receiving in-service training and not wearing a face mask could cause transmission of the COVID outbreak to the residents, staff and visitors.During a review of the Center for Disease Control: Infection control Guidance: SARS-CoV-2 dated June 24, 2024, indicated source control is recommended more broadly by those working or residing on a unit or area of the facility experiencing a SARS-CoV2 or other outbreak of respiratory infection.During a review of the Californian Department of Public Health, Health Associated Infectious Program Recommendations for the prevention and control of COVID-19 .In California Skilled Nursing Facilities 2024-2025 dated 11/2/2024, the policy indicated in the setting of an outbreak, it's essential that the facility has instituted source control masking ( source control masking - the use of masks to cover a person's mouth and nose and to help reduce the spread of large respiratory droplets to others [NAME] the person talks, sneezes or coughs). 2. During observation on 9/18/25 at 9:57 a.m. and 9/19/25 at 9:59 a.m. the facility receptionist area at the door was unmanned with boxes of N95 face mask on the counter with signs indicating visitors are to wear a mask due to the COVID outbreak. There were no staff performing visitor screening or temperature monitoring. There was a book on the receptionist desk for visitors to sign in and answer questions related to symptoms. Observed a visitor entered the facility without putting on a mask or signing in the book.During an interview on 9/19/25 at 10:00 a.m. with the Director of Nursing (DON), The DON stated the receptionist, and several other staff were out due to COVID. DON stated the receptionist area was unmanned at this time, and visitors are to self-sign in. DON stated no one was monitoring visitor self-sign -in.During a review of California Department of Public Health Healthcare-Associated Infections Program dated 2024-2025, the document indicated during periods of increased community transmission of respiratory viruses and in the event of an outbreak: implement active screening of visitors for signs and symptoms of respiratory virus infections

Based on interviews and record reviews, the facility failed to report of suspected allegations of abuse for two of two sampled residents (Resident 1 and Resident 2) within the required 24-hour time frames when:Resident 1 who had a bruise of unknown origin on the right upper arm was not reported to the State Survey Agency and Long-Term Care Ombudsman (LTCO, resident advocate) within the reporting time frame.Resident 2's suspected allegation of verbal abuse from an employee was not reported to the LTCO. These failures had a potential to delay protective investigations and placed Resident 1 and Resident 2 at risk for ongoing unaddressed abuse and potential harm. During a record review of Resident 1's admission Record (AR), printed on 9/29/25, the AR indicated Resident 1 was admitted to the facility in June 2025 with diagnoses of dementia (a condition that affects memory and thinking), age-related cognitive decline, and major depressive disorder (a condition where someone feels very sad, tired, hopeless for a long time. and it affects daily activities).During a record review of Resident 1's SBAR (Situation, Background, Appearance, Review and Notify) Communication Form, dated 11/25/25, the SBAR record indicated at around 9:00 a.m., Resident 1 was observed to have a bruise on her right upper arm and Resident 1 did not know how she got it.During a record review of the facility's Unusual Occurrence report, dated 11/27/24, the Unusual Occurrence report showed the investigation for Resident 1's bruise on the right upper arm from an unknown source was only initiated two days later after the bruise was first observed. The Unusual Occurrence report also showed the required notifications to the State Survey Agency were not made within the 24-hour reporting time frame. During a record review of Resident 2's AR, printed on 9/29/25, the AR indicated Resident 2 was admitted to the facility in December 2024 with diagnoses of cellulitis (skin infection) of abdominal wall and ileostomy status (presence of an opening in the stomach where waste comes out into a bag).During a record review of Resident 2's SBAR record, dated 1/27/25, the SBAR record indicated Resident 2 verbalized that a Certified Nurse Assistant (CNA) was verbally inappropriate and rude towards Resident 2. SBAR showed Resident had verbalized that the CNA told her, You're here because God doesn't like you.During an interview on 9/29/25 at 11:39 a.m. with the Infection Preventionist (IP) also Director of Nursing designee, IP stated they were unable to locate copies of notification receipts that should have been sent to the LTCO regarding the allegations of abuse for Resident 1 and Resident 2. The IP further stated the LTCO should have been notified of the allegations of abuse so the LTCO could conduct their own investigation, as they serve as an advocate for the residents.During an interview on 9/29/25 at 2:36 p.m. with the Administrator (ADM), ADM stated if there was an unknown source of an injury, she would have initiated an investigation and interviewed the staff immediately. ADM stated she would have also notified the State Survey Agency, LTCO, and the police department immediately or within 24 hours, as required by the regulation, in order to rule out rule out abuse. ADM further stated LTCO should have been notified of the allegations of abuse because LTCO may obtain additional information or a different perspective from residents during their interviews. ADM stated it was important to initiate a thorough investigation summary to ensure no other residents had experienced the similar allegation of abuse and to ensure safety of all residents. During a phone interview on 9/30/25 at 10:50 a.m. with LTCO 1, LTCO 1 confirmed they did not receive notifications of the alleged abuse of Resident 1 and Resident 2. LTCO 1 stated they checked their records found no documentation or reports related to the alleged incidents.During a record review of the facility's policy and procedure (P&P), titled Abuse Investigation and Reporting, dated March 2017, the P&P indicated, All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source ( abuse) shall be promptly reported to local, state and federal agencies.and thoroughly investigated by facility management. Findings of abuse investigations will also be reported.Role of the Administrator.1. If an incident of resident abuse.neglect or injury of unknown source is reported, the Administrator will assign the investigation to an appropriate individual.The Administrator will ensure any further potential abuse.Role of the investigator.3. The investigator will notify the ombudsman that an abuse is being conducted. The ombudsman will be invited to participate in the review process.Reporting.1. All alleged violations involving abuse.including injuries of an unknown source.will be reported by the facility Administrator, or his/her designee to the following agencies.a. The State licensing/certification agency.b. The local/State Ombudsman.2. Suspected abuse, neglect, .or mistreatment (including injuries of unknown source.) will be reported within two hours.If the events that cause the allegation do not involve abuse or not resulted in serious bodily injury, the report must be made in twenty-four hours.

Based on interviews and record reviews, the facility failed to ensure a thorough investigation was conducted and completed within five working days following an allegation of abuse for one sampled resident (Resident 2) and the facility did not not have an investigation summary documenting the findings and result of the investigation.This failure had the potential for the allegation of abuse to remain uninvestigated and placed Resident 2 at risk for ongoing abuse due to the absence of protective interventions and corrective actions. During a record review of Resident 2's admission Record (AR), printed on 9/29/25, the AR indicated Resident 2 was admitted to the facility in December 2024 with diagnoses of cellulitis (skin infection) of abdominal wall and ileostomy status (presence of an opening in the stomach where waste comes out into a bag. During a record review of Resident 2's SBAR (Situation, Background, Appearance, Review and Notify) record, dated 1/27/25, the SBAR record indicated Resident 2 verbalized that a Certified Nurse Assistant (CNA) was verbally inappropriate and rude towards Resident 2. SBAR showed Resident had verbalized that the CNA told her, You're here because God doesn't like you.During an interview on 9/29/25 at 11:39 a.m. with the Infection Preventionist (IP) also Director of Nursing designee, IP stated they were unable to locate the investigation summary for Resident 2. IP stated the investigation summary should have been done and completed within five working days to ensure there was sufficient time to conduct a thorough investigation of the alleged abuse. The IP further stated she could not determine what transpired during the investigation because there was no documentation showing the findings or results of the investigation.During an interview on 9/29/25 at 2:36 p.m. with the Administrator (ADM), ADM stated if there was an allegation of abuse, an investigation would be conducted. ADM stated she would also notify the State Survey Agency, Long-Term Care Ombudsman (LTCO) and the Police Department immediately or within 24 hours, as required by regulation, to rule out abuse. ADM stated she had five working days to complete a thorough investigation of an allegation of abuse. ADM stated it was important to have the investigation summary completed to ensure no other residents had experienced the same allegation of abuse and to ensure the residents involved were protected from further harm.During a record review of the facility's policy and procedure (P&P), titled, Abuse Investigation and Reporting, dated March 2017, the P&P indicated, All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source ( abuse) shall be promptly reported to local, state and federal agencies.and thoroughly investigated by facility management. Findings of abuse investigations will also be reported.6. The Administrator, or his/her designee, will provide the appropriate agencies or individuals listed above with a written report of the findings of the investigation within five working days of the occurrence of the abuse.

Based on observation, interview, and record review, the facility failed to maintain infection control practices during COVID-19 (a contagious virus that mainly affects the lungs and can range from) outbreak when:1. Multiple resident rooms housing COVID-19 positive residents were left with doors open.2. Resident 2 and Resident 3, who were COVID-19 positive, were observed outside of their isolation rooms.3. Certified Nurse Assistant (CNA) 1 who assisted Resident 3 inside the room did not have personal protective equipment (PPE, proper specialized clothing or equipment worn to protect against workplace hazards or diseases).These failures had the potential to expose staff, visitors, and other residents to COVID-19, increasing the risk of transmission and compromising the health and safety of residents and staff during an active outbreak.During a record review of Resident 2's admission Record (AR) printed on 9/18/25, the AR indicated Resident 2 was admitted to the facility in 2024 with diagnoses of type 2 diabetes (high blood sugar) and alcohol dependence with withdrawal (alcohol use disorder with physical or mental withdrawal symptoms). During a record review of Resident 3's AR printed on 9/18/25, the AR indicated Resident 3 was admitted to the facility in 2025 with diagnoses of pleural effusion (excess fluid build-up in the lungs) and essential hypertension (high blood pressure).During an observation on 9/18/25 at 10:47 a.m., the door to room [ROOM NUMBER], which was occupied by a COVID-19 positive resident and had a posted contact precaution (infection control measures, requiring healthcare workers to wear PPE to prevent the spread of microorganisms) sign, was observed left open. During an observation on 9/18/25 at 10:48 a.m., the door to room [ROOM NUMBER], which was occupied by a COVID-19 positive resident and had a contact precaution sign, was observed left open. During an observation on 9/18/25 at 10:49 a.m., the doors to room [ROOM NUMBER] and room [ROOM NUMBER], which were occupied by a COVID-19 positive residents and had a contact precaution sign, were observed left open. During an observation on 9/18/25 at 10:53 a.m., the door to room [ROOM NUMBER], which was occupied by a COVID-19 positive resident and had a posted contact precaution sign, was observed left open. During an observation and interview on 9/18/25 at 10:56 a.m., Resident 2 was walking with no assistance in the hallway using front wheeled walker. Resident 2 stated she was looking for a supervisor to speak with. Resident 2 was assisted to where Licensed Vocational Nurse (LVN) 1 who was right in front of room [ROOM NUMBER]. During an interview on 9/18/25 at 11:00 a.m. with LVN 1, LVN 1 stated Resident 2 was COVID-19 positive and should have remained in the room under isolation, and that the doors to all COVID-19 rooms should have been kept closed to prevent the spread of infection because COVID-19 is managed with contact and droplet transmission (viruses or bacteria spread through coughing, sneezing, or talking).During an observation on 9/18/25 at 11:20 a.m., Resident 1, seated in a wheelchair, was outside of his isolation room with his surgical mask lowered to his chin, leaving both nose and mouth exposed. During an observation on 9/18/25 at 12:01 p.m., CNA 1 was inside an isolation room without wearing complete PPE while assisting Resident 3, who was COVID-19 positive. The isolation room's trash receptacle for disposal of soiled PPE was positioned by the window and away from the door. After providing care, CNA 1 hurriedly exited the isolation room without closing the door.During an interview on 9/18/25 at 12:02 p.m. with LVN 2, LVN 2 stated the trash receptacle for soiled PPE should have been placed near the room's exit door to prevent staff from re-exposing themselves to infection across the room. LVN 2 further stated when CNA 1 removed the PPE and continued to assist Resident 3 before exiting the room, it had the risk for potential spread of infection. During an interview on 9/18/25 at 1:42 p.m. with Infection Preventionist (IP), IP stated the doors to COVD-19 isolation rooms should have been kept closed and that Resident 2 and Resident 3 should have remained in their rooms until completing the required 10-day isolation period to prevent the spread of COVID-19 to other residents and staff. IP further stated without adherence to COVID-19 prevention practices, cases could increase, and the outbreak would continue. During a record review of the facility's undated policy and procedure (P&P), titled, COVID-19 Clinical Protocol, the P&P indicated, 5. Exposed resident/s to symptomatic resident or staff with potential or positive COVD-19 should remain in their respective room.13. Ensure staff adhere to hand hygiene and appropriate use of PPE when going in and coming out of isolation room.19. Room door should be kept closed except when entering or leaving the room, and entry and exit should be minimized.

Based on observation, interview, and record review, the facility failed to meet the needs of five of five sampled residents (Resident 1, 2, 3, 4, and 5) when the facility did not develop and implement a comprehensive, person-centered care plan to address Resident 1, 2, 3, 4, and 5 ' s use of handheld call bells when the call light system was not operational. This failure had the potential to result in Residents 1, 2, 3, 4, and 5 not receiving appropriate care and monitoring. Findings: During a record review of Resident 1's admission Record (AR), dated 5/9/25, the admission Record indicated Resident 1 was admitted to the facility in March 2023 with diagnoses of weakness and history of falling. During a record review of Resident 1 ' s Brief Interview for Mental Status (BIMS, is a scoring system used to determine the resident's cognitive status regarding attention, orientation, and ability to register and recall information. A BIMS score 13 to 15 is an indication of intact cognitive response.), dated 3/3/25, the record indicated Resident 1's BIMS score was 13. During an interview on 5/8/25 at 12:07 p.m. with Resident 1, Resident 1 stated the call light system had not been working for more than a month. Resident 1 stated the facility kept telling them that they were working on it when they asked about the call lights. Resident 1 stated she refused to use the call lights because it was annoying. Resident 1 stated she preferred to yell out if she needed some help from the staff. During a record review of Resident 2's AR, dated 5/9/25, the AR indicated Resident 2 was admitted to the facility in October 2020 with diagnoses of Parkinson ' s disease (disorder of the central nervous system that affects movement, often including tremors) and absence of left leg below knee. During a record review of Resident 2 ' s Brief Interview for Mental Status dated 3/18/25, Resident 2 ' s BIMS score was 14 indicating intact cognitive response. During a concurrent observation and interview on 5/8/25 at 12:31 p.m. with Resident 2, a handheld bell was located on top of Resident 2 ' s tray table. Resident 2 stated the call light system had not been fully functioning for a couple of years. Resident 2 stated the facility had given them handheld bells in replacement for the call light buttons. Resident 2 stated other residents might have been greatly affected by not having the call light buttons because some were physically disabled. During a record review of Resident 3's AR, dated 5/9/25, the AR indicated Resident 3 was admitted to the facility in February 2025 with diagnoses of cerebral infarction (occurs when the blood supply to part of the brain is blocked or reduced) and gastrostomy status (an opening into the stomach from the abdominal wall, made surgically for the introduction of food). During a record review of Resident 3 ' s Brief Interview for Mental Status dated 3/18/25, Resident 3 ' s BIMS was not attempted and the record indicated Resident 3 was rarely/never understood. During an observation on 5/8/25 at 12:46 p.m. with Resident 3, Resident 3 was lying in bed with an ongoing tube feeding (medical device used to provide nutrition to people who cannot obtain nutrition by mouth, are unable to swallow safely, or need nutritional supplementation). Resident 3 ' s handheld call bell was located on the bedside drawer table and not within Resident 3 ' s reach. During an inteview on 5/8/25 at 12:49 p.m. with Certified Nurse Assistant (CNA) 1, CNA 1 stated Resident 3 was not cognitively alert and unable to verbalize his needs. CNA 1 further stated Resident 3 needed a lot of supervision to prevent falls and injuries. During an interview on 5/8/25 at 12:51 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated the call lights in the long-term unit had been broken more than a year ago and ever since then the residents had been using the handheld call bells. LVN 1 stated having no working call lights posed a lot of risks including falls and injuries. LVN 1 stated some residents were physically and mentally not able to use the handheld bells. LVN 1 stated some residents also refrained from using the handheld call bell because the sound was too loud and annoying them. During a record review of Resident 4 ' s AR, dated 5/9/25, the AR indicated Resident 4 was admitted to the facility in April 2025 with diagnoses of history of falling and schizophrenia (a mental disorder characterized by disruptions in thought processes, perceptions, emotional responsiveness, and social interactions). During a record review of Resident 4 ' s Brief Interview for Mental Status dated 4/15/25, Resident 4 ' s BIMS score was 10 indicating moderate cognitive impairment. During an observation and interview on 5/8/25 at 2:18 p.m. with Resident 4, Resident 4 had a handheld bell on top of the tray table within reach. Resident 4 stated he had a fall a week ago because he tried to get up on his own and he tripped. Resident 4 stated there were times when he used the handheld bell provided to him, the staff took a while to respond. During a record review of Resident 5 ' s AR, printed on 5/8/25, the AR indicated Resident 5 was admitted to the facility in February 2025 with diagnosis of Alzheimer ' s disease (a progressive disease that destroys memory and other important mental functions). During a record review of Resident 5 ' s Brief Interview for Mental Status dated 4/15/25, Resident 5 ' s BIMS score was 8 indicating moderate cognitive impairment. During a concurrent observation and interview on 5/8/25 at 2:25 p.m. with Resident 5, Resident 5 was lying in bed. Resident 5 had a handheld bell on top of the tray table not within Resident 5 ' s reach. Resident 5 was observed to be confused when Resident 5 stated he was asking for his mother in the room. Resident 5 stated he did not like using the handheld bell because he did not need think he needed it. During an interview on 5/8/25 at 5:43 p.m. with the Director of Nursing (DON), the DON stated they did not develop a person-centered comprehensive care plan to Residents 1, 2, 3, 4, and 5 when the call light system stopped working. The DON stated they should have developed a person-centered care plan for all residents who were using the handheld bells so that everyone from the Interdisciplinary Team (IDT, a team that includes staff members from multiple disciplines such as nursing, therapy, physicians, and other advanced practitioners) could have been all aware of how to provide care accordingly. During a record review of the policy and procedure (P&P), titled, Care Plans, Comprehensive Person-Centered, revised in December 2016, the P&P indicated, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident ' s physical, psychosocial and functional needs is developed and implemented for each resident . 7. The care planning process will . a. Facilitate resident and/or representative involvement; b. Include an assessment of the resident ' s strengths and needs . 8. The comprehensive, person-centered care plan will a. Include measurable objectives and timeframes; b. Describe the services that are to be furnished to attain or maintain the resident ' s highest practicable physical, mental, and psychosocial well-being; c. Describe services that would otherwise be provided for the above, but are not provided due to the resident exercising his or her rights, including the right to refuse treatment; g. Incorporate identified problem areas; h. Incorporate risk factors associated with identified problems; i. Build on the resident ' s strengths . 12. The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required comprehensive assessment (MDS).

Based on observation, interview, and record review the facility nursing staff did not perform hand hygiene and infection control prevention to industry standard when handling waste disposal after caring for two residents (Residents 1 and 2). This failure had the potential to cause the spread of infection, which could result in hospitalization and death. Findings: During a review of Resident 1 ' s Admission Record, the Admission Record indicated Resident 1 was admitted to the facility in 2023 with diagnoses of malignant neoplasm of prostate (a tumor - an abnormal tissue mass when cells divide and grow more than normal) and mild intermittent asthma (inflammation of the airway caused by allergens, dust, or other particles). During a review of Resident 2 ' s Admission Record, the Admission Record indicated Resident 2 was admitted to the facility in 2024 with diagnoses of heart failure, bacteremia, and sepsis and chronic obstructive pulmonary disease (COPD, refers to a group of diseases that cause airflow blockage and breathing-related problems. It includes emphysema and chronic bronchitis.). During an observation on 12/5/2024 at 2:20 p.m., License Vocational Nurse 1 (LVN 1) came out of a resident ' s room pushing the treatment cart with a trash bag tied to the treatment cart and filled with waste and used gloves. During an observation on 12/5/2024 at 12:45 p.m., there were two blood pressure machines placed in the hallway outside of rooms 218 and room [ROOM NUMBER], with a trash bag tied to each blood pressure machine filled with trash, used gloves and dirty paper towels. During an observation on 12/5/2024 at 1:05 p.m., Certified Nurse Assistant 1 (CNA 1), removed her dirty gloves after cleaning a standing scale, held the same gloves in one hand and went to the doorway of room [ROOM NUMBER]. CNA 1 placed the dirty gloves in her bent right arm, used hand sanitizer, placed the gloves in one hand and went into the room of Residents 1 and 2. CNA 1 used the dirty gloves to hold the doorknob to open the resident ' s bathroom and then went to assist Resident 1 in bed with the same dirty gloves in her hand. CNA 1 came out of the room, placed the dirty gloves in her bent arm and used hand sanitizer. During an interview on 12/5/2024 at 1:10 p.m., with CNA 1, CNA 1 stated she should have placed the dirty gloves in the trash before she went into the room. CNA 1 also stated to prevent the spread of germs, she should not have used hand sanitizer with the gloves in her hand. CNA 1 stated it is protocol to use hand sanitizer. During an interview on 12/5/2024 at 12:50 p.m., with the Infection Preventionist (IP), the IP stated staff are not supposed to tie trash bags to equipment used for resident care because it could spread infection from one resident to another. During a review of facility ' s policy and procedure (P&P), titled Personal Protective Equipment-Using Gloves, Revised 2010, the P&P indicated, The purpose to guide the use of glove, to prevent the spread of infection, to protect hands from potentially infectious material. Discard used gloves into the waste receptacle inside the examination or treatment room. Removing gloves, discard the gloves into the designated waste receptacle inside the room.

45091 Based on observation, interview, and record review, the facility failed to ensure food was stored and prepared in clean environment, within standards for safety when: 1. Floor drains were not maintained clean; 2. Kitchen tile floors were not clean and were not maintained in good repair; 3. Time/Temperature Control for Safety Food (TCS; a food that requires time/temperature control for safety to limit pathogenic microorganism growth or toxin formation) was not cooled safely and there was no cooldown documentation; 4. Meat was not thawed appropriately; 5. The inside of a food storage refrigerator was not clean; 6. An industrial can opener was not maintained and clean; 7. Clean plates were handled with dirty oven mitts; 8. A food service equipment drawer was not clean; 9. The ceiling above a food preparation area was not clean; 10. There was no airgap (a gap between the sink drain and the drain that leads to sewage drain. This gap prevents a back-up of non-potable water and/or bacteria into the sink) in the food preparation sink drain; and 11. Tube feeding formulas were stored past expiration dates and were available for use for three residents (Residents 13, 42, and 60). These failures had the potential to result in contamination of food leading to food borne illness, for 68 residents who resided in the facility. Findings: 1. During observation in the kitchen on [DATE] at 10:10 a.m., a drain cover over the floor drain in the middle of the dish room was not secured and when the drain grate was removed there was thick sludge build-up as well as standing water inside the drain. In addition, there were small flies around the drain when the grate was lifted, and there was a bad odor coming from the drain. During an interview and observation with the Certified Dietary Manager (CDM) 1 on [DATE] at 3 p.m., CDM1 stated the drain appeared to be backed-up, and sludge in drain could harbor bacteria and was a safety hazard. Review of the facility's Policy and Procedure (P&P) titled General Cleaning of Food and Nutrition Services Department dated 2023, showed floor drains must be scheduled for routine cleaning in order to maintained in a functional condition. The Maintenance Department will assist with more thorough cleanings to ensure the viability of the plumbing features. According to the 2022 Federal Food Code Annex, pooling liquid wastes could attract pests such as insects and rodents or contribute to problems with certain pathogens. 2. An observation in the kitchen on [DATE] at 10:10 a.m., showed tiles around the floor drain were loose and not attached. There were additional tiles around the floor that were broken off, had missing grout, and were collecting pools of water. During observation on [DATE] at 3:00 p.m. There was separation from wall and the floor tile, with no grout. The length was approximately 2 feet in length. The gap with no grouting had dark residue particles resembling food crumbs, and small pieces of trash collecting in the area. During a concurrent observation on [DATE] at 3:00 p.m., there were loose wall tiles along area behind the manual warewashing sink, which created a gap between the wall and the tiles. During concurrent interview and observation with CDM1 on [DATE] at 10:10 a.m. CDM1 stated having loose tiles and the pooled water could harbor bacteria and was a safety hazard. CDM1 stated he was aware of the broken tiles and put in a request for maintenance to fix the issue around one month ago. CDM 1 stated he was not aware of the loose tiles. He confirmed the floor was dirty and that the pooling water could harbor bacteria. During an interview on [DATE] at 12:50 p.m., Operations Manager (OM) confirmed the floors in the kitchen were reported on the maintenance log about a month ago and it just slipped through the cracks. According to the 2022 Federal Food Code, floors and floor coverings are to be constructed so they are smooth and easily cleanable. In addition, when cleaning methods other than water flushing are used for cleaning floors, the floor and wall junctures are to be coved and closed to no larger than 1 mm (millimeter). If water flush cleaning methods are used, wall junctures are to be coved and sealed. According to the Annex, pooling liquid wastes could attract pests such as insects and rodents or contribute to problems with certain pathogens. 3. An observation in the kitchen and interview on [DATE] at 9:47 a.m., showed cooked roast pork in a metal pan, stored in a reach-in refrigerator. CDM1 stated he cooked the roast pork the evening prior and placed the cooked pork in the reach-in refrigerator but did not enter the cool down temperatures in the cool down log. During an observation and interview with [NAME] 1 and CDM 1 on [DATE] at 10:35 a.m., [NAME] 1 stated she did not cool food down that needed to be documented on a cooldown log. When [NAME] 1 was asked about a pan of sliced beef located in a reach-in refrigerator, which was covered with plastic, labeled ,d+[DATE] Beef Roast, [NAME] 1 stated it was left over from yesterday's lunch trayline. [NAME] 1 stated she did not measure or document cooldown temperatures for the leftover beef roast. CDM 1 confirmed there were no cooldown temperatures documented for the beef. CDM 1 stated, there should be a logbook to document cooldown temperatures, but he had not seen it lately. During an interview on [DATE] at 9:56 a.m., CDM 1 said there should be documentation for cooling food items. Review of the facility's P&P titled Cooling and Reheating of Potentially Hazardous [PHF] or Time/Temperature Control for Safety Food dated 2023, showed TCS food included food of animal origin. When TCS food will not be served right away it must be cooled as quickly as possible. Cool cooked food from 140 degrees Fahrenheit (F) to 70 degrees F within two hours; then cool from 70 degrees F to 41 degrees F or less in an additional four hours for a total cooling time of six hours. When cooling down food, use the Cool Down Log to document proper procedure. Review of the facility's policy and procedure titled Leftover Foods dated 2023, showed leftover foods are those that have been prepared for a meal and not served. As soon as hot food has dropped to 140 degrees F, the proper methods of cooling food must be used and refer to the Cooling and Reheating of PHF/TCS Food Policy. 4. During an observation on [DATE] at 10:33 a.m., a 13 pound raw pork roast thawed in a cardboard box on the lower level of refrigerator #2, adjacent to two large cardboard boxes containing small carton of vanilla and chocolate protein shakes. The bottom surface of the cardboard box the pork was stored in, was visibly wet. The pork roast was soft to the touch and was dated [DATE] with a use by date of [DATE]. During an interview on [DATE] at 9:47 a.m., CDM 1 stated he cooked the pork last night with a use-by date of [DATE], and the cooked pork was now stored in the refrigerator. During an interview on [DATE] at 11:30 a.m., CDM 1 confirmed the pork was cooked on the fourth day into the thawing process, and it should not have been cooked and instead discarded. During an interview on [DATE] at 9:56 a.m., CDM 1 stated meat should be thawed in the refrigerator in a plastic tub. CDM 1 confirmed if meat was thawed in a cardboard box, this could result in cross contamination from the juices of the thawed meat to other items in the refrigerator. Review of the facility's P&P titled Thawing of Meats dated 2023, showed thawing meat properly could be done in the refrigerator. Allow 2 to 3 days to defrost, depending on the quantity and total weight of the meat. Label the defrosting meat with pull and use by date. Use a drip pan under food being thawed so drippings do not contaminate other food. 5. An observation in the kitchen on [DATE] at 10:40 a.m., showed Refrigerator #2 stored containers of milk and juices. There was an accumulation of a sticky, white residue, and a sticky, dark residue on the wire, metal shelving inside the refrigerator. The wire shelving surface was rough and bumpy from the residue build-up, and sticky residue wiped off with a paper towel. During interview on [DATE] on 10:42 a.m. with CDM1, he stated the refrigerator should be on a deep cleaning schedule and that the racks looked dirty. CDM 1 stated the residue build-up might have been from spilled milk and juices. Review of the facility's P&P titles Refrigerator and Freezer dated 2023, showed maintaining a clean refrigerator can improve the safety and quality of foods. Refrigerators should be on a weekly cleaning schedule. Wipe up spills immediately. According to the 2022 Federal Food Code, multi-use food-contact surfaces shall be smooth, and equipment food-contact surfaces are to be clean to sight and touch. Nonfood-contact surfaces of equipment are to be kept free of an accumulation of dust, dirt, food residue, and other debris. 6. An observation in the kitchen on [DATE] at 10:48 a.m. showed a large metal industrial can opener stored in a base (the can opener holder) attached to a metal table. There was accumulated dark matter on the can opener base, as well as the can opener blade. The surface around the blade was sticky to the touch. In addition, the surface of the can opener metal cogwheel (the part that helps turn the can) had dark orange build-up. During a concurrent observation and interview on [DATE] at 10:50 a.m., CDM1 was asked how often the can opener was cleaned. CDM1 stated the can opener was deep cleaned once a week. CDM 1 confirmed there was black residue build-up on the can opener base and the surface around the blade was sticky. CDM1 stated the cogwheel had rust or residue on the surface. CDM 1 stated a dirty can opener could cause foodborne illness or metal contamination from the rust. Review of the facility's P&P titled Can Opener and Base dated 2023, showed proper sanitation and maintenance of the can opener and base is important to sanitary food preparation. The can opener must be thoroughly cleaned each work shift and, when necessary, more frequently. 7. An observation in the kitchen on [DATE] at 11:53 a.m. during trayline food service, [NAME] 2 wore oven mitts and handled the top surface of plates, which were used to plate resident food. The oven mitts had dried residue on the outside surface around the finger and thumb areas. During interview on [DATE] at 11:57 a.m. CDM1 stated the oven mitts should be cleaned when they were used and/or dirty. CDM 1 confirmed the oven mitts used by [NAME] 2 to handle the clean dishes had a film on the outside and pointed to the dried residue on the outside of the mitts. CDM1 said the oven mitts should not be used to handle clean plates. CDM 1 stated it was inappropriate to use dirty objects to handle clean plates as this could result in cross-contamination. According to the 2022 Federal Food Code, cleaned and sanitized utensils shall be handled so that contamination of food-contact surfaces is prevented. 8. An observation in the kitchen on [DATE] at 10:05 a.m., showed a drawer used to store serving scoops had particles resembling food crumbs on base of drawer with various size scoops resting on top. There was also a sticky substances around the rim of the drawer. During interview on [DATE] at 10:05 a.m. CDM1 confirmed the scoop drawer was not cleaned and stated having these substances in and on the drawer could result in cross-contamination of the serving scoops, as well as possibly resulting in foodborne illness. According to the 2022 Federal Food Code, equipment food-contact surfaces are to be clean to sight and touch. Nonfood-contact surfaces of equipment are to be kept free of an accumulation of dust, dirt, food residue, and other debris. 9. During observation in the kitchen on [DATE] at 10:40 a.m., four ceiling tiles had visible accumulated, gray, fuzzy matter on the surface. These ceiling tiles were located above the food preparation area. During interview on [DATE] at 10:40 a.m. CDM1 stated maintenance was responsible for cleaning ceiling tiles in the kitchen. During interview on [DATE] at 3:00 p.m., Maintenance (Main) stated kitchen staff were responsible for cleaning ceiling tiles. Review of the facility's policy and procedure tiled Walls, Ceilings, and Light Fixtures dated 2023, showed ceilings must be washed twice a year and must be cleaned more often as necessary. According to the 2022 Federal Food Code, physical facilities shall be cleaned as often as necessary to keep the clean. 10. An observation in the kitchen on [DATE] at 11:20 a.m. showed the food preparation sink drain was plumbed directly into the wall. During interview and observation with the Operations Manager (OM) on [DATE] at 3:30 p.m., OM confirmed there was no visible gap in the food preparation sink drain. According to the 2022 Federal Food Code, a direct connection may not exist between the sewage system and the drain originating from equipment in which food, portable equipment, or utensils are placed. 11. A review of Resident 13's Admission Record printed [DATE], indicated Resident 13 was admitted to the facility in 2023 with multiple diagnoses, which included an admission diagnosis of Chronic Obstructive Pulmonary Disease (COPD, refers to a group of diseases that cause airflow blockage and breathing-related problems, including emphysema and chronic bronchitis). A review of Resident 42's Admission Record printed [DATE], indicated Resident 42 was admitted to the facility in 2023 with multiple diagnoses, which included an admission diagnosis of Cerebral Infarction . (death of an area of brain tissue when a blocked blood vessel prevents delivery of an adequate blood and oxygen supply to the brain). A review of Resident 60's Admission Record printed [DATE], indicated Resident 60 was admitted to the facility in 2024 with multiple diagnoses, which included an admission diagnosis of Nontraumatic Intracerebral Hemorrhage . (a type of stroke that occurs when bleeding happens in the brain without trauma or surgery). During a concurrent observation and interview on [DATE], at 3:54 p.m., with Director of Nursing (DON), the medication room was observed. Three 1500 milliliter nutritional tube feeding formulas with a use by date of [DATE] were stored and available for resident use. DON stated the formula was expired and they would throw it in the trash. DON stated, I wouldn't give that to a resident. DON stated, they didn't want to give residents anything expired to protect their safety. During a review of Resident 13's Doctor's Order, dated [DATE], the Order indicated Resident 13 had a doctor's order for provide 1700mL . formula . During a review of Resident 42's Doctor's Order, dated [DATE], the Order indicated Resident 42 had a doctor's order for every shift . T/F (tube feeding) formula . During a review of Resident 60's Doctor's Order, dated [DATE], the order indicated Resident 60 had a doctor's order for T/F Formula . 1500mL. During a review of the facility's policy and procedure (P&P) titled, Enteral feedings - Safety Precautions, Revised [DATE], the P&P indicated, Maintain inventory controls and discard any formula past the expiration date. 50120

Based on observation, interview, and facility document review, the facility failed to ensure: 1. Residents had a location to safely store perishable food brought into the facility by family/visitors; and 2. A policy described the safe storage of food brought in by family members. This failure had the potential to result in foodborne illness from unsafe food storage, decreased food intake, and did not create a homelike environment for 65 residents who took food by mouth out of a census of 68. Findings: During an interview on 7/16/24 at 2:40 p.m., Certified Nursing Assistant (CNA) 1 stated sometimes food brought in by family/visitors was stored for residents in the staff refrigerator. CNA 1 stated she thought perishable food could be stored up to 24 hours in the staff refrigerator. During an interview on 7/16/24 at 2:48 p.m., CNA 2 stated sometimes family and visitors brought in food for residents, but the facility did not store residents' perishable food because there was not a refrigerator for this purpose. CNA 2 stated if milk was at a resident's bedside during her shift, she would discard it the next day when she was back for her next shift. CNA 2 was asked what the procedures were if a family member brought in a food item such as meat lasagna for a resident. CNA 2 stated if the meat lasagna was brought in during her shift in the afternoon, she would leave it at the resident's bedside in case the resident wanted to eat it for dinner. CNA 2 stated if the meat lasagna was still at the resident's bedside the next day, then she would discard it. An observation on 7/17/24 at 11:05 a.m., showed a refrigerator in the staff breakroom. There was not an internal thermometer inside the refrigerator. During an interview on 7/17/24 at 11:10 a.m., the Restorative Nursing Assistant (RNA) stated she cleaned the staff refrigerator, and she was not aware of a thermometer or a temperature log for the staff refrigerator. RNA stated there was not a refrigerator to store residents' personal perishable food. During an interview on 7/17/24 at 12:42 p.m., the Director of Nursing (DON) stated she was under the impression residents were allowed to keep perishable food for the day. DON stated if a perishable food was brought in for a resident at 8 a.m., the food could be stored in the resident's room until midnight. DON stated she did not know how long perishable food could be stored without refrigeration. DON stated there was not a specific place to store residents' personal perishable food. Review of the facility's policy and procedure titled Food Brought by Family/Visitors, revised 2014, showed family members should inform nursing staff of their desire to bring food into the facility. Perishable foods must be stored in re-sealable containers with tightly fitting lids in the refrigerator. Containers will be labeled including the use-by-date. It was noted this policy did not describe how many hours/days perishable food could be stored for the resident. According to the 2022 Federal Food Code, except during preparation, cooking, or cooling, or when time is used as the public health control, Time/Temperature Control for Safety (TCS) food is to be maintained at or above 130 degrees, or at or below 41 degrees F. In addition, if time without temperature control is used as the public health control there can be up to a maximum of 6 hours with an initial temperature of 41 degrees or less. The food may not exceed 70 degrees F within a maximum time period of 6 hours. 50120

Based on observation, interview and record review, the facility failed to ensure the menu was followed for 6 residents on Renal diets (diet that promotes kidney health) and Renal Consistent Carbohydrate (CCHO; a diet typically prescribed to control blood sugar) out of 65 residents who received food from the kitchen. This failure had the potential to result in providing residents on a Renal diet and Renal CCHO diets with an inadequate and/or a harmful amount of nutrients, further compromising residents' medical status. Findings: Review of tray tickets for lunch dated 7/15/24 and used for the lunch trayline on 7/15/24, showed 3 residents received a Renal diet and 3 residents received a Renal CCHO diet. During concurrent tray line observation and record review on 7/15/24 at 12:00 p.m., lunch trays were prepared for residents. The trays included desserts which were placed on the tray by Dietary Aide (DA) 1. The trays with a tray ticket that specified the resident was on a Renal diet or Renal CCHO, had a cup of cappuccino chocolate mousse. Review of the cook's spreadsheet titled Summer Menus dated 7/15/24, showed the dessert for Regular diets was cappuccino mousse, the dessert for Renal diets was two small sugar cookies, small-approximately two inches, and the dessert for Renal CCHO was two small diet sugar cookies. During an observation of trayline and concurrent interviews with DA1, [NAME] 2, and the Certified Dietary Manager (CDM) 1 on 7/15/24 starting at 12 p.m., the surveyor asked DA 1 if residents on a Renal diets should receive mousse or cookies according to the menu, DA 1 confirmed cookies. DA 1 confirmed she placed the Cappuccino Mousse on the trays for the Renal diets. DA 1 placed eight cookies in plastic bags but did not switch out the mousse for the cookies on the Renal trays and left the kitchen. When the surveyor asked [NAME] 2, who also placed food on the trays, if the cookies should replace the mousse for the Renal diets, [NAME] 2 said she was not responsible for the desserts. When CDM 1 was asked if eight cookies were appropriate for the Renal diets, he stated he did not know. During an interview on 7/18/24 at 9:56 a.m., CDM 1 stated he did not clarify with the Registered Dietitian (RD) how many cookies the Renal diets should have received for lunch on 7/15/24 and what type of diet cookies the Renal CCHO diets should have received. During a phone interview with RD1 on 7/18/24 at 12:05 p.m., RD1 stated the menu should have been followed for lunch on 7/15/24. In a consecutive phone interview with RD1 on 7/18/24 at 1:45 p.m., RD1 stated regular vanilla wafers were not appropriate for the Renal CCHO diet and she was not sure if the kitchen had diet/low carbohydrate cookies available. 50120

Based on observation, interview, and record review the facility failed to provide the appropriate food texture for mechanical soft diets. This deficient practice had the potential to cause difficulty with eating, chewing, and/or swallowing leading to an increased risk of choking for 10 of 10 residents who received prescribed mechanical soft diets. Findings: Review of the Cooks spreadsheet titled Summer Menus dated 7/15/24, showed residents prescribed a Mechanical Soft diet received ground French Dip-Roast Beef moistened with broth, and chopped corn coleslaw. During an observation of trayline food service and concurrent interviews with [NAME] 1 and the Certified Dietary Manager (CDM) 1 on 7/15/24 starting at 12:00 p.m., residents who's tray ticket indicated a physician prescribed Mechanical Soft diet were served dry, shredded roast beef on a bun, with no added au jus (a light broth or gravy usually made with the meat's natural juices). In addition, Mechanical Soft diets were served a bowl of dry coleslaw (shredded cabbage salad). [NAME] 1 confirmed she did not moisten the mechanical beef with the au jus. CDM1 stated confirmed the mechanical meat was dry and it should have the au jus added to the meat. During an observation and interview on 7/15/24 at 1:10 p.m., CDM 1 confirmed the coleslaw served to Mechanical Soft diets was dry and was not mixed with a dressing or any type of moistener. During an interview and facility document review on 7/15/24 at 1:45 p.m., the recipe for the coleslaw was reviewed with CDM 1, and he confirmed the coleslaw recipe included but was not limited to shredded cabbage, lemon juice and mayonnaise, and the ingredients were to be all combined. During interview on 7/17/24 at 2:50 p.m., the Speech Language Pathologist (SLP) stated in general, for residents on a Mechanical Soft diet, moist food, such as cabbage mixed with a sauce, was safer than dry cabbage. Review of the facility'sDiet Manual dated 2020, showed the Mechanical Soft diet is designed for residents who experience chewing or swallowing limitations. Meats are to be ground with meat juices, gravy or sauce. Dry meat is not allowed. 50120

Based on observation, interview, and facility document review, the facility failed to fortify resident food according to physician orders. This failure had the potential to result in decreased calorie intake for two (Residents 9 and 14) out of seven residents who had physician prescribed fortified diets. Findings: An observation of trayline food service on 7/15/24 at 12 p.m., showed resident diets printed on tray tickets, and fortified was included in seven resident diets. [NAME] 2 called out diets according to the tray ticket to [NAME] 1. Then [NAME] 1 placed hot food on plates according to the diet called out. [NAME] 2 did not call out fortified when she called out diets with fortified printed on the tray ticket. When the surveyor asked how diets were fortified, [NAME] 1 stated residents with fortified diets received margarine on the sweet potato fries. [NAME] 1 informed [NAME] 2, she had to call out fortified when it was printed on the ticket in order for her to know to place margarine on the sweet potato fries. [NAME] 1 confirmed she did not call out fortified printed on the tray tickets for the first food cart delivered which carried Resident 9 and Resident 14's trays. Review of the lunch tray tickets dated July 15, 2024, showed Resident 9 and 14 were to receive a Fortified diet. During an interview on 07/18/24 at 9:56 a.m., Certified Diet Manager (CDM) 1 confirmed fortified diets were physician prescribed. Review of the facility's Diet Manual dated 2020, showed the Fortified Diet is designed for residents who cannot consume adequate amounts of calories and/or protein to maintain their weight or nutritional status. The goal is to increase the calorie density of the foods commonly consumed by the resident. The amount of calorie increase should be approximately 300-400 per day. Examples of adding calories may include extra margarine or butter to food items. 50120 the facility did not ensure physicians orders were followed for fortified diet FACILITY Dining Observation

Based on observation, interview, and record review, the facility failed to ensure the call light (a device used by a patient to signal his or her needs for assistance) was functioning for 13 of 68 sampled residents (Resident 32, 168, 40, 174, 26, 51, 20, 31, 41, 2, 4, 5, and 53). This deficient practice had the potential to result in the delay of care and services. Findings: 1. a. During a review of Resident 32's Admission Record, dated 7/17/24, indicated Resident 32 was admitted to the facility on [DATE] with multiple diagnoses that included Parkinson's Disease (a progressive disorder that affects nervous system and parts of the body controlled by the nerves), absence of right and left legs below knees. During a review of Resident 32's Minimum Data Set (MDS - a standardized assessment and screening tool), dated 4/21/24, indicated Resident 32 had a Brief Interview for Mental Status (BIMS - a tool used to assess mental function) score of 14. Meaning Resident 32 was able to understand and understood others. The MDS also indicated Resident 32 was always incontinent of both bladder and bowel. b. During a review of Resident 168's Admission Record, dated 7/17/24, indicated Resident 168 was admitted to the facility on [DATE] with multiple diagnoses that included weakness, migraine (severe headache) and urinary tract infection. c. During a review of Resident 40's Admission Record, dated 7/17/24, indicated Resident 40 was admitted to the facility on [DATE] with multiple diagnoses that included urinary tract infection. During a review of Resident 40's MDS, dated [DATE], indicated Resident 40 had a BIMS score of 13. Meaning Resident 40 was able to understand and understood others. The MDS also indicated Resident 40 required partial/moderate assistance with toileting hygiene and toilet transfer. d. During a review of Resident 174's admission record, dated 7/17/24, indicated Resident 174 was admitted to the facility on [DATE] with multiple diagnoses that included unspecified injury. During a review of Resident 174's MDS, dated [DATE], the MDS indicated, Resident 174 had a BIMS score of 09. Meaning, Resident 174's cognition was moderately impaired. The MDS also indicated, Resident 174 was occasionally incontinent of bladder and bowel. e. During a review of Resident 26's Admission Record, dated 7/17/24, indicated Resident 26 was originally admitted to the facility on [DATE] and was readmitted on [DATE] ,with multiple diagnoses that included obesity, spinal stenosis (a condition that causes pressure on the spinal cord), polyneuropathy (malfunction of many peripheral nerves), neuromuscular dysfunction of bladder (lack of bladder control due to brain, spinal cord and nerve problem) and weakness. During a review of Resident 26's MDS, dated [DATE] indicated Resident 26 had a BIMS score of 13. The MDS also showed, Resident 26 was occasionally incontinent of urine and always incontinent of bowel. f. During a review of Resident 51's Admission Record, dated 7/17/24, Resident 51 was admitted to the facility on [DATE] with multiple diagnoses that included, unspecified injury, neuromuscular dysfunction of bladder, chronic pain syndrome and unspecified nondisplaced fracture. During a review of Resident 51's MDS, dated [DATE], indicated Resident 51 had a BIMS score of 12. Meaning Resident 51's cognition was moderately impaired. The MDS also indicated Resident 51 was always incontinent of bowel. During a concurrent observation and interview on 7/15/24 at 9:54 a.m. with Resident 32, call bell was on the overbed table. Resident 32 stated, she had been using call bell for help, call light has been broken months. During a concurrent observation and interview on 7/15/24 at 10:05 a.m. with Resident 168, Resident 168 stated, call bell was inadequate. Resident 168 further added, last night, she waited for one hour after ringing call bell for her pain medication. Resident 168 also stated call bell was not effective in getting help. During a concurrent observation and interview on 7/15/24 at 10:22 a.m. with Resident 26 in the presence of Certified Nurse Assistant (CNA) 4, Resident 26 stated, call light was broken for weeks now. Resident 26 also stated, the hand bell did not work, when you ring the bell, it takes forever for the staff to come. During a concurrent observation and interview on 7/15/24 at 10:22 a.m. with Resident 51 in the presence of CNA 4, Resident 51 stated, call light did not work. Resident 51 further added, you can ring it (hand bell), they don't come right away. CNA 4 was observed to check the call lights attached to the walls and confirmed Resident 51 and Resident 26's call lights did not work. CNA 4 stated, it has been two weeks since call lights were broken. During a concurrent observation and interview on 7/15/24 at 10:37 a.m., with Resident 40, Resident 40 stated, it was hard to get help from staff because call light did not work. During an interview on 7/15/24 at 10:57 a.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated, the were issues with call lights. LVN 1 also stated, quality of care was impacted when resident's call lights do not function. During an interview on 7/16/24, at 10:08 a.m., with CNA 3, CNA 3 stated, the call light problem (being broken) has existed since she began her employment one month ago. CNA 3 further stated, the hand bell given to residents with call light issues were not effective as CNAs had to check which room the hand bell was coming from. During a concurrent observation and interview on 7/16/24 at 10:36 a.m. with Resident 174, Resident 174 stated, call light has not worked in over a week, no one comes when you ring hand bell. Resident 174 further added, he had to wait for staff to walk by and call for help. During a concurrent observation and interview on 7/16/24 at 12:23 p.m. with Maintenance (MAIN), MAIN was observed checking resident call lights and confirmed the call lights for Resident 32, 168, 40, 174, 26, 51 were broken. MAIN also stated, he was designated to fix call lights but was not successful even after changing call light fixtures. MAIN further added, he notified Operations Manager (OM) regarding broken call lights one week ago. During an interview on 7/16/24, at 12:43 p.m., with OM, OM stated he was aware of the call light not functioning properly in multiple resident rooms. OM also stated, the facility made attempts to fix the call light but was not successful. 45091 2. A review of Resident 20's Admission Record printed 7/17/24, indicated Resident 20 was admitted to the facility in 2022 with multiple diagnoses, which included an admission diagnosis of Other Specified Disorders of the Brain (a medical classification under the range of Diseases of the nervous system) During a concurrent observation and interview on 7/16/24, at 9:54 a.m., with Resident 20, Resident 20's call did not work. Resident 20 stated their call light has been broken for a week and staff were aware. Resident 20 stated it made them upset. During a review of Resident 20's Minimum Data Set (MDS, an assessment tool used to guide care), dated 5/10/24, the MDS indicated Resident 20 had a Brief Interview for Mental Status (BIMS, a screening tool used to assess cognition) score of 13, meaning intact cognition. The MDS indicted Resident 20 was, always incontinent, for urine and bowel (unable to control keeping urine or feces in the body). The MDS indicated Resident 20 needed Partial/moderate assistance, for toileting hygiene, roll left and right, lying to sitting on side of bed, sit to stand, chair/bed-to-chair transfer, toilet transfer, and tub/shower transfer. A review of Resident 31's Admission Record printed 7/17/24, indicated Resident 31 was admitted to the facility in 2022 with multiple diagnoses, which included an admission diagnosis of Cerebral Infraction (death of an area of brain tissue when a blocked blood vessel prevents delivery of an adequate blood and oxygen supply to the brain). During a concurrent observation and interview on 7/16/24, at 9:48 a.m. Resident 31's call did not work. Resident 31 stated their call light has been broken for a week and staff were aware. Resident 31 stated it made them upset. During a review of Resident 31's MDS dated [DATE], the MDS indicated Resident 31 had a BIMS score of 13, meaning intact cognition. The MDS indicated Resident 31 needed Supervision or touching assistance, for lying to sitting on side of bed, Sit to stand, Chair/bed-to-chair transfer, and toilet transfer. A review of Resident 41's Admission Record printed 7/17/24, indicated Resident 41 was admitted to the facility in 2023 with multiple diagnoses, which included an admission diagnosis of Parkinson's Disease (A brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination. Symptoms usually begin gradually and worsen over time. As the disease progresses, people may have difficulty walking and talking. They may also have mental and behavioral changes, sleep problems, depression, memory difficulties, and fatigue.). During a concurrent observation and interview on 7/15/24, at 1:33 p.m., with CNA 4, CNA 4 confirmed Resident 41's call light did not work. During a review of Resident 41's MDS dated [DATE], the MDS indicated Resident 41's cognitive skills for daily decision making, was moderately impaired. The MDS indicated Resident 41 was, always incontinent, for urine. The MDS indicated Resident 41 needed Substantial/maximal assistance, for toilet transfer. The MDS indicated Resident 41 needed partial/moderate assistance, for toileting hygiene, roll left and right, sit to lying, lying to sitting on side of bed, sit to stand, and chair/bed-to-chair transfer. 49498 3. a. During the resident council interview on 7/17/24 at 10:33 a.m. with Resident 2, Resident 2 stated the call light glitches, sometimes it worked, sometimes it did not, and had been like that for a week. During a record review of Resident 2's MDS dated [DATE], indicated Resident 2's score was 14 out of 15, indicating intact mental status. The MDS indicated Resident 2 required partial/moderate assistance from staff for toileting hygiene, shower/bathing, lower body dressing, lying to sitting on side of bed, sit to stand, chair to bed transfer and toilet transfer. b. During a concurrent observation and interview on 7/15/24 at 11:06 a.m. in Resident 4's room, Resident 4 pressed the call button. Resident 4 stated he needed to be changed. During an observation on 7/15/24 at 11:07 a.m. outside Resident 4's room, the call system light above the door had no light to alert the staff. During a concurrent observation and interview on 7/18/24 at 11:43 a.m. with Certified Nurse Assistant (CNA) 5 in Resident 4's room, CNA 5 pressed Resident 4's call button then went out of the room to check the call system light above the door. CNA 5 stated Resident 4's call light did not turn on. During a concurrent observation and interview on 7/18/24 at 11:55 a.m. in Resident 4's room, CNA 5 removed Resident 4's call system cord plug from the port then plugged in new one. CNA 5 pressed the call button then went out of the room to check the call system light above the door. CNA 5 stated Resident 4's call light did not turn on. During a review of Resident 4's undated Admission Record, indicated Resident 4 was admitted to the facility in 7/24/23 with multiple diagnoses, which included an admission diagnosis of Vascular 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). During a review of Resident 4's MDS dated [DATE], the MDS indicated Resident 4 had a BIMS score of 08 out of 15, meaning moderate cognitive impairment. The MDS indicted Resident 4 was always incontinent of bowel function (unable to control keeping feces in the body). The MDS indicated Resident 4 was dependent from staff for toileting hygiene and required partial/moderate assistance for mobility to roll left and right and lying to sitting on side of bed. c. During an observation on 7/15/24 at 10:14 a.m. in Resident 5's room, Resident 5's white call system cord was on the floor and was separated from the plug attached to the call system port located at the wall. During a concurrent observation and interview on 7/18/24 at 11:47 a.m. with Certified Nursing Assistant (CNA) 5 in Resident 5's room, Resident 5's white call system cord was on the floor and was separated from the plug attached to the call system port located at the wall. CNA 5 stated the call cord plug and the cord was separated. CNA 5 stated the call cord separated from the plug when the head of the resident's bed was elevated and was pulled from the wall. During an interview on 7/18/24 on 11:49 a.m. with Resident 5, Resident 5 stated, she asked her roommate, Resident 39, with working call system, to press her call button to call the staff for her. During a review of Resident 5's undated Admission Record, indicated Resident 5 was admitted to the facility on [DATE] with multiple diagnoses, which included an admission diagnosis of Personal history of Transient Ischemic Attack (TIA- a short period of symptoms like those of a stroke. It's caused by a brief blockage of blood flow to the brain.), During a review of Resident 5's Minimum Data Set (MDS, an assessment tool used to guide care) dated 5/20/24, the MDS indicated Resident 5 had a Brief Interview for Mental Status (BIMS, a screening tool used to assess cognition) score of 11 out of 15, meaning moderate cognitive impairment. The MDS indicted Resident 5 was occasionally incontinent of urine and bowel function (unable to control keeping urine and feces in the body). The MDS indicated Resident 5 required substantial/maximal assistance from staff for toileting hygiene and required partial/moderate assistance for mobility to roll left and right and sit to lying on bed. d. During the resident council interview on 7/17/24 at 10:35 a.m. with Resident 53, Resident 53 stated the call light in her bathroom was not working. During a record review of Resident 53's MDS dated [DATE], indicated Resident 53's BIMS score was 13 out of 15, indicating intact mental status. The MDS indicted Resident 53 was always incontinent of urine and bowel function (unable to control keeping urine and feces in the body). The MDS indicated Resident 53 required partial/moderate assistance from staff for toileting hygiene, shower/bathing, lower body dressing, lying to sitting on side of bed, sit to stand, chair to bed transfer and toilet transfer.

Based on observation and interview, the facility failed to provide a comfortable, temperature-controlled environment for one of six residents (Resident 319) when Resident 319's window was in a fixed open position and found to be non-functional due to a missing crank. This failure prevented Resident 319 from opening or closing the window at the resident's discretion to control the room's temperature. Findings: During a review of Resident 319's Minimum Data Set (MDS - an assessment tool used to guide care) assessment dated [DATE], Section C showed a Brief Interview for Mental Status (BIMS - an assessment tool used to evaluate mental status) score of 12 out of 15, indicating the resident had moderately impaired mental status but could communicate needs. During a concurrent observation and interview on 7/15/2024 at 10:00 am with Resident 319 in her room, the window was missing a crank handle and could not be closed. Resident 319 stated she was unable to close the window adjacent to the foot of the bed resulting in a draft on her feet at night. Resident 319 stated the open window was bothersome because it made her feet cold and it was reported to staff on 7/14/2024. During an interview on 7/17/2024 at 2:30 pm, with Maintenance (MAIN), MAIN stated he was unaware of the broken crank on the window. Main stated staff report items in need of repair to him and if he is unable to repair it a vendor is brought in. MAIN stated he was not familiar with, nor used, a maintenance log to track or report broken items.

Based on observation, interview, and record review, the facility failed to ensure medication error rate did not exceed five percent. There were four medication errors out of 26 opportunities for errors, which resulted in an error rate of 15.38 percent (%). 1. For Resident 39, Licensed Vocational Nurse (LVN) 2 administered insulin (a medication that helps people control their blood sugar) that was expired for 13 days. 2. For Resident 220, LVN 3 administered Senna (a medication used to relieve constipation) . and Divalproex (a medication used to treat seizures) 2hrs (hours) over their appropriate scheduled timeframe, and Levetiracetam (a drug used to treat seizures) 3hrs over it's appropriate scheduled timeframe. These failures had the potential to jeopardize resident 39 and 220's health due to unsafe medication administration practices not being followed. Findings: 1. A review of Resident 39's Admission Record printed [DATE], indicated Resident 39 was admitted to the facility in 2024 with multiple diagnoses, which included Type 2 Diabetes Mellitus (a long-term disease in which the body cannot regulate the amount of sugar in the blood) with Diabetic Neuropathy, unspecified (a complication of diabetes that causes nerve damage throughout the body). During an observation on [DATE], at 11:58 a.m., with LVN 2, LVN 2 was observed while they administered insulin to Resident 39. Resident 39's insulin medication label indicated, Discard 31 days after opening, and Date open [DATE]. During an interview on [DATE], at 12:55 p.m., with LVN 2, LVN 2 stated, they trashed the insulin. LVN 2 stated a medication's mechanism of action can be decreased if it was given past the expiration date. During an interview on [DATE], at 12:52 p.m., with Director of Nursing (DON), DON stated, their policy for insulin was to document the open date on the insulin bottle and appropriately dispose of the insulin on the manufacture's recommended expiration date, which was usually 28 or 31 days after opening. DON stated it was important to use insulin within the manufacture's recommended timeframe to ensure the medication was most effective. During a review of Resident 39's Doctor's Order, dated [DATE], the order indicated Resident 39 had a doctor's order for Insulin Regular Human Injection Solution 100 Unit/mL (milliliter) (a short-acting insulin) . Inject as per sliding scale . subcutaneously (under the skin) before meals . During a review of Residents 39's SBAR (situation, background, assessment, and recommendation) Communication Form, dated [DATE], the SBAR indicated on [DATE], Resident was given insulin that was past it's 28 use date. The SBAR indicated Recommendations of Primary Clinicians . Continue to monitor for adverse effects r/t (related to) expired insulin such as uncontrolled glucose, N/V (nausea/ vomiting) . During a review of the facility's policy and procedure (P&P) titled, Insulin Administration, revised [DATE], the P&P indicated, Purpose . To provide guidelines for the safe administration of insulin to residents with diabetes. The P&P indicated Steps in the Procedure (Insulin Injections via Syringe) . Check expiration date, if drawing from an opened multi-dose vial. If opening a new vial, record expiration date and time on the vial (follow manufacturer recommendations for expiration after opening). During a review of the facility's policy and procedure (P&P) titled, Medication Administration General Guidelines, dated 2007, the P&P indicated, No expired medication will be administered to a resident. 2. A review of Resident 220's Admission Record printed [DATE], indicated Resident 220 was admitted to the facility in 2024 with multiple diagnoses, which included Cerebral Infarction, Unspecified (death of an area of brain tissue when a blocked blood vessel prevents delivery of an adequate blood and oxygen supply to the brain). During an observation on [DATE], at 11:24 a.m., with LVN 3, LVN 3 was observed while they administered medications to Resident 220. LVN 3 administered Senna, Divalproex, and Levetiracetam, to Resident 220. During an interview on [DATE], at 11:45 a.m., with LVN 3, LVN 3 stated their policy was to give medications up to 1hr (hour) before or after the doctor's ordered time. LVN 3 stated it was important to give medications on time as ordered because it could have disturbed their medication schedule. During an interview on [DATE], at 12:40 p.m. with DON, DON stated their policy was to administer medications up to 1hr before or after their doctor's ordered scheduled time. DON stated it was important to give medications on time to ensure they were effective. During a review of Resident 220's Doctor's Orders, dated [DATE], the orders indicated Resident 220 had a doctor's order, dated [DATE], for Senna Oral Tablet 8.6 MG . Give 2 tablet by mouth two times a day for bowel regularity . The orders indicated Resident 220 had a doctor's order, dated [DATE], for Divalproex Sodium Oral Tablet Delayed Release 500 MG (milligram) . Give 1 tablet by mouth two times a day for epilepsy (a group of brain disorders that causes seizures) The orders indicated Resident 220 had a doctor's order, dated [DATE], for Levetiracetam Oral Tablet 250 MG . Give 1 tablet by mouth two times a day for epilepsy. During a review of Resident 220's Medication Administration Record (MAR), dated [DATE], the MAR indicated resident 220 had Senna Oral Tablet 8.6 MG . scheduled for two times a day . at 0900 and 2100. The MAR indicated Resident 220 had Divalproex Sodium Oral Tablet Delayed Release 500 MG . scheduled for two times a day . at 0900 and 2100. The MAR indicated Resident 220 had Levetiracetam Oral Tablet 250 MG . scheduled for two times a day . at 0800 and 1800. During a review of Residents 220's SBAR Communication Form, dated [DATE], the SBAR indicated on [DATE], Resident received medication late including Divalproex 500 mg and senna 8.6 mg. The SBAR indicated, Inform MD (medical doctor) and RP (responsible party) and continue to monitor for adverse side effects of late administration. During a review of the facility's policy and procedure (P&P) titled, Medication Administration General Guidelines, dated 2007, the P&P indicated, Medications are administered within 60 minutes of scheduled time .

Based on observation, interview, and record review, the facility failed to follow infection control practices for two of two sampled residents (Residents 5 and 39), when the following was observed: 1. Licensed Vocational Nurse 3 (LVN) did not clean and sanitize the glucose monitor (a device for measuring the concentration of glucose in the blood) in between finger stick blood sugar tests (a test that measures blood glucose levels by pricking a fingertip with a lancet and applying a drop of blood to a test strip in a glucose monitor) for resident 5 and 39. 2. LVN 3 disposed Resident 5 and 39's contaminated blood sugar lancets in residents 5 and 39's trash cans. 3. LVN 3 did not perform hand hygiene in between resident 5 and 39's finger stick blood sugar tests. These failures placed Residents 5 and 39 at risk for injury, cross contamination, and infection. Findings: A review of Resident 5's Admission Record printed 7/17/24, indicated Resident 5 was admitted to the facility in 2021 with multiple diagnoses, which included Unspecified Sequelae (an aftereffect of a disease) of Unspecified Cerebrovascular Disease (a disorder that results from inadequate blood flow in the brain's blood vessels). A review of Resident 39's Admission Record printed 7/17/24, indicated Resident 39 was admitted to the facility in 2024 with multiple diagnoses, which included Type 2 Diabetes Mellitus (a long-term (chronic) disease in which the body cannot regulate the amount of sugar in the blood) with Diabetic Neuropathy, unspecified (a complication of diabetes that causes nerve damage throughout the body). During an observation on 7/15/24, at 11:58 a.m., LVN 3 was observed while they did a fingerstick blood sugar test on Residents 5 and 39. LVN 3 took Resident 5's fingerstick blood sugar test and disposed the contaminated lancet in the resident's trash can. Then LVN 3 took Resident 39's fingerstick blood sugar test. LVN 3 did not clean, disinfect, or sanitize the blood glucose monitor in between resident tests. LVN 3 did not perform appropriate hand hygiene in between resident tests. LVN 3 disposed Resident 39's contaminated lancet in the resident's trash can. During an interview on 7/18/24, at 12:55 p.m., with Director of Nursing (DON), DON stated their policy was to dispose contaminated lancets in the sharps container (A specialized waste container designed to safely dispose of sharp medical instruments and other items, such as needles, scalpels, and lancets. Sharps containers are typically made of rigid, puncture-resistant plastic or metal with leak-resistant sides and bottom, and a tight-fitting lid that allows sharps to be deposited but is too small for a hand to fit through). DON stated contaminated lancets disposed in resident trash cans placed residents at risk for injury and infection. DON stated their policy was to clean and sanitize blood glucose monitors in between each resident use. DON stated performing fingerstick blood sugar tests with blood glucose monitors that were not cleaned and sanitized in between each resident use, placed residents at risk for cross contamination and infection. DON stated their policy was to perform appropriate hand hygiene when performing fingerstick blood sugar tests in between each resident. DON stated residents were placed at risk for cross contamination and infection when appropriate hand hygiene was not done in between each resident fingerstick blood sugar tests. During a review of Resident 5's Doctor's Order, dated 4/25/23, the Order indicated Resident 5 had a doctor's order for FBS . (fasting blood sugar, a blood test that measures the level of sugar in blood after a person has not eaten or consumed anything but water for 8-12 hours, by pricking the fingertip with a lancet to produce a drop of blood). During a review of Resident 39's Doctor's Order, dated of 4/12/24, the Order indicated Resident 39 had a doctor's order, for Finger stick blood glucose .(also known as finger stick blood sugar test). During a review of the facility's policy and procedure (P&P) titled, Cleaning and Disinfection of Resident-Care Items and Equipment, revised July 2014, the P&P indicated, Reusable resident care equipment will be decontaminated and/or sterilized between residents according to manufactures' instructions. During a review of the facility's policy and procedure (P&P) titled, Sharps Disposal, revised January 2012, the P&P indicated, This facility shall discard contaminated sharps into designated containers. The P&P indicated Contaminated sharps will be discarded into containers that are: a. closable; b. puncture resistant; c. leakproof on sides and bottom; d. labeled or color-coded in accordance with our established labeling system; and e. impermeable and capable of maintaining impermeability through final waste disposal. During a review of the facility's policy and procedure (P&P) titled, Insulin Administration, revised September 2014, the P&P indicated, Purpose . To provide guidelines for the safe administration of insulin to residents with diabetes. The P&P indicated Steps in the Procedure (Insulin Injections via Syringe) 1. Wash hands 2. Check blood glucose per physician order or facility protocol. 50013

Based on observation and interview, the facility had 34 resident (Rt) rooms (100, 102, 104, 106, 107, 108, 109, 110, 111, 112, 113, 114, 116, 118, 200, 202, 204, 208, 210, 211, 212, 213, 214, 215, 216, 217, 218, 219, 220, 221, 222, 223, 224, and 225) with multiple beds that provided less than 80 square feet per (sq.ft) resident who occupied these rooms. This failure had the potential to result in inadequate space for the delivery of care to each of the residents in each room, or for storage of the residents' belongings. Findings: During observations between 7/15/24-7/18/24, the following resident rooms and corresponding square footage were identified: Room Sq ft Sq ft/resident 100 232.55 77.52 102 150.54 75.27 104 149.41 74.71 106 149.41 74.71 107 151.47 75.73 108 150.33 75.16 109 151.62 76.62 110 154.54 75.27 111 151.25 75.62 112 149.19 74.59 113 142.37 71.18 114 154.4 76.2 115 233.18 77.73 116 150.33 75.18 118 149.19 74.59 200 149.19 74.59 202 150.33 75.16 204 149.42 74.71 206 232.55 77.52 208 149.19 74.59 210 149.42 74.71 211 233.18 77.73 212 149.42 74.71 213 155.62 77.81 214 149.19 74.59 215 152.4 76.2 216 151.47 75.73 217 151.25 75.62 218 150.33 75.16 219 150.1 75.05 220 15.47 75.73 221 237.18 79.06 222 150.33 75.16 223 149.41 74.7 224 151.47 75.73 225 149.42 74.7 During random observations of care and services from 7/15/24-7/18/24, there was sufficient space for the provision of care for the residents in all rooms. There was no heavy equipment kept in the rooms that might interfere with resident care and each resident had adequate personal space and privacy. There were no complaints from residents regarding insufficient space for their belongings. There were no negative consequences attributed to the decreased space and/or safety concerns in the 34 rooms. Recommend granting room size waiver.

Based on record review and staff interview, the facility failed to ensure that one of three sampled residents (Resident 3) receive adequate supervision or a monitoring device (bed/chair alarm) to prevent accidents. Resident 3 was admitted with a broken right hip on 4/17/14 and was at high risk for falls. On 4/18/14 at 8:19 AM, the night nurse recommended that the day nurse get an order for [REDACTED]. A bed alarm was not obtained and Resident 3 fell out of bed at 8 at 8:20 PM sustaining a right hip dislocation. Findings: Record review on 4/29/14 on the admission record showed, Resident 3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 3 fall risk evaluation record dated 4/17/14 showed a score of 10 which represents Resident 3 was a high risk for falls. Resident 3 physician admission orders [REDACTED]. The nurses notes, 4/18/14 at 8:19 AM (morning), showed Resident 3 was alert and responsive with unclear speech, a fall risk with precautions in place, endorsed to AM shift licensed nurse to get an order for [REDACTED]. The nurses notes, 4/18/14 at 11 PM, showed Resident 3 had an unwitnessed fall at 8:20 PM (evening). Resident 3 complained of pain at 10:45 PM and the physician was notified with an order for [REDACTED]. The nurses notes 4/18/14 at 11 PM showed Resident 3 was found on the floor and put back to bed. Resident 3 told staff she slid off the bed while trying to use the bed pan. The nurses notes, 4/18/14 at 11 PM, showed that family came in after being notified of fall, and asked why Resident 3 did not have a bed alarm? The nurses notes 4/18/14 at 11 PM showed the charge nurse informed the family there were no bed alarms available at this time. The nurses notes, 4/19/14 at 8:55 AM, showed x-ray was done around 2 AM and the results were received around 3 AM. The nurses notes, 4/19/14 at 8:55 AM, showed the physician was notified with an order to send Resident 3 to hospital. Resident 3 x-ray report 4/19/14 at the hospital compared to the x-ray report 4/15/15 showed a dislocation of the right hip prosthesis. The orthopedic consultant report on 4/19/14 at the hospital showed "a simple dislocation despite hardware, recommends attempting bedside reduction under sedation, usual technique, may need operating room (OR) if unable." On 5/8/14 at 2 PM RN (Registered Nurse) 1 stated Resident 3 was on fall precautions and the bed was lowered. RN 1 stated she did not believe there was a bed alarm. RN 1 stated, PM Shift had looked for an alarm, given her report, she looked for an alarm, and there was no alarm available. On 5/9/14 at 2:45 PM, CNA (certified nurse aide) 1 stated she was instructed that Resident 3 was a fall risk and to keep the bed low. CNA 1 stated, when Resident 3 family left the facility, Resident 3 made an attempt to get out of bed. CNA 1 stated, Resident 3 did not have a bed alarm. The facility's policy, "Fall Prevention," 9/1/08 showed, " the purpose was to prevent accidents by providing an environment that is free from hazards over which the facility has control. "All residents shall be assessed for being at risk for falls and any resident identified as "at risk" for falls shall have an individual plan of care that includes interventions to prevent falls for occurring." The policy showed "a licensed nurse will assess all residents on admission and quarterly for risk factors for falls and will initial a care plan for all residents at risk for falls." The policy showed, "post falls the licensed nurse will assess the resident for injuries and necessary treatments, licensed nurse will notify attending physician and responsible party." ______________________________________________________________________________ Class "B" Citation 02-1070- 60-F The facility violated the aforementioned regulation by failing to provide adequate supervision or a monitoring device (bed/chair alarm) to prevent Resident 3 getting out of bed unassisted on 8:20 p.m. on 4/18/14, sustaining a right hip dislocation. Resident 3 was admitted with a broken right hip on 4/17/14 and was at high risk for falls. On 4/18/14 at 8:19 AM, the night nurse recommended that the day nurse get an order for [REDACTED]. A bed alarm was not obtained and Resident 3 fell out of bed at 8 at 8:20 PM sustaining a right hip dislocation. Record review on 4/29/14 showed Resident 3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident 3's fall risk evaluation record, dated 4/17/14, showed a score of 10 which represents Resident 3 was at high risk for falls.Resident 3's physician admission orders [REDACTED].The nurses' notes ,dated 4/18/14 at 8:19 a.m., showed Resident 3 was alert and responsive with unclear speech, a fall risk with precautions in place, endorsed to day shift licensed nurse to get an order for [REDACTED]. The nurses notes, dated 4/18/14 at 11 p.m., showed Resident 3 had an unwitnessed fall at 8:20 p.m. Resident 3 was found on the floor and put back to bed. Resident 3 told staff she slid off the bed while trying to use the bed pan. The nurses' notes showed that family came in after being notified of fall, and asked why Resident 3 did not have a bed alarm and the charge nurse informed the family there were no bed alarms available at this time. Resident 3 complained of pain at 10:45 p.m. and the physician was notified with an order for [REDACTED]. The x-ray was done around 2 a.m. and the results were received around 3 a.m. and Resident 3 was sent to hospital and treated for [REDACTED].The orthopedic consultant report on 4/19/14 at the hospital showed Resident 3 had "a simple dislocation despite hardware, recommends attempting bedside reduction under sedation, usual technique, may need operating room (OR) if unable."On 5/8/14 at 2 p.m., RN (Registered Nurse) 1 stated Resident 3 was on fall precautions and the bed was lowered. RN 1 stated she did not believe there was a bed alarm and that the evening Shift had looked for an alarm, given her report, she looked for an alarm, and there was no alarm available.On 5/9/14 at 2:45 p.m., CNA (certified nurse aide) 1 stated she was instructed that Resident 3 was a fall risk and to keep the bed low. CNA 1 stated Resident 3 did not have a bed alarm and when Resident 3 family left the facility, Resident 3 made an attempt to get out of bed. The facility's policy, "Fall Prevention, "9/1/08 showed", the purpose was to prevent accidents by providing an environment that is free from hazards over which the facility has control. "All residents shall be assessed for being at risk for falls and any resident identified as "at risk" for falls shall have an individual plan of care that includes interventions to prevent falls for occurring." The policy showed "a licensed nurse will assess all residents on admission and quarterly for risk factors for falls and will initial a care plan for all residents at risk for falls."