Every finding on record at Fremont Healthcare Center

Based on observation, interviews, and record reviews, the facility failed to provide one of six sampled residents (Resident 6), prescribed antibiotic and topical corticosteroid as ordered by the physician, and failed to document why the medication was not given.This failure had the potential for worsening skin infection for Resident 6.During a record review on 2/11/26 at 2:35 p.m., with Registered Nurse 3 (RN 3), Resident 6's face sheet indicated the resident was admitted on [DATE] with the diagnosis of C-diff (Clostridioides difficile-a bacterium that can infect your large intestine and cause severe inflammation and diarrhea).During a review of Resident 6's Minimum Data Set (MDS clinical assessment tool used to evaluate the physical, functional, cognitive, and psychosocial status of every resident), the MDS, Section C- cognition indicated the Resident 6 had a Brief Interview for Mental Status (BIMS) score of 14 means cognitively intact with normal thinking and memory. Resident 6' MDS, Section I -Active diagnosis indicated Resident 6 had C-diff, end stage renal disease, and type 2 diabetes mellitus.During a review of Medication Order (MO) , dated 2/12/26, the MO indicated fidaxomicin (antibiotic used to treat diarrhea caused by Clostridioides difficile (C-diff) bacteria) tablet 200 mg orally, twice a day 9:00 a.m., and 5:00 p.m., Special instructions indicated take 1 tablet (200mg) by mouth twice a day for 10 days for C. Diff. The new order e (electronic) Prescription was transmitted to (name of the pharmacy) on 2/12/26 at 09:30 p.m., In addition, there was a MO for triamcinolone acetonide cream 0.1% topical (antibiotic for skin infection). Special instructions indicated to apply into the affected areas as directed twice a day for itchiness. The new order ePrescription was transmitted to pharmacy on 2/12/26 at 9:27 p.m.During an interview on 8/12/26 at 2:35 p.m., with RN 3, RN 3 stated the antibiotic fidaxomicin is not a medication stored in the facility or in the emergency kit (E kit- a collection of basic items and survival supplies that a household needs to stay safe and self-sufficient for several days following a disaster or evacuation). RN 1 stated the medication order was sent to pharmacy, to be filled. RN 3 stated that the facility does not have the topical cream in house.During a concurrent interview and record review on 2/12/26 with the Director of Nursing (DON), pharmacy General Information was reviewed and indicated pharmacy had a new order cut-off time (the last time that new order can be submitted) and delivery window (the time that pharmacy can deliver the medication to the facility). The new cut-off-time for new medication orders were Monday through Sunday at 7:30 p.m. and the delivery window was from 10:15 p.m. to 1:15 a.m. DON stated the medication would be delivered during the next delivery window. During the review of the pharmacy shipping manifest dated 2/13/26 at 12:07 p.m., the shipping manifest indicated the fidaxomicin 200 mg tablet and triamcinolone 0.1% cream was received in the facility on 2/13/26 with no time stamp of delivery.During a review of the Medication Administration History (MAH), dated 2/13/26 -2/22/26 , the MAH indicated, Resident 6 was administered fidaxomicin 200 mg orally once on 2/13, 2/14, 2/18, 2/19, and 2/20/26. The MAH did not have documentation why the fidaxomicin second dose was missed on those dates, and not administered at all on 2/15, 2/16, 2/17, and 2/21/26. Additionally, during a review of the MAH dated 2/13/26 -3/10/26 for the triamcinolone acetonide cream indicated the medication was unavailable on 2/13 and 2/15/26 for administration.During a review of the facility's policy and procedure P&P titled, Medication Pass Guideline, dated 12/17/25, the P&P indicated Physician's Orders- Medications are administered in accordance with written orders of the attending physician . Begin new medication orders timely and routine orders on the same day ordered, unless the next dose would be normally given the next day .The nurse is responsible to read and follow instructions on the prescription label .

Based on interview and record review for two of three sampled residents (Resident 1 and Resident 2), the facility failed to follow their policies and procedures (P&P) for reporting to appropriate agencies the physical altercation on 2/24/26, between Resident 1 and Resident 2. The facility failed to confirm reported physical altercation between Resident 1 and Resident 2 was received by the licensing agency and local agency in a timely manner. This failure to report promptly resulted in:1. Potential to negatively impact the protection of residents from abuse. 2. Licensing agency unaware of the physical altercation between Resident 1 and Resident 2 until after the receipt of facility's Abuse Investigation Summary on 2/27/26. A review of Resident 1's Face Sheet indicated resident was readmitted to the facility on [DATE] with diagnoses that included osteoarthritis (chronic joint condition) and myocardial infarction (heart attack). A review of Resident 2's Face Sheet indicated resident was readmitted to the facility on [DATE] with diagnoses that included Alzheimer's disease (a brain condition that causes a progressive decline in memory, thinking, learning, and organizing skills), schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), and bipolar disorder (a serious mental illness that causes unusual shifts in mood, energy levels, and behavior). A review of Resident 1 and Resident 2's Incident Report, dated 2/24/26, indicated Resident 1 reported that Resident 2 slapped Resident 1 on the left shoulder for no reason. Resident 2 allegedly yelled at Resident 1 and told her to move out. A review of the facility's record titled, Communication Result Report, dated 2/25/26, at 5:06 p.m., indicated, result of a fax sent to the State Agency (SA) District Manager (DM) on 2/25/26, at 4:59 p.m., showed, Result - E-3) 3), Page Not Sent - pages (P.) 1-5 (Cover sheet and Elder Abuse Report Form [SOC 341]), of the reported incident that happened between Resident 1 and Resident 2, dated 2/24/26. Further review of the Communication Result Report indicated, Reason for error.E. 3) No answer. A review of the facility's record titled, Communication Result Report, dated 2/25/26, at 5:07 p.m., indicated, result of a fax sent to a local agency (LA) on 2/25/26, at 5 p.m., showed, Result - E-3) 3), Page Not Sent - pages (P.) 1-5 (Cover sheet and Elder Abuse Report Form [SOC 341]), of the reported incident that happened between Resident 1 and Resident 2, dated 2/24/26. Further review of the Communication Result Report indicated, Reason for error.E. 3) No answer. During a concurrent interview and record review of the Administrator's (ADM) incident report, on 3/18/26, at 1:31 p.m., with the Director of Nursing (DON), DON noted Communication Result Report showed an error occurred during the process of sending the reported incident to the SA and LA. DON stated the fax did not go through related to no answer, result from the receiver of the fax. During a concurrent interview and record review on 3/18/26, at 2:24 p.m., with the ADM, Fax Communication Result Reports were reviewed. One report was sent to SA and another to LA and both faxes resulted in failed communication. ADM stated it was an honest mistake on ADM's part and will remember to confirm sent faxes were received with no errors, to prevent late reporting. During an interview on 3/18/26, at 2:48 p.m., with the Unit Manager (UM), UM stated, Somebody must have placed the Fax Communication Result Report in the ADM's box without checking the fax went through or not. UM stated it was important to check that faxed documents went through smoothly to intended receiver. A review of the facility's policy and procedure (P&P) titled, Abuse Investigation and Reporting, dated 11/17/25, indicated, All allegation of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (Abuse) shall be promptly reported to the appropriate local, state and/or federal agencies (as defined by current regulations) and thoroughly investigated by Company management. Findings of abuse investigations will also be reported to local law enforcement and the Office of the Ombudsman.Reporting 1. All alleged violations involving abuse.will be reported by the Company Administrator, or his/her designee, to the following persons or agencies: a) The State licensing/certification agency responsible for surveying/licensing the facility; b) The local/State Ombudsman.e) Law enforcement officials.An alleged violation of abuse.will be reported immediately but not later than: a) Two (2) hours if the alleged violation involves abuse OR has resulted in a serious bodily injury; or b) Twenty-four (24) hours if the alleged violation does not involve abuse AND has not resulted in serious bodily injury.3. Verbal/written notices to agencies may be submitted via special carrier, fax, email, or by telephone.5. 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 (5) working days of the occurrence of the incident.

Based on observation, staff interviews, record reviews, and meal testing, the facility failed to ensure that pureed diets were prepared according to the facility's diet manual requirements for 20 of 97 sampled residents who received pureed diets. This deficient practice had the potential to cause swallowing difficulty and choking risk for residents requiring pureed diets for their safety. Review of the facility diet manual, titled Diet Manual for Rehabilitation, Residential, and Long Term Care Communities, Nutrition Therapy Essentials, dated 2023, showed it was reviewed and approved by the facility's Registered Dietitian on 2/5/25. Review of the section titled Puree showed the diet was indicated for individuals who had dysphagia (difficulty swallowing) for reasons such as stroke, head trauma, or Alzheimer's disease. All foods should be smooth and pureed to the consistency of pudding. Review of a policy titled Food Preparation, Subject: Food Cookery, dated 2023, showed Pureed Food Preparation (follow menu recipes) .Pureed foods should be prepared to the consistency and thickness of mashed potatoes.Review of an undated document titled Mariner Healthcare, Spring/Summer 2025, Diet Spreadsheet, Week 5, Day 30, showed foods and portions to be served to residents with various diets on 9/16/25, including pureed chicken taco meat, pureed bread, pureed pinto beans, pureed sauteed onions and peppers, margarine and pureed emerald pears at lunch on 9/16/25.During lunch meal preparation observation and interview on 9/16/25 at 10:20 a.m., FSW 1 was observed pureeing chicken in a Robo Coupe food processor. FSW 1 stated that the puree was considered finished when it looks like mashed potatoes. After FSW 1 completed the pureed process, small chunks of chicken were observed remaining around the top edge of the Robo Coupe container.During a review of the facility's Pinto Beans SCR Dried PU, Quantified Recipe-1178, Day 30 Lunch, No.2, indicated process until smooth. During a review of facility's Chicken Taco Meat 3oz PU, Quantified Recipe-1171, Day 30 Lunch, No.8, indicated process chicken meat until smooth using 1 oz slurry per portion.During a review of facility's Sauteed Onions & Peppers FRSH PU, Quantified Recipe -1181, Day 30 Lunch indicated process until smooth using 1 TSP thickener per portion and check product consistency periodically.During an interview with FSW 1 on 9/16/25 at 11:07 a.m., they stated they used the regularly prepared soft taco chicken, chicken base, water and taco seasoning (cumin) when pureeing the chicken for lunch. They stated they didn't measure everything because they made it all the time and knew what to do. The ingredients cited matched the ingredients listed in the recipe, but the quantities of the ingredients were unknown.During a meal test tray process with the Registered Dietitian (RD) and Certified Dietary Manager (CDM) on 9/16/25 at 12:54 p.m., pureed chicken with gravy, pureed pinto beans, pureed peppers and onions, and pureed bread were tested. The consensus was that the pureed chicken tasted good, but the consistency was not smooth and contained small detectable pieces of chicken. The pureed bread tasted good like bread, consistency was smooth, it did not taste starchy, and it softly mounded on plate. The pureed beans were not smooth and contained pieces of skin. The pureed peppers and onions were not smooth, with detected pieces of skin, which did not meet the smooth consistency required for a pureed diet.

Based on observation, interview and record review, the facility failed to provide staff supervision for five sampled residents (Resident 99, 11, 20, 24 and 91 during smoking to ensure an environment free of accident hazards.This failure had the potential to cause fire hazards, injuries, and jeopardize the health and safety of the residents.During an observation on 9/16/25 at 10:15 a.m. Resident 99 smoking a cigarette outside her room by the sliding door leading to the smoking patio. There was an oxygen tank filled with oxygen beside her bed (Bed D) in her room, and an oxygen concentrator with oxygen in her space next to Bed C. Certified Nursing Assistant (CNA) 5 confirmed that Resident was smoking. On approaching Resident 99, Resident 99 quickly put out the cigarette and dropped the cigarette butt on the ground already with two cigarette butts. Resident 99 did not have a smoking apron while smoking. Also, in the patio, were four residents (Residents 11, 20, 24, and 91) sitting in their wheelchairs smoking in the non-designated area by the tree. None of the residents had a smoking apron (a piece of fabric that covers the lap and chest and cannot be ignited by a cigarette).During an interview on 9/16/25 at 10:18 a.m. with CNA 5, CNA 5 stated she was not the one assigned to Resident 99 and did not know where her assigned CNA was. CNA 5 stated Resident 99 was not far from the oxygen in the room while smoking outside by the sliding door and it was not safe. CNA 5 acknowledged that Resident 99 usually goes out by herself to smoke and staff were supposed to be there with residents when they are smoking.During an interview on 9/16/25 at 10:20 a.m. with Resident 99 in the patio by her room sliding door, Resident 99 acknowledged she was supposed to be smoking in the designated area. She stated the designated area was by the wall/fence where the green steel table with attached benches, and ash tray were. Resident 99 stated the other smoking designated area was by the tree. When asked, Resident 99 stated she was unable to wheel herself out to smoke, but she held onto the wall and pushed herself out.During a concurrent observation and interview on 9/16/25 at 10:25 a.m. with Director of Maintenance (DM) when he was called to measure the distance from the smoking area to the sliding door of Resident 99's room. DM indicated the space with the designated smoking area sign was the only designated area for smoking for residents.During a review of Resident 99's smoking assessment dated [DATE], it indicated Resident 99 was modified independence and needed supervision. The smoking assessment indicated Resident 99 had a diagnosis related to seizure activity. Resident 99's care plan dated 1/29/25 indicated, Resident will utilize designated area for smoking, exercise smoking safety, and with interventions that included smoking materials to be stored securely as per protocol, supervise smoking (if necessary) in designated areas to assure safety.During an interview on 9/16/25 at 10:56 a.m. with Resident 11, who was Resident 99's roommate, Resident 11 stated she smoked independently and did not have a smoking schedule, and the facility allowed it, and she kept her cigarettes with her.During a review of Resident 11's smoking assessment, dated 7/2/25, the smoking assessment indicated Resident 11 was a safe independent smoker. Resident 11's care plan with dated 1/31/25 indicated goal included will utilize designated areas for smoking, and with interventions that included smoking apron (if needed), smoking materials to be stored securely as per protocol.During an interview on 9/16/25 at 10:59 a.m. with Resident 99, Resident 99 stated she kept her cigarettes with her and was not following her smoking schedule posted on the wall in her room. She stated she goes out to smoke when she wants. During a concurrent observation and interview on 9/16/25 at 11:15 a.m. with Resident 20, Resident 20 stated the facility did allow her to smoke independently and she could go out whenever she wanted. She stated she kept her cigarettes with her and the facility allowed it. An oxygen concentrator with oxygen was in Resident 20's room by her bedside.During a review of Resident 20's smoking assessment dated [DATE], the smoking assessment indicated Resident 99 had a diagnosis related to seizure activity. It indicated Resident 20 was modified independence required supervision. Resident 20's care plan dated 6/3/25 indicated will utilize designated areas for smoking, exercise smoking safely, with interventions that included Educate the Resident about oxygen safety precautions., smoking apron if needed, smoking materials to be stored securely per protocol, supervise smoking (if necessary) in designated areas to assure safety.During a concurrent observation and interview on 9/16/25 at 11:30 a.m. Resident 91 was in his room sitting in his wheelchair by his bedside, Resident 91 had deformed hands. Resident 91 stated he had no smoking schedule. Resident 91 stated he did go out to smoke by himself without staff present and someone (resident) helped with the lighter.During a review of Resident 91's smoking assessment dated [DATE], the smoking assessment indicated modified independence and required constant supervision while smoking. The care plan for Resident 91 dated 7/2/25 indicated, Resident will utilize designated areas for smoking, exercise smoking safely, with interventions that included maintain a safe environment for smoking, smoking apron (if needed), smoking materials to be stored securely as per protocol, supervise smoking (if necessary) in designated areas to ensure safety.During a concurrent interview and record review on 9/16/25 at 12:05 p.m. with Registered Nurse (RN) 3, RN 3 stated Resident 99's smoking assessment dated [DATE] indicated supervision because it was not safe for her to smoke without supervision. RN 3 stated Resident 99's quarterly assessment dated [DATE] indicated Resident 99 was independent. RN 3 stated the assessment for 8/26/25 was wrong and Resident 99 should be supervised because she was noncompliant. RN 3 stated Resident 99 should be smoking in the designated area by the wall to ensure safety to prevent passive smoking (secondhand smoking) for other residents and safety for those on oxygen and for Resident 99 herself.During a concurrent record review and interview on 9/16/25 at 12:15 p.m., with RN 3 and Director of Nursing (DON), DON stated residents were not allowed to keep the smoking materials in the room. DON stated it was a fire hazard for residents to keep smoking materials in the room and be smoking in the non-designated areas. DON stated he was not sure if the residents have a smoking schedule. DON stated he found out from social services that residents who smoke have an individualized smoking schedule. DON stated the CNAs were supposed to supervise the residents when they smoke. A list of smokers was provided by the facility; a total of 12 smokers were on the list. RN 3 identified the residents who needed supervision, a total of seven and those who needed constant supervision were two. RN 3 stated, for residents who had independent on their smoking assessment (three residents) it meant they were able to light the cigarette. During an interview on 9/18/25 at 12:10 p.m. Resident 24 stated she did not have a smoking schedule, and acknowledged she went to smoke with Residents 11, 20, and 91on Tuesday morning, 9/16/25. During a review of Resident 24's smoking assessment dated [DATE], the smoking assessment indicated Resident 99 had a diagnosis related to seizure activity. It indicated Resident 24 was modified independence and required supervision. Resident 24's care plan dated 10/1/21 indicated Resident will smoke in designated area without occurrence of untoward incident, exercise smoking safely, with interventions that included maintain a safe environment for smoking, smoking apron if needed, smoking materials to be stored securely as per protocol, supervise smoking (if necessary) in designated areas to ensure safety.During a concurrent observation and interview with Resident 11 on 9/18/25 at 12:15 p.m.in the smoking patio. Some staff were having their lunch in the smoking non-designated area by the tree with a no smoking sign on the fence. Resident 11 stated that staff told them that area by the tree was a designated area for smoking. Resident 11 then stated, technically, it is not a designated area for smoking, staff do have their lunch there and if staff come out for lunch, we would leave.During a review of the facility's policy and procedure (P&P), titled Guidelines-Smoking Safety, undated, the P&P indicated .this facility to promote a safe, healthy, and smoke-free environment for residents, staff, visitors, contractors. Smoking poses significant health risks, creates fire hazards.During a review the facility's P&P titled Smoking policy, undated, the P&P indicated, to establish a process for residents who wish to smoke to do so in a safe manner.Residents, regardless of safe smoking assessment result, will need to keep smoking materials in the nurses' station. They may smoke only in the designated smoking area outside the building.Residents with a current diagnosis of documented seizure activity will be considered a supervised smoker.

Based on observation interviews and record review, the facility failed to ensure food that was brought in from outside sources and belonged to residents was properly stored under sanitary conditions when:1. The resident refrigerator was not clean.2. Nine of 24 food items observed did not have proper labeling or dating.3. Nursing staff were unsure of the facility's policy and procedure regarding residents' food brought from outside sources, and the policy was not followed.4. One resident stated they had financial loss because their food recently purchased was discarded from the refrigerator.This failure had the potential to place residents at risk for foodborne illness, cross-contamination and financial loss for residents when their personal food was removed from the refrigerator. (cross-reference F812). On 9/16/25, at 3:08 p.m., an observation of the refrigerator designated for residents to store food brought from home and outside sources was conducted with the Infection preventionist (IP). The following were noted:1. The resident refrigerator was not clean.The resident refrigerator had brown stains, food debris on the shelves and yellow stains on the interior door storage. IP stated that housekeeping cleaned the refrigerator and IP checked for proper food labeling. 2. Nine of 24 food items observed did not have proper labeling or dating.One container of ice cream for room [ROOM NUMBER]C stored without a resident name.One opened bag of Oreo Thin Cookies for room [ROOM NUMBER]A stored without a resident name. The bag was opened on 7/21/25 and the Manufacturer's expiration date was 9/10/25.One unopened bag of cooked shrimp for room [ROOM NUMBER]A stored without a resident name. The date received was 9/9/25.One frozen pizza for room [ROOM NUMBER]A stored without a resident name. The dated received was 8/25/25.One unopened bag of raw shrimp stored without a resident name or received date. The manufacturer's expiration date was 7/26/26. IP stated nursing staff would cook shrimp for resident in the microwave oven.One container of Breyer's Ice Cream stored without a resident name or received date. One opened bottle of Brisk Pink Lemonade stored without a resident name, opened date, or received date.One opened carton of Your Good Foods Soymilk was stored without a received date or opened date. The manufacturer's use by date was 5/16/26, however the manufacturer's food label indicated it should be used within seven to ten days after opening. One opened carton of Good & Gather Half & Half stored without a resident name, received date, or opened date. The manufacturer's best by date was 11/26/25 and indicated Enjoy within seven days after opening.3. Nursing staff were unsure of the facility's policy and procedure regarding residents' food brought from outside sources, and the policy was not followed.During an interview on 9/17/25, at 12:34 p.m., CNA 1 stated that resident food should be checked for the expiration date and labeled with resident's name and received date. CNA 1 was uncertain about the requirement for labeling the date the item was opened. 4. Residents lost their food stored in the refrigerator due to improper labeling.During an interview on 9/17/25 at 12:50 p.m., Resident 96 stated that all their food had been removed from the resident refrigerator. Resident 96 explained that they had purchased [NAME] sausage and three bags of hard-boiled eggs that week from Raley's and none of the items had been opened. Resident 96 stated that their room number was written on the bags and that they normally used some eggs and sausage each day to supplement what they did not receive from the kitchen. Resident 96 stated that last night the refrigerator door was locked, and the refrigerator was cleaned out.During an interview on 9/18/25 at 9:05 a.m., IP stated she had provided multiple in-services to CNAs and nurses regarding resident food from home and had occasionally educated residents as well. IP stated food from outside should be labeled with the resident's name, date received, and date opened. During a review of facility Policy & Procedure (P&P) titled Food Brought from Outside the Facility, Revision: 4.0, approved on 9/12/25, indicated Perishable food must be stored in a re-sealable container with tightly fitting lids in a refrigerator. Containers will be labeled with the resident's name, the item and 'used by' date.During a review of P&P titled Food Receiving and Storage of Cold Foods Release/Revision date 1/31/25, indicated All open food items will have an open date and use-by-date per manufacturer's guidelines. During a review of P&P titled Food Brought in From Outside Sources Release/Revision date 1/31/25, indicated All food brought in should be checked by the charged nurse or Director of Food and Nutrition Services. It must be placed in a tightly sealed container with the resident's name and date on it.

Based on observation, interview and record review, the facility failed to observe infection control practices when the following were observed:1. 1. Housekeeper (HK) 1 used non-EPA (Environmental Protection Agency- responsible for the protection of human health and the environment) approved cleaning solution to disinfect floors. 2. 2. Registered Nurse (RN) 2 did not wash and dry hands thoroughly before, during and after Resident 83's wound therapy.3. 3. RN 2 did not use sterile gloves when holding a moist surface over the wound during Resident 83's wound care treatment.These failures had the potential for spread of infections among residents at the facility.1. During a concurrent observation and interview on 9/15/25 at 10:07 a.m. with HK 1, HK 1 was observed mopping floors. HK 1 stated, she used a mixture of three gallons (gal- standard unit of measuring liquid volume) of water and 90 milliliters (mL- small unit of measuring liquid volume) of Fabuloso multi-purpose cleaner. HK 1 stated, it was standard to use the mixture of water and multi-purpose cleaner to mop all Resident care area floors including Rooms with known infections. During a concurrent interview and record review on 9/15/25 at 4:00 p.m. with the Maintenance Assistant (MA), MA showed, facility used Fabuloso, a cleaning solution brand that was labeled Multi-purpose Cleaner. MA stated, he was not sure if Fabuloso Multi-purpose Cleaner was a disinfectant. During an interview on 9/16/25 at 9:40 a.m. with Infection Preventionist (IP), IP acknowledged cleaning solution used by HK 1 was not EPA approved. IP added, it was important to use EPA approved disinfectant to disinfect resident care areas and common areas because EPA approved disinfectants was part of precautionary to stop the spread of infection between residents/resident rooms especially that there was Covid-19 (highly contagious illness caused by virus that spreads through droplets and tiny particles from an infected person) case in the facility.During a concurrent interview and record review on 9/16/25 at 2:20 p.m. with IP, the facility's Policy and Procedure (P&P) titled, Cleaning and Disinfecting Residents' Rooms, dated 8/2013 was reviewed. The P&P indicated under General Guidelines .2. Environmental surfaces will be disinfected (or cleaned) on a regular basis (e.g., daily, three times per week and when surfaces are visibly soiled. 3. Manufacturer's instructions will be followed for proper use of disinfecting (or detergent) products. Furthermore, the P&P also indicated, .12. The Environmental Services Director and Administrator, in conjunction with the Infection Preventionist, will select appropriate facility disinfectants. The P&P also revealed under Equipment and Supplies, The following equipment and supplies will be necessary when performing this procedure. 1. a. Disinfectant solution;During a concurrent interview and record review on 9/16/25 at 2:21 p.m. with IP, the facility's P&P titled, Cleaning and Disinfection of Environmental Surfaces, dated 6/2009, indicated under Policy Statement, Environmental surfaces will be cleaned and disinfected according to current CDC recommendations for disinfection of healthcare facilities and the OSHA Bloodborne Pathogens Standard. Under Policy Interpretation and Implementation 1. The following categories are used to distinguish the levels of sterilization/disinfection necessary for items used in resident care and those in the resident's environment: .c. Non-critical items are those that come in contact with intact skin but not mucous membranes (1) Non-critical environmental surfaces include bed rails, some food utensils, bedside tables, furniture and floors. 2. Non-critical surfaces will be disinfected with an EPA-registered intermediate or low-level hospital disinfectant according to the label's safety precautions and use directions. a. Most EPA-registered hospital disinfectants have a label contact time of 10 minutes.6. A one-step process and an EPA-registered hospital disinfectant designed for housekeeping purpose will be used in resident care areas where: a. uncertainty exists about the nature of the soil on the surfaces. b. uncertainty exists about the presence of multidrug-resistant organisms on such surfaces. The IP confirmed, HK 1 did not use an EPA registered disinfectant when mopping the floors of Resident care area and common area. IP added, the multi-purpose cleaning solution that HK 1 used was not effective to kill bacteria and had the potential to spread infection.During a review of facility's P&P titled, Common (Public) Areas Cleaning, undated, indicated under FUNDAMENTAL INFORMATION; Equipment .Quaternary Compound (chemical ingredient found in disinfectants) A germicidal disinfectant commonly used in ordinary environmental sanitation of non-critical areas, such as floors, furniture, and walls; .uses for individual product must be approved by the EPA.Under PROCEDURE .8. Dry mop, then wet mop hard surface floors daily with disinfectant solution.According to the Centers for Disease Control and Prevention (CDC);The Recommendations for Disinfection and Sterilization in Healthcare Facilities, dated 2008, indicated as follows: .5. Cleaning and Disinfecting Environmental Surfaces in Healthcare Facilities. 5.b. Disinfect (or clean) environmental surfaces on a regular basis (e.g., daily, three times per week) and when surfaces are visibly soiled. 5. c. Follow manufacturers' instructions for proper use of disinfecting (or detergent) products - such as recommended use-dilution, material compatibility, storage, shelf-life, and safe use and disposal.5. e. Prepare disinfecting (or detergent) solutions as needed and replace these with fresh solution frequently (e.g., replace floor mopping solution every three patient rooms, change no less often than at 60-minute intervals), according to the facility's policy.5. g. Use a one-step process and an EPA-registered hospital disinfectant designed for housekeeping purposes in patient care areas.https://www.cdc.gov/infection-control/hcp/disinfection-sterilization/summary-recommendations.html5. Cleaning and Disinfecting Environmental Surfaces in Healthcare Facilities2. During a review of Resident 83's Face sheet, undated, the face sheet indicated Resident 83 was admitted on [DATE] and was re-admitted on [DATE].During a review of Resident 83's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 8/7/25, indicated Resident 83 had multiple diagnoses that included, cutaneous abscess of abdominal wall (a collection of pus under the skin of belly caused by an infection).During a wound care treatment observation on 9/17/25 at 2:01 p.m. in the presence of IP, RN 2 did not wash and dry hands thoroughly before applying gloves prior to wound therapy. RN 2 also did not wash hands between glove changes and after wound therapy. During an interview on 9/17/25 at 2:35 p.m. with RN 2, RN 2 stated she did not wash hands with soap and water before, during and after wound therapy because the standard practice was to use Alcohol Based Hand Rub (ABHR).During an interview on 9/17/25 at 3:44 p.m. with IP, IP stated, the expectation was for RN 2 to wash hands with soap and water before and after wound therapy. IP added, hand washing with soap and water was the most simple and practical way to prevent the spread of infection.During a review of facility's P&P titled, Negative Pressure Wound Therapy, undated, indicated under Steps in the Procedure .2. Wash hands and apply gloves 3. Clean wound. 4. Remove gloves 5. Wash hands and apply clean gloves.3. During a wound care treatment observation on 9/17/25 at 2:01 p.m. RN 2 did not wear sterile gloves when cleaning Resident 83's open wound with wet gauze. During an interview on 9/18/25 at 11:55 a.m. with RN 2, RN 2 stated, she was unaware of using sterile gloves for cleansing Resident 83's wound. RN 2 also added, she was unaware of the availability of sterile gloves because she did not know where to get the supply of sterile gloves. RN 2 further added, it was important to use sterile gloves when physically touching Resident 83's open wound because of risk for infection.During a review of facility's P&P titled, Wound Care and Treatment, undated, indicated .2. Wash and dry your hands thoroughly.10. Wear sterile gloves when physically touching the wound or holding a moist surface over the wound.23. Wash and dry your hands thoroughly.

Based on observations, interviews and record reviews the facility failed to ensure adequate and effective maintenance of the kitchen, and preventive maintenance of the kitchen's equipment when:1. The physical plant of the kitchen such as walls, floors, doors and air gaps were not maintained in a manner to promote ease of cleaning, sanitation and food safety (Cross Reference F812).2. Refrigerator and freezer units were not well-maintained and had damaged gaskets, condensation, icicles and ice buildup, mold growth on one refrigerator door, and grime on condenser fans and covers.3. Manufacturer's instructions were not followed for cleaning the ice machine.4. There was not an effective preventive maintenance system or documentation in place to ensure proper function and life of the equipment in the kitchen.These failures had the potential to result in foodborne illness for residents consuming food from the facility's kitchen.Review of an undated document titled Maintenance/Plant Operations Department Director - Hourly showed The Manager will ensure the equipment, facility, and grounds are safe, well-maintained in accordance with all current federal, state and local standards, guidelines and regulations. The position is responsible for.maintaining physical plant and essential mechanical electrical.equipment in a safe operating condition. Essential responsibilities included: Develops schedule for.maintenance projects, such as painting and window cleaning.Maintains an equipment log with all warranties of equipment and all preventative maintenance performed in the facility in accordance to the facilities Policy and Procedures.Participates in rounding.A review of the 2022 FDA (Food and Drug Administration) Food Code showed: Non-food-contact surfaces shall be free of unnecessary ledges, projections, and crevices, and designed and constructed to allow easy cleaning and to facilitate maintenance (FDA Food Code 2022, S4-202.16). Non-food contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris (FDA Food Code 2022, S4-601.11). Nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues (FDA Food Code 2022, S4-602.13). Smooth means: (3) A floor, wall, or ceiling having an even or level surface with no roughness or projections that render it difficult to clean. (FDA Food Code 2022, S1-201.10(B)(3)) Equipment shall be maintained in a state of repair and condition that meets the requirements specified under Parts 4-1 and 4-2. (B) Equipment components such as doors, seals, hinges, fasteners, and kick plates shall be kept intact, tight, and adjusted in accordance with manufacturer's specifications (FDA Food Code 2022, S4-501.11). The presence of food debris or dirt on nonfood contact surfaces may provide a suitable environment for the growth of microorganisms which employees may inadvertently transfer to food. If these areas are not kept clean, they may also provide harborage for insects, rodents, and other pests (FDA Food Code 2022 Annex 3, S4-602.13) During the initial tour of the kitchen on 9/15/25 from 9:45 a.m. to 11:10 a.m., and throughout the survey:1. The physical plant of the kitchen such as walls, floors, doors and air gaps were not maintained in a manner to promote ease of cleaning, sanitation and food safety (Cross Reference F812). Floors tiles had cracks, tiles were absent under the three-compartment sink, and there was an accumulation of grime around the edges near walls and stationary equipment such as refrigerators and ovens. The black floor coving around refrigerator four was damaged and open, with potential to provide harbor to insects such as cockroaches. Walls had chipped, worn and missing paint, rendering them uncleanable. Some holes in walls in the dry storage area had been patched but not painted, rendering them uncleanable. Baseboards throughout the kitchen were damaged and uncleanable. Doors throughout the department showed damage, missing paint/finish, rendering them uncleanable. They all showed an accumulation of grime on the doors and door frame areas, increasing potential for cross contamination. Cross-contamination is the process by which bacteria or other microorganisms are unintentionally transferred from one substance or object to another, with harmful effect. During an observation on 9/15/25 at 10:38 a.m., the air gap on the food preparation sink was severely rusted and had an unknown black substance crawling up and around it. During a follow-up observation on 9/15/25 at 2:42 p.m., the rusted air gap looked like it had been cleaned out, yet black debris remained. A white paper towel used to wipe inside the air gap returned black chunks of debris and other black/brown substance. During an additional follow-up observation and concurrent interview with the Maintenance Assistant (MA) on 9/15/25 at 3:15 p.m., he stated the air gap was very old and rusted and needed to be replaced, and the black substance and particles scooped from the air gap with a white paper towel were chunks of rust. During an interview with the Director of Maintenance (DM) and Maintenance Assistant (MA) on 9/17/25 at 9:00 a.m., DM stated the Maintenance Department role in the kitchen was to clean and buff the floor, fix the lights as needed, and they would look at the steamer. He stated the MA was the main maintenance person at the facility, but the DM was present at the facility an average of two to three days a week when he was not helping other corporate facilities. DM stated they could only work in the kitchen at night and that made it harder to get the work done, but the work got completed when he had time, after helping other facilities. He stated they did not keep a list of work orders or any history of completed work orders from the kitchen.The DM stated they didn't have a formal work order system and that facility work order needs were communicated at morning meetings where managers verbally asked for help. He stated things like baseboards, flooring, lights, and clogged drain repairs had historically been requested. He stated while the Maintenance Department had a log book for maintenance requests, requests often didn't get written on the log, and they weren't tracked. He stated they had a maintenance log for each nursing station, but they didn't have a separate one for the kitchen, and kitchen needs were written on the log for the nursing station near the kitchen.Review of a policy titled Sanitation and Infection Control, Subject: Canned and Dry Goods Storage, dated 2023, showed storage area will be cleaned and maintained.Review of a document provided by Maintenance titled Kitchen Deep Cleaning Schedule 2025, showed monthly 2025 dates signed by the MA, with the last date 8/29/25. It provided no further information. 2. Refrigerator and freezer units were not well-maintained and had damaged gaskets, condensation, icicles and ice buildup, mold growth on one refrigerator door, and grime on condenser fans/covers.During observations on 9/15/25 beginning at 9:54 a.m., the kitchen's refrigerators and freezers were surveyed, accompanied first by the CDM and then by the Registered Dietitian (RD), who concurrently explained the numbering of refrigerators/freezers used below, since they were not all labeled with their corresponding numbers.#1 Freezer (Arctic Aire, 2-door reach-in), showed the temperature at -7 degrees Fahrenheit ( F, a measurable unit of temperature). The interior contained frozen vegetables and desserts. There was condensation around the door frame, and icicle drips hung from the center of the top right door frame, generally indicating a problem with the door gaskets. In a concurrent interview, the Certified Dietary Manager (CDM) stated the freezer was new and had just recently been replaced. #2, Freezer, (M3 Turbo 2-door reach-in), showed a temperature -9 F. There was a black substance resembling mold at top of door/frame and on the door gasket, and ice accumulated along the side gaskets of the right door. The freezer contained frozen meat and other protein foods. In a concurrent interview, the CDM stated maintenance was aware of the gasket issue, but they were having a hard time getting a new gasket. #3 Combination refrigerator and freezer ([NAME], 2-door reach-in), showed the refrigerator at 36 F, and the freezer at 0 F. The interior showed brown grainy substance across the shelves and condenser fans that could be scratched off with a fingernail. The refrigerator contained assorted cheeses. In a concurrent interview, the RD agreed there was brown discoloration on the shelves and condenser fan, and stated This was on my last report from the end of August. During an observation of #5 Refrigerator (Utility, 2-door reach-in) on 9/15/25 at 10:10 am, it contained dairy products, egg salad, chicken salad and tuna salad. There was grime on the condenser fans, and hinges, and there was rust on the shelves. Temperatures of foods registered Tuna Salad 46.4 F - (prepared on 9/12); Egg Salad 44.5 F (prepared on 9/14), and Chicken Salad 46.8 F (prepared on 9/13).Review of a policy titled Sanitation and Infection Control Subject Refrigerated Storage, dated 2023, showed Perishable food should be stored at less than or equal to 41 F.Review of a document titled Refrigerator Temperature Monitoring, dated September 2025, showed AM and PM temperatures for Refrig #1, Refrig #2, and Refrig #3. These numbers did not match up with the refrigerator and freezer numbering system previously provided by the CDM and RD. The log directed Record refrigerator temperatures twice per day, temps should read < 41 F. PM temperatures were missing on 9/15 for refrigerators #2 and #3. Morning temperatures documented on 9/16 showed #1 = 32 F, #2 = 39 F, #3 = 40 F. During an observation on 9/15/25 at 10:48 a.m., #4 Refrigerator (Norlake, 3-door reach-in) located next to tray line (resident meal tray assembly process), contained portioned food for tray line, and fresh produce. On the food preparation side of the refrigerator, the broken gasket hung down approximately two inches below the bottom of one door. The shelves had rust. There was grime around doors/hinges and handles.During an observation o 9/16/25 at 11:15 a.m., a refrigeration repair/vendor arrived and worked on refrigerator #5, up on a ladder, looking at the top of the refrigerator. All food had been removed from the refrigerator. In a concurrent interview, the CDM stated the refrigeration vendor was there to check and fix the temperature on refrigerator #5. During an observation on 9/16/25 at 4:07 p.m., Refrigerator #5 was empty and held two 2 thermometers registering 40 F. During an interview with the DM on 9/17/25 at 9:00 a.m. he stated maintenance only checked the temperatures of the refrigerators and freezers and did not do any other maintenance on them. The repair vendors only came when Maintenance called them to come. There was no regularly scheduled preventive maintenance on the kitchen equipment. DM stated he was notified of a problem with refrigerator #5 when staff told him about it. They checked the temperature and called the repair vendor. DM stated the vendor found the Freon level was low, causing it to go out of temperature range. During further interview, the DM stated he was still looking for the right gasket for refrigerator #4, and the gasket he received about a week ago was the wrong part. He stated they also replaced the rusty air gap the previous day. 3. Manufacturer's instructions were not followed for cleaning the ice machine.Review of a policy titled Sanitation and Infection Control, Ice Handling, dated 2023, showed Water filters on ice machines should be checked and maintained following manufacturer guidelines by the maintenance department. The ice machine should be emptied and sanitized on a monthly basis or per manufacturer's recommendations. The drain area will be cleaned and disinfected weekly. The exterior of the ice machine will be cleaned and sanitized weekly. The inside gaskets of seals will be wiped down weekly by the Department of Food and Nutrition Services to remove any potential mold/calcium buildup.Review of a document titled Food & Nutrition: Ice Machine - Cleaning & Sanitizing Log, Kitchen, with the years 2024 and 2025 documented through 6/20/25 (before the new ice machine was installed), showed the a monthly check in the yes column (unknown what yes meant). Corrective Action comments showed Clean filter wash tray with warm water on 2/1/24, 8/5/24, 9/9/24, 2/4/25, 3/14/25, 4/11/25, 5/11/25, 6/20/25. On 8/21/25 it stated Sanitized by vendor. On 1/6/25 it stated Clean filter, wash try with warm water, Black residue coming out from around motor, clean and wipe off the black residue. There was no documentation since the new ice machine was installed.Review of documents titled Quality Assessment for Performance Improvement, dated 1/31/25 through 8/26/25 showed the results of the kitchen sanitation inspections completed monthly by the RD. Regarding the question Ice machine is clean? Schedule in place for proper cleaning?, the RD documented NO:1/31/25 - Pink discoloration inside the machine, outside (of the) kitchen (ice machine on nursing units) (had) lime and black discoloration near the water dispenser; the waste tray is overflowing.2/28/25 - Inside the kitchen: pink discoloration on the white part of the dispenser and inside the machine; Outside the kitchen (ice machine on nursing units): the exterior needs to be wiped and the dispensers have lime built-up. Missing cleaning documentation on 2/3, 2/9-2/10, 2/16-2/17, 2/19-2/20.3/31/25 - Pink and yellow discoloration.4/28/25 - Pink discoloration an juice marks.5/30/25 - Dripping water; Outside the kitchen (ice machine on nursing units), the dispensers need cleaning6/15/25 - Inside the kitchen: pink discoloration noted and it is dripping water; Outside the kitchen (ice machine on nursing units) pink and yellow discoloration on the outerior (exterior); the area near the dispensers need to be cleaned; the removable top was not closed properly.7/28/25 - Pink and brown discoloration possibly from beverages on the gray broad inside the machine. The kitchen has a new ice machine.8/26/25 - Yes, the ice machine was clean.During an interview with the MA on 9/15/25 at 3:15 p.m., he stated the Scotsman Ice Machine was new, installed July 2025. He stated he usually cleaned it every month or two with warm water. He did not use any chemicals. The MA stated they had a vendor who came and cleaned the ice machine with chemicals twice a year.The MA removed the cover on the ice machine to show the motor area - had dust. He stated he cleaned that area with warm water. He stated he wiped down the opening to the ice collection bin and wiped that down. He stated he didn't ever empty the ice out of the bin. Review of the manufacturer's instructions for the ice machine titled Scotsman Ice Systems, Installation and User's Manual for Air and Water Cooled Modular Cuper Prodigy Elite A Series, dated June 2022, showed It is the User's responsibility to keep the ice storage bin in a sanitary condition.or.sanitation will not be maintained. The machine should be cleaned and sanitized a minimum of twice per year or as frequently as local health codes require (frequency would be as often as needed to keep the machine clean and is influenced by the water characteristics at the facility). Eighteen steps are outlined including but not limited to scale removal using Scotsman Clear 1 scale remover for the cleaning cycle and to soak/scrub removable parts; Sanitizing the removed parts and spillway, removing any buildup or debris; running the sanitizing cycle with Nu-Calgon IMS Sanitizer, removing all ice from the storage bin and pour excess sanitizer down the drain.During an interview with the DM on 9/17/25 at 9:00 a.m. he stated they had a contract with the ice machine vendor to clean the ice machine twice annually, but they had to call them to have them come. They had a second ice machine, usually located in the nursing area, that nursing used for residents, but it broke and was removed from the building the first week in September. 4. There was not an effective preventive maintenance system or documentation in place to ensure proper function and life of the equipment in the kitchen.A review of the RD's monthly Quality Assessment for Performance Improvement reports dated 7/21/25 and 8/24/25 communicated kitchen sanitation and maintenance concerns. The 7/21/25 maintenance concerns included black fans dusty/not clean, refrigerator #5 would not hold temperature. The 8/24/25 report maintenance concerns included #5 fridge cannot keep proper temperature, #4 fridge torn gaskets and black discoloration in the gaskets, and shelves that store plate covers are rusty. These deficiencies were not corrected as of the survey beginning 9/15/25.During an interview with the DM on 9/17/25 at 9:00 a.m. he stated They had the hood cleaned by outside professionals, he thought that happened monthly. He stated their preventive maintenance list included tasks like checking the boiler, pilot lights. They only checked the temperatures of the refrigerators and freezers - they provided no other maintenance. Review of an undated policy titled Preventive Maintenance Program showed A basic preventive maintenance program results in a cleaner, safer, and more efficient operation with fewer deficiencies and emergency repairs. The Company has established the following elements for a successful preventive maintenance program: A Company-wide system to communicate issues or items that need attention, repair, or replacement, a daily routine walk-through by the Administrator, a maintenance representative, and a clinical representative is recommended; A schedule for performing preventive maintenance; Guidelines for touch-up painting.Review of an undated policy titled Preventive Maintenance Schedule, showed Preventive maintenance is performed according to schedule to ensure compliance with applicable regulations. It stated a successful system was dependent on a routine schedule (monthly, quarterly, semi-annually or annually), and checklists to document completion of tasks. It specified Touch-Up Painting was part of preventive maintenance and should be built into the weekly checklist to be completed over time. The time period for touching-up the average size building (90-120 beds) is approximately one month. An additional section titled Preventive Maintenance Subject Area showed a list of facility equipment and how often it should receive maintenance. The list included the dishwasher, grease trap inspection, ice machines, range and fryer, range hood, steam cooker and steam table, however, all it showed for refrigerators and freezers was to check their temperature weekly.Review of the [NAME] Refrigeration website https://www.hobartcorp.com/kitchen-equipment-repairs showed An unreliable refrigeration unit can spoil an entire walk-in's worth of produce, costing you a lot of money in replacement costs, downtime, and more.Review of a document titled Arctic Aire Commercial Freezers and Refrigerators Installation, Operation & Maintenance Manual, dated 2020, obtained from the Arctic Aire website https://arcticairco.com/PDFs/2020-owner-manuals/2020-AR-AF-manual.pdf showed these main points in instructions for maintenance: Clean the interior and exterior using soap and warm water; Clean the condenser coil a minimum of every 90 days, but if there is a large amount of debris.reduce cleaning cycle to every 30 days.use a brush or vacuum or compressed air as needed; If heavy grease is present use a refrigeration degreasing agent designed specifically for the condenser coils. Failure to maintain a clean condenser coil can initially cause high temperatures and excessive run times. Continuous operation with dirty or clogged condenser coils may result in compressor failures. Neglecting the condenser coil cleaning procedures will void any warranties associated with the compressor.Review of an undated document titled Turbo air M3 Series Reach-Ins Refrigerators & Freezers Installation and Operation Manual, obtained from the Turbo Air Inc. website https://turboairinc.com/wp-content/uploads/2020/01/M3-Reach-Ins_HC.pdf showed these main points in instructions maintenance: Clean the interior and exterior using soap and warm water; the condenser coil must be free of dust, dirt and grease, requiring cleaning at least every three months or as needed; periodically empty the drain pan.Review of a document titled Preventive Maintenance Monthly Checklist (Form) dated 2025 showed a facility-wide checklist of maintenance task and a monthly box where maintenance staff placed a hash mark when the work was completed. Kitchen tasks included: Inspect convection ovens, with nine steps; Dishwasher Operations, with nine steps; Steam table operation with three steps; Gas Range and Deep Fat Fryer Operation, with five steps; Inspect range hood, with three steps; and Steam Cooker's Operation, with 11 steps. The refrigeration units and ice machines were not included.Review of documents titled Safety Committee Meeting dated 1/31/25 through 9/2/25 showed reporting when the ice machines were cleaned, and projects such as Deep cleaning kitchen floor and vent - Pending; kitchen light bulbs were replaced; Kitchen ice machine was repaired; kitchen freezer was not working - pending due to buying parts; need to install new kitchen ice machine; 6/25/25 ice machine in hallway was not working; kitchen deep cleaning was done; 8/26/25 air gap was installed in the kitchen (3-compartment sink);During an interview with the Certified Dietary Manager on 9/17/25 at 2:10 p.m., regarding kitchen maintenance, she stated maintenance came to the kitchen when work was needed, and they also did daily rounds of the kitchen.During an interview with the Registered Dietitian (RD) on 9/17/25 at 3:43 p.m., she was asked if she included maintenance issues when conducting her monthly inspections of the kitchen. She replied she looked at lights, flooring but not holes in the walls and things like that. She stated she provided her reports to the CDM, and Administration to be addressed, and the CDM followed up with the Maintenance Department about maintenance needs. The RD stated if a repair was not completed timely, she told the Administrator, who should contact Corporate. She explained It takes some time to fix things. Easy things are done quickly. Other maintenance that was less easy to complete required Administration approval, and bigger projects/equipment that required approval from corporate took longer to achieve.During an interview with the Administrator on 9/18/25 at 2:05 p.m., he stated sanitation and maintenance of the kitchen was important. He stated he had some ideas for helping with that and he was talking with corporate about it.

Based on observations, interviews and record reviews, the facility failed to ensure a comfortable work environment for staff working in the kitchen when kitchen air temperatures exceeded the acceptable range for air temperatures on two observed days.This failure had the potential to result in staff heat exhaustion, cross contamination (the process by which bacteria or other microorganisms are unintentionally transferred from one substance or object to another, with harmful effect) of food and equipment from staff sweat, and the potential to impede safe and appealing food temperatures for food safety and resident satisfaction.Review of an undated document titled Maintenance/Plant Operations Department Director - Hourly showed The Manager will ensure the equipment, facility, and grounds are safe, well-maintained in accordance with all current federal, state and local standards, guidelines and regulations. Review of an undated facility policy titled Air Temperature Readings, showed The acceptable range for air temperatures is 70 - 81 F ( F means degrees Fahrenheit, a measurable unit of temperature).Review of the California Code of Regulations, CCR Title 8, S3396 showed indoor work area temperatures should not exceed 82 F.Review of a policy titled Sanitation and Infection Control Subject Canned and Dry Goods Storage, dated 2023, showed dry goods storage areas should be maintained at 50 F to 70 F.Review of the United Stated Department of Agriculture (USDA) guidelines for dry food storage https://www.cde.ca.gov/ls/nu/fd/properstoragetemperatures.asp showed Many items such as canned goods, baking supplies, grains, and cereals may be held safely in dry storage areas. The guidelines below should be followed: Keep dry storage areas clean with good ventilation to control humidity and prevent the growth of mold and bacteria; Store dry foods at 50 F for maximum shelf life. However, 70 F is adequate for dry storage of most products. During an observation in the kitchen on 9/15/25 at 2:42 p.m., the kitchen air temperature felt uncomfortably warm. In a concurrent interview, the Certified Dietary Manager (CDM) agreed it was warm. She stated when it was warm she encouraged staff to drink enough water, and she had the Maintenance Department check everything (air handling). The surveyor placed her thermometer on a cart in the center of kitchen for approximately 5 minutes and it read the air temperature as 88.5 F. During an observation on 9/16/25 at 11:15 a.m., Food Service Worker 2 (FSW2) worked at the food preparation station. Her face was red and sweating. She wiped her face with her bare hands, walked to handwashing sink and wiped her face again with a paper towel. She did not wash her hands before she returned to food preparation activities.During an observation and concurrent interview with the Director of Maintenance (DM) on 9/17/25 at 1:45 p.m., regarding the air temperature in the kitchen, DM stated the temperature in the kitchen was controlled with the thermostat in the hallway outside the kitchen. The locked thermostat showed the corridor temperature at 78 F.During an observation in the kitchen on 9/17/25 at 1:48 p.m., the surveyor placed her thermometer on a cart in the center of the kitchen for approximately 5 minutes and it read the air temperature as 90.5 F. The tray line area with steam table, stove and ovens off and empty of any food showed 89.9 F. In a concurrent interview, the CDM agreed it was warm.During an interview with DM on 9/17/25 at 1:50 p.m., he stated, I made a mistake, and the hallway thermostat did not control the kitchen temperature. He stated the hallway thermostat controlled the air conditioning in the nursing areas. He stated the kitchen did not have a thermostat because it had a swamp cooler. He stated he would go up on the roof and check the swamp cooler.During an interview with DM on 9/18/25 at 12:30 pm he stated the kitchen swamp cooler was now working. He stated he found a loose wire when he went on the roof the previous day.

Based on observations, interviews and record reviews, the facility failed to ensure sanitation in the kitchen when: 1. The kitchen was not sanitary or well maintained.2. Food was not stored according to professional standards of practice.3. The Equipment was not maintained clean.4. Staff did not consistently perform their duties according to professional standards of practice to avoid cross-contamination (the process by which bacteria or other microorganisms are unintentionally transferred from one substance or object to another, with harmful effect).5. Resident food in the resident refrigerator was not adequately or consistently labeled and dated to ensure food safety and resident satisfaction.6. Ambient food cooling was not consistently documented7. Contaminated rags were left unattended in random areas of the kitchen.These failures had the potential to result in foodborne illnesses for residents who consumed meals prepared in the facility. Review of the 2022 Food and Drug Administration (FDA) Food Code S4-601.11 showed (A) Equipment food-contact surfaces and utensils shall be clean to sight and touch. (B) The food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue and other debris. Annex 3, S4-602.13 showed the presence of food debris or dirt on nonfood contact surfaces may provide a suitable environment for the growth of microorganisms which employees may inadvertently transfer to food. If these areas are not kept clean, they may also provide harborage for insects, rodents, and other pests.During a review of the Policy and Procedure (P &P), titled Sanitation and Infection Control, release/revision date 1/31/25, the P&P indicated that .Employee must follow the specific procedures in all areas list below to ensure the department operated under sanitary conditions on a daily basis (for) Areas: .8. Refrigerated Storage, 9. Freezer Storage, 12. Cleaning Schedules,13. Sanitizing Equipment, Food and Utility Carts.During a record review of Registered Dietitian (RD)'s monthly Quality Assessment for Performance Improvement report dated 8/24/25 indicated multiple sanitation, equipment issue had been identified. Yet the kitchen was not found to be sanitary. 1. The kitchen was not sanitary or well maintained (Cross Reference F908).During the initial tour on 9/15/25 from 9:45 am to 11:10 am the kitchen was not sanitary. Walls had chipped/missing paint rendering them uncleanable and had holes that could harbor pests. Flooring was in disrepair, with missing tiles, cracks, and damaged/cracked coving rendering them uncleanable and providing potential harbor for insects. There was black buildup along floor edges, and around the bottom of stationary equipment. Trash can lids had gray grime. Tape and sticker residue that could be a source of cross contamination were seen on solid surfaces such as the shelf above tray line, sides of refrigerators, some carts, and other surfaces. The telephone was visibly soiled with grime, dust and sticker/tape residue. [NAME] binders used to hold recipes, food sanitation and safety logs, and other information throughout the kitchen were soiled and sticky.During observation accompanied by the Registered Dietitian (RD) on 9/15/25, at 10:11a.m., a black standing fan was positioned next to tray line (resident meal tray assembly process) near the cook's food production area and was coated with dust that could potentially cross-contaminate food. The RD stated the fan should be cleaned by the maintenance department. During an observation on 9/15/25 at 10:40 a.m., the air gap under the two-compartment sink was observed to be rusty and filled with black matter. The black matter was able to be scooped out. During a follow-up interview with the Maintenance Assistant on 9/15/25 at 3:15p.m., he stated the air gap was very old, very rusty and needed to be replaced. He stated the black particles scooped from the air gap were chunks of rust. During an observation near the dish room on 9/15/25, at 11:06 a.m., a large metal drying rack for insulated lids (for patient meal plates) was observed to have multiple rusted areas. In a concurrent interview, the RD stated the rack was rusty and should be replaced. During a concurrent observation and interview with the RD on 9/16/25, at 8:53 a.m., the area between the steam table and refrigerator four had dust and spider webs. The RD stated that the area was dusty and needed to be cleaned.During a concurrent observation and interview with the RD on 9/16/25, at 8:55 a.m., the water tank opening of the coffee machine was observed with black residue on one side and white lime scale on the other. RD stated that she was aware of these conditions. 2. Food was not stored according to professional standards of practice.2A. Refrigerators and Freezer food storage: During a concurrent observation and interview on 9/15/25 at 9:57 a.m., with Registered Dietitian (RD) and Certified Dietary Manager (CDM), greasy film covered the exterior door and handles of freezer one. Freezer two had a black substance resembling mold along the top of the door and frame. RD stated the substance was mold. Refrigerator three had a greasy film across the exterior doors and handles. The interior had food debris and a buildup of brown grainy residue on the shelves and condenser fans that could be easily scratched off with a fingernail. RD stated there were some particles and brown discoloration. During a concurrent observation and interview with RD on 9/15/25, at 10:10 a.m., refrigerator five had rust on the shelves, and grime was present on the condenser fans. RD stated she conducted monthly kitchen inspections, was aware of these issues, and had reported them to the CDM in August 2025. During further observation of refrigerator five, containers of tuna salad, chicken salad and egg salad were observed. The tuna salad label showed it was prepared on 9/12, and its internal temperature read 46.4 degrees Fahrenheit ( F - a measurable unit of temperature). The chicken salad label showed it was prepared on 9/13, and its internal temperature read 44.5 F. The egg salad label showed it was prepared on 9/14, and its internal temperature read 46.8 F. Safe refrigerated food storage temperatures are less than 41 F. Staff removed all food from the refrigerator and a repair vendor came the next day to repair it.During a record review of facility's P& P titled Sanitation and Infection Control, subject: Frigerated Storage, revision on date 1/31/25 indicated All perishable food will be stored in refrigerated store. Refrigerated areas will be managed so that proper time temperature is maintained to avoid food spoilage and time temperature abuse. No.8. Perishable foods should be stored less than or equal to 41 F. 2B. Dry Food Storage:During an observation with the CDM on 9/15/25 at 10:52 a.m., the dry storage areas were not sanitary. Walls, trims, and doors were uncleanable due to damage, missing paint and holes. There was a buildup of grime on many surfaces, especially the doors, trim, and light switches - high touch areas where cross-contamination could occur. Two out of two white rectangular food storage bins containing white rice and thickener were soiled with gray grime. The food scoop above the bins had accumulated food debris on the scoop and in the scoop holder. Fourteen out of fourteen round clear bins storing assorted grains and other dry foods were soiled with dust, grime and food particles. These conditions had the potential to promote microbial growth, and to attract rodents and insects to the food storage areas.A large black cart had a buildup of food debris, tape residue, and grime. Two of the shelves stored trays of large blue insulated mugs. The trays and the mugs were wet, and the mugs were filled half full of water. In a concurrent interview, the CDM stated the mugs were clean and were used to provide hydration to residents. She stated the mugs were switched out daily and would have ice added to them the next day before being distributed to residents. During a review of facility's P&P titled Sanitation and Infection Control, subject: Canned and Dry Goods Storage, revision on date 1/31/25, No.1. Food store areas will be clean, dry, and free of pests, contamination by condensation.No. 2. The storage area (cupboards, shelves, drawers, store room) will be clean and dry. No.16. Bins holding dry goods such as flour, sugar, beans, ect. must be clearly labeled, dated on the lid or front of the container and dated when the product was put into the bin. Scoops are to be stored in a separate area, not inside food containers, and need to be cleaned each time they are used. 3. The equipment was not maintained clean. During the initial tour in the cook's area on 9/15/25 from 9:45 a.m. to 11:10 a.m. the pot and pan rack above the 3-compartment sink was fuzzy with grease and dust. Sticky gray residue coated the top of the plate warmer, and the on/off switch was damaged and uncleanable. The stove and ovens had built up grime on the handles, knobs, and ledge surfaces. There was burned-on grease down the side of the stove. In general, utility carts throughout the kitchen had grime accumulation and food debris around edges, corners, handles, and wheels. A review of the kitchen's August cleaning log titled Cleaning Schedule, showed pot/pan, grill, oven/range, and cart cleaning schedule signing sheet has been signed off by staff every day.During an observation in the cook's area with Food Service Worker (FSW) 1 on 9/15/25 at 10:10 a.m., a large wire whip hanging above the three-compartment sink was observed with fuzzy dust and grime. FSW 1 immediately took the whip to the dishwasher. During concurrent observations and interviews in the cook's area on 9/15/25 at 10:14 a.m., two drawers containing tray line serving utensils and other assorted equipment were soiled. Three of 29 scoops in the top drawer had food residue and FSW 1 agreed they were not clean. The RD agreed that three of 29 scoops were stored wet and the drawer was not clean. She stated the scoops were supposed to be air-dried before being put away. The second drawer, three clear plastic food storage containers with assorted utensils, biscuit cutters, and a grater that were soiled.Two cardboard boxes for dispensing plastic wrap and foil were soiled with grease and grime. RD stated that since the residue was on the outside of the boxes, she considered it acceptable.The knife rack on the wall had grime on the top and held knives and metal spatulas. One of two metal spatulas had a broken brown plastic handle. One of three knives had a creamy white food accumulation down the length of the blade.During an observation on 9/15/25, at 10:13 a.m., the tray line eating utensil holder for resident trays was covered with debris and crumbs. During a concurrent observation and interview with RD and FSW 2 on 9/15/25 at 10:45 a.m., grime was observed on the mount and screws of the can opener, as well as on blue shaft guides. The mount was damaged and some of its finish was missing. FSW 2 took the can opener to the dishwasher. A review of the kitchen's August cleaning log titled Cleaning Schedule, showed can opener, trayline-work table/counters cleaning schedule signing sheet has been signed off by staff every day. The foil and plastic wrap dispensers were not on the cleaning checklists4. Staff did not consistently perform their duties according to professional standards of practice to avoid cross-contamination.During an observation on 9/15/25 at 12:05 p.m., FSW 8 picked up crumpled (soiled/used) napkin from the floor, put it in the trash, got something out of refrigerator four and returned to tray line duties without washing hands. During an observation on 9/16/25 at 11:19 a.m., FSW 2 was making chicken/tuna/egg salad at the food preparation station, their face was red with sweat. FSW 2 wiped their face with bare hands, walked to the handwashing sink and wiped their face again with a paper towel, without washing their hands, FSW 2 returned to food preparation. During an observation and interview on 9/17/25 at1:48 p.m., FSW 9 was scrapping residents' lunch trays without an apron on.During an interview on 9/17/25 at 2:11 p.m., CDM stated that staff should wash their hands after picking up trash from the floor and after wiping their face. During an observation from 9/15/25 through 9/18/25, CDM has fake nails. During a follow-up interview on 9/18/25 at 9:46 a.m., CDM stated that she believes nail polish was okay, if staff contact food, then need to wear gloves. During a review of facility's P&P titled Sanitation and Infection Control, subject: Personal Hygiene, revision on date 1/31/25, No. 3. Department of Food and Nutrition Services employees fingernails should be clean, clipped and free of fingernail polish.5. Resident food in the resident refrigerator was not adequately or consistently labeled and dated to ensure food safety and resident satisfaction. (Cross Reference F813).During a concurrent observation and interview on 9/16/25 at 3:08 p.m., with Infection preventionist (IP), the unit refrigerator designated for residents to store food brought from home and outside sources was observed. The following items were noted:One container of ice cream for room [ROOM NUMBER]C stored without a resident name.One opened bag of Oreo Thin Cookies for room [ROOM NUMBER]A stored without a resident name. The bag was opened on 7/21/25 and the Manufacturer's expiration date was 9/10/25.One unopened bag of cooked shrimp for room [ROOM NUMBER]A stored without a resident name. The date received was 9/9/25.One frozen pizza for room [ROOM NUMBER]A stored without a resident name. The date received was 8/25/25.One unopened bag of raw shrimp stored without a resident name or received date. The manufacturer's expiration date was 7/26/26. IP stated nursing staff would cook shrimp for resident in the microwave oven.One container of Breyer's Ice Cream stored without a resident name or received date. One opened bottle of Brisk Pink Lemonade stored without a resident name, opened date, or received date.One opened carton of Your Good Foods Soymilk stored without a received date or opened date. The manufacturer's use by date was 5/16/26 and the product indicated it should be used within seven to ten days after opening. One opened carton of Good & Gather Half & Half stored without a resident name, received date, or opened date. The manufacturer's best by date was 11/26/25 and indicated Enjoy within seven days after opening.During a review of facility Policy & Procedure (P&P) titled Food Brought from Outside the Facility, Revision: 4.0, approved on 9/12/25, indicated Perishable food must be stored in a re-sealable container with tightly fitting lids in a refrigerator. Containers will be labeled with the resident 's name, the item and 'used by' date.During a review of P&P titled Food Receiving and Storage Of Cold Foods Release/Revision date 1/31/25, indicated All open food items will have an open date and use-by-date per manufacturer's guidelines. During a review of P&P titled Food Brought in From Outside Sources Release/Revision date 1/31/25, indicated All food brought in should be checked by the charged nurse or Director of Food and Nutrition Services. It must be placed in a tightly sealed container with the resident's name and date on it.6. Ambient food cooling was not consistently documented.A record review of facility's September Cooling Log on 9/16/26 at 4:09 p.m., no temperature was entered into the cooling log for chicken salad made on 9/15/25. No temperatures were logged for egg/tuna/chicken salad prepared on and seen in refrigerator on 9/16/25.During an interview on 9/18/25 at 9:14 a.m., in the kitchen, RD stated we have cooling log, we have been using it without consistency. 7. Rags were left unattended in random areas of the kitchen.During observation, unattended rags were observed on multiple days and areas as below:On 9/15/25 at 9:45 a.m., there was an unattended rag on dish room counter dirty side.On 9/16/25 at 10:20 a.m., there was an unattended rag on the counter in the cooking area.On 9/16/25 at 11:00 a.m., there was an unattended rag on the utility cart.On 9/16/25 at 4:07 p.m., two unattended towels were observed in the food preparation/cook's area. A sanitizer bucket was located on the dirty counter in the dish room with very little sanitizer in it. The rags were not submerged in the sanitizer solution and one rag was observed unattended on the counter.

Based on observation, interviews and record review, the facility failed to ensure two (Resident 68 and 79) of five sampled residents were free from unnecessary drugs when: 1. Resident 68 with diagnosis of non-Alzheimer's dementia was administered Haloperidol (Haldol an antipsychotic medication) for hitting and grabbing, an inadequate indication for use.Facility did not address Resident 68's involuntary jerky movements as an adverse reaction for the use of Haldol.Facility did not attempt gradual dose reduction (GDR) for Resident 68 use of Haldol. Gradual Dose Reduction (GDR) is the stepwise tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the dose or medication can be discontinued.(Non-Alzheimer's Dementia is a progressive disease that destroys memory and other important mental functions).(Antipsychotic medication are drugs used to treat schizophrenia and bipolar serious mental health conditions, capable of affecting the mind, emotions, and behavior). 2. Resident 79 was administered Lorazepam (anti-anxiety medication) in excessive dose over a 24-hour period that exceeds the amount recommended by the manufacturer.These failures had the potential for residents to receive unnecessary drugs and to suffer adverse medication side effects.1.During a review of Resident 68's Annual Minimum Data Set (MDS- a federally mandated resident assessment and care guide tool), dated 12/25/24, the MDS indicated Resident 68's Basic Interview of Mental status (BIMS, a scoring system used to determine the resident's cognitive status regarding attention, orientation, and ability to register and recall information. A BIMS score of thirteen to fifteen is an indication of intact cognitive status.) Resident 68's score was 13 meaning intact cognition. Resident 68 had clear speech, usually understand and understood others. MDS indicated Resident 68 had no potential indicator of Psychosis, no hallucination or delusion. Resident 68 had no physical, verbal, or other behavioral symptoms directed toward others e.g., hitting, grabbing, threatening, screaming at others. MDS indicated Resident 68 did not exhibit rejection of care or wandering behavior. Resident 68's diagnoses included Non-Alzheimer's Dementia.During a review of Resident 68's Physician Order Report (POR) dated 5/6/24, the POR indicated, physician prescribed Resident 68 to receive the followings:Haloperidol tablet 10mg by mouth twice daily for schizophrenia manifested by hitting and grabbing.Haloperidol tablet 10mg give 5 mg by mouth daily in the afternoon for schizophrenia manifested by hitting and grabbing.Haloperidol Decanoate solution 100mg/ml give 1ml intramuscular administer 1 ml via intramuscular every 28 days for schizophrenia manifested by hitting and grabbing.Further review of Resident 68's MDS, dated [DATE], MDS indicated Resident 68 did not have a diagnosis of schizophrenia.During a review of Resident 68's Medications Administration Record (MAR), dated 8/1/25 to 8/31/25 and 9/1/25 to 9/18/25, the MAR indicated Resident 68 was administered Haldol 10 mg by mouth twice daily and Haldol 5 mg by mouth daily in the afternoon for schizophrenia manifested by hitting and grabbing. During a concurrent observation and interview on 9/18/25 at 8:14 a.m. with Resident 68, Resident 68 sat at the reception area scrolling on his electronic device. Resident 68's right upper arm stump jerked uncontrollable. Resident 68 stated his whole body shakes from time to time. Resident 68 stated he need help to address involuntary shakes movement he had over his body. Resident 68 stated the jerky movement was getting worse. During an interview on 9/18/25 at 8:20 a.m. with Certified Nursing Assistant (CNA3), CNA 3 stated she was Resident 68 care giver during morning shift. CNA3 stated that Resident 68 had uncontrollable body movements because he had Parkinson disease. CNA3 stated that Resident 68 had no behavioral problems, no hitting or grabbing. CNA3 said Resident 68 liked to sit at the reception area with his electronic devise or attend activities.During an interview on 9/18/25 at 8:09 a.m. with Licensed Vocational Nurse (LVN1), LVN1 stated Resident 68 had no behavioral problems, no hitting or grabbing. LVN1 stated Resident 68 had uncontrollable body movements because he had Parkinson disease. LVN1 stated the uncontrollable body movement could probably be a side effect for Haldol use.During a review of Resident 68's Monthly IDT psychotropic review (IDT), observation dates, 7/3/25, 8/20/25 and 9/9/25 indicated Resident 68 had zero behaviors and zero side effects for the use of Haldol observed per month.During a telephone interview on 9/18/25 at 12:19 p.m. with Resident 68's Medical Doctor (MD1), MD1 stated he recently took over Resident 68's care and had deferred Resident 68 behavior and psychotropic medication management to the psychiatric. MD1 encouraged surveyor to review Resident 68's psychiatric notes. During a review of Resident 68's Psychiatric Visit Progress Reports (PR), dated 4/9/24, the PR indicated an order to discontinue Haldol afternoon dose/order.During a review of Resident 68's Consultant Pharmacist (CP) report titled, Note to the Physician/Prescriber (MRR), dated 6/16/25, the MRR indicated that Resident 68 has been taking antipsychotic Haldol Deconate monthly, Haldol 10mg twice a day and 5mg at 1PM. MRR indicated for physician to evaluate, consider a dose reduction and attempt dose reduction to discontinue 1PM dose of Haldol. Further review of Resident 68's MRR indicated that the recommendation to discontinue 1PM dose of Haldol was declined.During a concurrent interview and record review on 9/18/25 at 12:08 p.m. with Registered Nurse/Unit Manager (RN3), Resident 68' Psychiatric notes and MRR dated 6/16/25 were reviewed. RN3 stated Resident 68 CP recommendations to attempt GDR for Resident 68's use of Haldol and discontinued Haldol afternoon dose was declined because prior attempts at GDR had failed. RN3 could not provide documentation to support the attempts that were made at reducing Resident 68's use of Haldol. RN3 stated Resident 68 had involuntary body movements because Resident 68 had Parkinson disease. RN3 could not provide documentation to support that GDR was attempted for Resident 68's use of Haldol.During a concurrent interview and record review on 9/18/25 at 2:40 p.m. with DON, Resident 68 MRRs were reviewed. DON stated Resident 68 was transferred to hospital several times in the past and that is why GDR had failed. DON could not provide documentation to support that GDR was attempted for Resident 68's use of Haldol.During a review of Resident 68's Preadmission Screening and Resident Review (PASRR), dated 2/27/23, the PASRR indicated Resident 68 had no serious mental illness.(PASRR is a federal requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are appropriately placed in nursing homes for long term care). According to the manufacturer, elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death. Haldol can increase the risk of death in elderly people who have memory loss, and this drug is not approved to treat mental problems related to dementia. {Reference: https://www.dailymed.nlm.nih.gov}2.During a review of Resident 79's Significant change in status Minimum Data Set (MDS-a federally mandated resident assessment and care guide tool), dated 9/1/25, the MDS indicated Resident 79 was [AGE] years old. MDS indicated Resident 79 had short-term and long-term memory problems. Resident 79 had slurred or mumbled speech. Resident 79 rarely make self-understood or understand others. MDS indicated Resident 79 had no physical, verbal or other behavioral symptoms directed towards others. MDS indicated Resident 79 did not exhibit rejection of care or wandering behavior. Resident 68's diagnoses included Non-Alzheimer's Dementia.During a concurrent observation and interview on 09/18/2025 8:21 a.m. with CNA4 in Resident 79's room, Resident 79 laid in bed mumbled incomprehensible words to herself. CNA4 stated that Resident 79 mumbles to herself and tap her finger on the mattress.During a review of Resident 79's POR dated 8/28/25, the POR indicated, physician prescribed Resident 79 to receive Lorazepam 1mg one tablet via gastric tube (GT) every 6 hours for 90 days as needed (PRN) for anxiety manifested by constantly moving in bed.(A gastric tube, also known as a gastrostomy tube (G-tube), is a flexible, hollow tube inserted through the abdominal wall and into the stomach).Further review of Resident 79's MDS, dated [DATE], MDS indicated Resident 79 did not have a diagnosis of anxiety.During a review of Resident 79's Medication Administration Record (MAR), dated 7/1/25 to 7/31/25, 8/1/25 to 8/31/25 and 9/1/25 to 9/18/25, the MAR indicated Resident 79 was administered Lorazepam 1mg every 6 hours PRN for anxiety, more that recommended daily dose of 2 mg/day. Resident 79 received Lorazepam 1mg three times on 7/20/25, 7/28/25, 8/4/25, 8/12/25, 8/18/25, 8/19/25, 8/26/25, 8/27/25, 9/1/25, 9/2/25, 9/6/25, 9/8/25, 9/15/25, and 9/16/25. The MAR indicated that Resident 79 was administered Lorazepam total of 3mg/day PRN in excessive dose more than recommended daily dose of 2mg/day.{Reference: https://www.dailymed.nlm.nih.gov}During an interview on 9/18/25 at 8:30 a.m. with LVN 1, LVN1 stated Resident 79 mumbled at times. LVN1 said Resident 79 taps her finger on her mattress. LVN1 said Resident 79 received Lorazepam 1mg PRN every 6 hours as ordered by the physician.During a telephone interview on 9/18/25 at 1:30 p.m. with CP, CP stated the manufacturer's recommended dose for the use of Lorazepam in elderly was 2mg over a 24-hour period.During an interview on 9/18/25 at 2:33 p.m. with DON, DON stated he did not know the manufacturer's recommended daily dose for the use of Lorazepam in the elderly. During a review of the facility's policy and procedure (P&P) titled, Psychotropic Medication Assessment & Monitoring, dated 12/13/2024, the P&P indicated, Psychotropic drugs are used only when necessary, and then at the lowest effective dose. Monitoring for drug side effects leads to early identification and reporting. The Interdisciplinary Team assesses and monitors the appropriateness, effectiveness and side effects associated with psychotropic medications for each resident via the MDS process

Based on observations, interviews and record review, the facility failed to ensure food provided to residents was palatable (refers to the flavor and taste of food) and served at a safe and appetizing temperature when1. Four out of 97 residents sampled stated the food did not taste good.2. Three out of 97 residents sampled stated hot food was not served hot.These deficiencies had the potential to result in decreased resident satisfaction with meals, food safety issues, and decreased resident meal intakes that could lead to weight loss and malnutrition.Review of a policy titled Nutrition Care, Subject: Residents Rights, dated 2023, showed Residents have the right to: be served food per their individual preferences, within restrictions imposed by the diet; refuse any food items and receive an appropriate food substitute; refuse their therapeutic diets; be served food per their ethnic, cultural, and/or religious beliefs.1. Residents 88, 99, 75, and 96 stated the food was not palatable.During an observation of the lunch meal tray line (resident meal tray assembly process) hot foods on 9/15/25 at 11:50 a.m., the steam table looked like it held regular and texture modified foods but did not appear to hold additional low sodium versions of foods.During observations of lunch tray line (resident meal tray assembly process) on 9/15/25 beginning at 11:50 a.m., and on 9/16/25 beginning at 11:45 a.m., it was noted that common condiments such as salt, pepper and sugar were not placed on resident trays. Margarine and salad dressings were added, and occasionally herb seasoning.During an interview with FSW 2 on 9/16/25 at 4:07 p.m., they stated all the foods they served on tray line were low sodium. They stated that sometimes if they used butter in a recipe, they didn't add the salt because the butter was already salty.During an interview with the RD on 9/16/25 at 4:07 p.m., she stated they didn't prepare any different foods for low sodium diets. They didn't put salt on resident meal trays, but CNA's should automatically give condiments to regular diets. The RD stated they didn't put the condiments on the trays because It's the protocol here, the way it's always been done.During an interview with Resident 88 in their room on 9/17/25 at 10:21 a.m., they stated they would like the food better If the food wasn't so bland. They stated residents had to ask for salt and pepper. They didn't ask for it, often because they didn't think to ask for it (timely). During an interview with Resident 75 in the corridor on 9/17/25 at 10:40 a.m., they stated sometimes they liked the food, but it wasn't good when it was fried, or they served it with noodles. The food is very, very terrible.During an interview with Resident 99 in their room on 9/17/25 at 11:08 a.m., they stated the food was Fair to Middlin. They stated the food had no flavor. The C.N.A.s (Certified Nursing Assistants) did not offer condiments. Residents had to ask for them, and then the C.N.A.'s would provide condiments, but they couldn't have salt because of their diet order. Sometimes they received Mrs. Dash herb seasoning.During an interview with Resident 96 in their room on 9/17/25 at 12:50 p.m., he stated the meat provided was fatty and poor quality, the hamburgers from the facility had so much filler in them that they didn't even taste like hamburgers. The chicken was always either burnt or raw, nothing in the middle. The hard-boiled eggs he received this morning were soft boiled and couldn't even be peeled.During an observation of nursing delivery of meal trays to residents on 9/17/25 at 12:50 p.m., Certified Nursing Assistant 8 (CNA 8) , delivered meals to 2 residents and no condiments were observed offered.During an observation and concurrent interview during nursing delivery of meal trays to residents on 9/17/25 at 12:50 p.m., CNA 9 stated there was a basket of condiments on each meal cart with salt, pepper, sugar, tea, and that they asked every patient if they would like condiments (within the diet order). They stated the kitchen placed salad dressings and herb seasoning on trays when desired by the patient, but nursing had to go to the kitchen for those if they were not on the trays and the resident wanted them. He went to get a basket of condiments. There was no basket in one cart so he got one from another cart. It contained salt, pepper, sugar, Sweet Plus (sugar substitute), teabags.During an interview with the RD on 9/17/25 at 3:43 p.m., she stated condiments were provided to residents by nursing because they didn't want to send a bunch of condiments on the trays if they weren't going to be used, and residents could ask for more seasoning/condiments if they wanted. If residents had special preferences the kitchen could put condiments on the tray based on diet order and what the resident wanted. She stated that gravy provided with meals should be regular, (not Low sodium). Review of a Centers For Disease Control (CDC) website titled About Sodium and Health, https://www.cdc.gov/salt/about/index.html showed Americans consume more than 3300 mg per day on average. One teaspoon of table salt contains about 2400 mg of sodium.Review of an undated document titled Mariner Healthcare FW25 Average Cycle Nutritional Summary, showed nutrient analysis daily averages of nutrients for the regular menu, using the Dietary Reference Intakes reference for females age [AGE]-70. It showed sodium content averaged around 3800 mg to 4,292 mg daily.Review of the facility diet manual, titled Diet Manual for Rehabilitation, Residential, and Long Term Care Communities, Nutrition Therapy Essentials, dated 2023, showed it was reviewed and approved by the facility's Registered Dietitian on 2/5/25. Review of the section titled 2-3 Grams (2000-3000 Milligrams (mg)) Sodium diet showed it would provide 2000-3000 mg sodium daily.Review of a policy titled Meal Service, Subject: Tray Assembly, dated 2023 showed Preset trays may only include non-perishable items prior to meal service. This includes.Condiments (to be placed on a tray according to the resident's preference, request, or diet order).Review of a policy titled Meal Service, Subject: Delivery of Food Carts and Tray Service,: dated 2023, described the nursing meal delivery process. It did not include any information about condiments or offering condiments to residents when delivering meal trays. 2. Food was not consistently served at an appetizing temperature:During an interview with the Registered Dietitian (RD) on 9/15/25 at 9:54 a.m., she stated she inspected the kitchen, did a test tray, observed tray line, and monitored food temperatures monthly. Review of a policy titled Food Preparation, Subject: Food Cookery, dated 2023, showed Food temperatures will be monitored each meal to assure standards are met. Corrective actions will be taken to meet temperature standards. Hot food must be a minimum of 140 F (degrees Fahrenheit, a measurable unit of temperature) at time of serving and perishable cold food at a maximum of 41 F at serving. Review of an undated policy titled Serving Food, showed Although there are no specific state and federal requirements concerning point of delivery food temperatures, the American Hospital Association has guidelines that are acceptable for health care. These guidelines showed Hot Foods 110 F or above, Hot liquids 150 F or above, Hot cereals 150 F or above, Soups 130 F or above, Cold liquids/milk-based foods 50 F or below, Other Cold Foods 65 F or below.Review of a policy document titled Proper Temperatures for Meal Preparation and Service, dated 2023, listed these proper temperatures for meal preparation/holding for service: poultry 165 F/140 F, vegetables 145 F/140 F, grains 165 F/140 F and dairy products 41 F/41 F. Legumes (beans) were not specifically listed.Review of an undated document titled Mariner Healthcare, Spring/Summer 2025, Diet Spreadsheet, Week 5 Day 30 showed the lunch meal on 9/16/25 included Soft Chicken Taco, Wheat Bread, Pinto Beans, Sauteed Onions & Peppers, Margarine, and Emerald Pears.During an observation and concurrent interview with the Registered Dietitian (RD) and Certified Dietary Manager on 9/16/25 at 12:52 p.m., test trays were evaluated for a regular diet and a pureed diet, with focus on appearance, temperature, texture and flavor. Regular trayBeans - 113.8 F - RD and CDM thought they tasted good, like beans. Surveyor thought they were bland, needed at least salt seasoning.Chicken - 126 F - Unanimous tasted really good.Peppers and Onions - 143.6 F - Unanimous tasted good. Pureed trayPureed Chicken with Gravy - 130.3 F - Unanimous tasted good. Consistency not smooth, small detectable pieces of chickenPureed Bread - 120.4 F - Tastes good like bread, Consistency is smooth, does not taste starchy, softly mounded on plate.Beans - 122.9 F - RD, CDM and Surveyor [NAME] thought they tasted like beans, good. Surveyor [NAME] thought they tasted bland. Consistency not smooth, pieces of skin detected.Peppers and Onions - 120.1 F - Unanimous taste good. Consistency was not smooth, pieces of skin detected. Milk 47.3 F During an interview with Resident 88 in their room on 9/17/25 at 10:21 a.m., they stated the food was often cold and greasy. During an interview with Resident 75 in the corridor on 9/17/25 at 10:40 a.m., they stated food was cold all the time. During an interview with Resident 99 in their room on 9/17/25 at 11:08 a.m., they stated the food was often cold. A review of the RD's monthly Quality Assessment for Performance Improvement reports dated 7/21/25 and 8/24/25 communicated concerns regarding menu, recipes, portion control, therapeutic diets, food safety, sanitation and showed ongoing monthly issues with test trays showing recipes not being followed, texture modification being performed correctly, and suboptimal food temperatures:8/24/25 Following menu and recipes: Recommend continuing in-service cooks and dietary aides about following recipes for pureed food. Food Safety: Suboptimal food temperature. Please see the test tray report for details. Please in-service staff on making the correct consistency of the pureed food.7/28/25 Following menu and recipes: Please see details in test tray report. Recommend continuing in-service cooks and dietary aides about following recipes for pureed food. Food Safety: Suboptimal food temperature. Please see the test tray report for details. 6/15/25 Following menu and recipes: Please see details in test tray report. Recommend continuing in-service cooks and dietary aides about following the spreadsheet and menu for the modified texture, therapeutic diet and portion sizes. Food Safety: Suboptimal food temperature. Please see the test tray report for details. 5/30/25 Following menu and recipes: Please see details in test tray report. Recommend continuing in-service cooks and dietary aides about following the spreadsheet and menu for the modified texture, therapeutic diet and portion sizes. Food safety: Please see the test tray report for details.4/28/25, Following menu and recipes: Please see details in test tray report. Recommend continuing in-service cooks and dietary aides about following the spreadsheet and menu for the modified texture and portion sizes. Food safety: Please see the test tray report for details.3/31/25 Following menu and recipes: Please see details in test tray report. Recommend continuing in-service cooks and dietary aides about following the spreadsheet and menu for therapeutic diet, modified texture, and portion sizes. Food safety: Please see the test tray report for details.2/28/25 Following menu and recipes: Please see details in test tray report. Recommend continuing in-service cooks and dietary aides about following the spreadsheet and menu for therapeutic diet, modified texture, and portion sizes. Food safety: Please see the test tray report for details.1/31/25 Following menu and recipes: Please see details in test tray report. Recommend continuing in-service cooks and dietary aides about following the spreadsheet and menu for therapeutic diet, modified texture, and portion sizes. Food safety: Please see the test tray report for details. Waiting on parts of the steam table to arrive.

Based on observation, staff interviews, and record reviews, the facility failed to ensure sufficient competent dietary services staff to consistently meet professional standards of practice for safe food preparation and service when:Staff did not clean fixed equipment (equipment that cannot be cleaned in a dishwasher, or the 3-compartment sink such as counters, carts, and refrigerators) according to manufacturer's instructions and professional standards of practice and the equipment was not sanitary.Staff did not consistently perform professional standards of practice to minimize the risk of cross-contamination. Staff did not puree foods according to recipe and diet manual specifications.Staff did not complete ambient food cooling logs consistently. These failures had the potential to result in foodborne illness for all residents who consumed meals from the facility's kitchen, and to result in difficulty swallowing and choking for residents on puree diets (cross-reference F812, F805).During an interview on 9/16/25 at 10:20 a.m., Food Service Worker (FSW) 1 stated they had worked there for more than 20 years. They stated they did not take breaks because if they did, they would not have enough time to complete their responsibilities.Review of 2025 in-services provided by the Certified Dietary Manager (CDM), dated 1/3/25 showed Staff will understand that working off the clock is not accepting at all times. Staff must follow company's policy. Staff will understand that clocking in early is not acceptable.Per Mariner's handbook minimum requirement for clocking in was 7 minutes before shift starts and 7 minutes after shift ends.A review of the [NAME] Competency Skills Checklist, dated 8/18/25 for FSW1, confirmed FSW 1 was not successful in consistently completing all cleaning and sanitation responsibilities. During an interview on 9/17/25 at 2:10 p.m., CDM stated the kitchen was fully staffed. She explained that new staff received hands-on training with a peer and the CDM shadowed them. Training lasted at least two weeks, until the new staff were competent to perform the job independently. CDM stated staff completed an annual skill check for training and competency purposes.Review of a policy titled Employee Orientation Program, dated 2023, showed All employees will receive orientation and on-going in-service education to ensure adequate knowledge and competence in all areas of food service. New employees will be trained on the job and competence will be verified before performing assigned duties. Review of the Employee Orientation Checklist within the policy showed it included 28 topics and subtopics such as menus, modified diets, portion control, recipes, sanitation, and equipment (use, cleaning and maintenance). A checklist of areas requiring verification of competence showed 27 topics including handwashing, cleaning, dish washing, and equipment cleaning (refrigerators, carts, etc.).A review of the [NAME] Competency Skills Checklist for the following FSWs showed: FSW 1 - 8/18/25 - Was verified competent in 27 out of 33 topics including following standardized recipes, correct temperatures, cleans and sanitizes work surfaces, equipment and utensils before and after use, etc. The six areas assessed as unsatisfactory and requiring more training and re-evaluation included ensuring appropriate texture modifications for residents; monitoring food quality, taste, appearance and consistency of food; monitoring and maintaining the cleanliness of the kitchen and food storage areas; and disposing of expired products. Signed/evaluated by CDM and Registered Dietitian (RD). FSW 2 - 8/20/25 - Was verified competent in 26 out of 33 topics including cleans and sanitizes work surfaces, equipment and utensils before and after use, monitoring and maintaining the cleanliness of the kitchen and food storage areas. Areas unsatisfactory included: demonstrates of correct techniques for measuring, mixing, chopping, slicing and portioning; Prepares special diets according to residents medical and dietary needs; Checks and records temperatures of refrigerators and freezers; Checks internal temperatures of hot and cold foods before serving; and Ensures food presentation is appealing and appetizing. Signed/evaluated by CDM. FSW 7 - 8/18/25 - Was competent in 31 out of 33 topics including cleans and sanitizes work surfaces, equipment and utensils before and after use, monitoring and maintaining the cleanliness of the kitchen and food storage areas. Areas unsatisfactory including disposing of expired food and ensuring food presentation is appealing and appetizing. Signed/evaluated by CDM and RD.Competence in performing ambient food cooling was not included in the form. A review of the Dietary Department's Orientation and Skills Checklist Dietary Aide, for FSW 6, dated 5/30/24, showed they were competent worktable as of function, including safe cooling process; handwashing; food storage (refrigerators, freezers, dry storage - sanitation), consistency modification; demonstrates how to clean large equipment and appliances in the kitchen; demonstrates how to clean and sanitize work table; and demonstrates competency in the safe cooling process using the cool down log. Signed off /evaluated by CDM 6/2/25.1. Staff did not clean fixed equipment according to manufacturer's instructions and professional standards of practice, and the equipment was not sanitary (Cross Reference F812).Throughout the survey, beginning 9/15/25 at 9:10 am, and ending 9/18/25 at 5:00 pm, the kitchen and its equipment were observed to be unsanitary. Refrigerators and carts were not clean, food storage areas were not clean, floors were not clean; doors, switches, knobs, handles, telephone and other high touch areas were not clean, increasing the risk of cross contamination (the process by which bacteria or other microorganisms are unintentionally transferred from one substance or object to another, with harmful effect). Review of the 2022 Food and Drug Administration (FDA) Food Code showed: S4-603.15 showed If washing in sink compartments or a ware washing machine is impractical such as when the equipment is fixed or the utensils are too large, washing shall be done using alternative means with the following procedures. A. Disassembled to allow detergent access to all parts; B. Scraped to remove food particles; C. Washed. S4-603.16 showed equipment must be rinsed with potable water after washing. S4-702.11 showed Utensils and food contact surfaces of equipment shall be sanitized before use after cleaning. S4-901.11 showed air drying is required after cleaning and sanitizing equipment and utensils.Review of the undated Ecolab Oasis146 Multi-Quat Sanitizer Instruction Manual, https://manuals.plus/asin/B07ZZGJK92#:~:text=Application%20Methods:,Non%2Drefillable%20container showed Prior to sanitization, surfaces must be thoroughly cleaned and rinsed.Spray the diluted solutions directly onto the pre-cleaned surface, ensuring the surface remains visibly wet for at least 60 seconds (1 minute) for sanitization. Allow to air dry.During an interview with FSW 3 on 9/15/25 at 2:53 p.m., they stated that they did their cleaning daily. They cleaned the floor, and wiped everything down. They stated they only used sanitizer to clean counters and resident meal carts between meals unless they were really dirty. they stated that they power-washed the meal carts once a week using detergent, rinse, and sanitizer.Review of a policy titled Sanitizing Equipment, Food and Utility Carts, dated 2023, showed 4. All kitchen equipment and surfaces which come in contact with food will be cleaned and sanitized after each use. 5.Food and utility carts will be cleaned and sanitized after each meal or use.During an interview with FSW7 on 9/18/25 at 10:55 a.m., they stated that when they were assigned the refrigerator and freezer task, they checked the temperature, checked the label and date of foods inside, discarded expired foods, and if something was dirty on the bottom they would wipe it out using a sanitizer bucket or sanitizer spray bottle and a rag. They stated they never took everything out to clean it, and never used the wash, rinse, sanitize or air dry process to clean the refrigerator or freezer.Review of the policy titled Sanitation and Infection Control Subject: Cleaning Refrigerators, dated 2023, showed wash all shelves by cleaning with a wet cloth or removing them and washing in a sink of hot, soapy water. Rinse, sanitize and air dry the shelves.A review of facility's Cleaning Schedule, dated August 2025, showed staff documented they completed the daily cleaning of freezers, refrigerators, carts, and can opener. However, during observations throughout the survey, the equipment was not clean (Cross Reference F812). A review of the RD's monthly kitchen inspection reports Quality Assessment for Performance Improvement, for June, July, and August 2025, showed repeated issues such as refrigerators, carts, stoves, ovens, plate warmer, can opener and mount, toaster, knives, coffee machine, and juice machine were not clean.2. Staff did not consistently perform professional standards of practice to minimize the risk of cross-contamination (Cross Reference F812). 2A. Handwashing - During an observation on 9/15/25 at 12:05 p.m., FSW 8 picked up trash from the floor and did not wash their hands before obtaining something from the refrigerator and returning to tray line duties. During an observation on 9/16/25 at 11:19 a.m., FSW 2 wiped sweat off their face and did not wash hands before returning to food preparation. During an interview on 9/17/25 at 2:11 p.m., CDM stated that staff should wash their hands after picking up trash from the floor and after wiping their face. Review of a policy titled Food Preparation, dated 2023, Hands should be properly washed prior to food preparation.Review of facility's dietary in-service for handwashing on 2/27/24, indicated ALWAYS wash your hands after touching your hair, face or body, touching anything else that may contaminate hands. 2B. Aprons: During an observation and concurrent interview on 9/17/25 at 1:48 p.m., FSW 9 scrapped residents' soiled lunch trays without an apron on, increasing risk of cross contamination with her clothing. They stated they weren't worried about their clothes.Review of a policy titled Sanitation and Infection Control, Subject: Personal Hygiene, dated 2023, showed Clean aprons should be worn at all times and changed as needed (minimum daily). Aprons should be worn in the Department of Food and Nutrition Services and removed during breaks, tray delivery and visits to residents.During an interview with the CDM on 9/17/25 at 2:10 p.m., she stated staff should be wearing aprons when scraping resident meal trays or working in the dish room due to potential cross contamination.2C. Unattended Rags - Throughout the survey, beginning 9/15/25 at 9:10 am, and ending 9/18/25 at 5:00 pm, cleaning rags were observed left unattended on carts, counters, boxes, in the dish room, cook's area, and food preparation areas of the kitchen (Cross-Reference F812).During an interview with the CDM on 9/17/25 at 2:10 p.m., she stated cleaning rags should be kept in the sanitizer bucket. Review of the 2022 Food and Drug Administration (FDA) Food Code S3-304.14 showed Cloths in-use for wiping counters and other equipment surfaces shall be held between uses in a chemical sanitizer solution.3. Staff did not puree foods according to recipe and diet manual specifications (Cross- Reference F805).Review of the facility diet manual, titled Diet Manual for Rehabilitation, Residential, and Long Term Care Communities, Nutrition Therapy Essentials, dated 2023, Puree diet section showed All foods should be smooth and pureed to the consistency of pudding. Review of a policy titled Food Preparation, Subject: Food Cookery, dated 2023, showed Pureed Food Preparation (follow menu recipes) .Pureed foods should be prepared to the consistency and thickness of mashed potatoes.During lunch meal preparation observation and concurrent interview on 9/16/25 at 10:20 a.m., FSW 1 was observed pureeing food for the lunch meal. They stated they pureed enough when they looked like mashed potatoes. After FSW 1 completed the pureed process, small chunks of chicken were observed remaining around the top edge of the Robo Coupe container. During a follow-up interview on 9/16/25 at 11:07 a.m., FSW 1 stated they did not measure the ingredients because they had made it so many times, they knew what to do.Review of the recipes used that day for pureed soft chicken tacos, pureed pinto beans, and pureed sauteed onions and peppers showed they were to be pureed until smooth. (Cross-Reference F805)During a meal test tray process with RD and CDM on 9/16/25 at 12:54 p.m., the pureed chicken with gravy, pureed pinto beans, pureed onions, pureed peppers and onions and pureed bread were tested. The chicken consistency was not smooth and contained small detectable pieces of chicken. The pureed beans were not smooth and contained pieces of skin. The pureed peppers and onions were not smooth, with detected pieces of skin, which did not meet the smooth consistency required for a pureed diet. Review of the [NAME] Competency Skills Checklist for FSW 1, signed 8/18/25, showed FSW 1 required more training and re-evaluation in Ensures appropriate texture modifications.During an interview with the RD on 9/17/25 at 3:43 p.m., regarding the pureed foods not being smooth, she stated cooks needed to do a taste test with the food they were preparing, and to test the consistency of the food.4. Staff did not complete ambient food cooling logs consistently. Review of FDA Food Code 2022, Section 3-501.14 Cooling, showed Time/Temperature control for Safety Food shall be cooled within 4 hours to 5oC (41oF) or less if prepared from ingredients at ambient temperature, such as .canned tuna P.During an observation of the #5 Refrigerator on 9/15/25 at 10:06 am, it contained:Tuna Salad - Prepared On 9/12, Use By 9/15 Temperature 46.4 FEgg Salad - Prepared On 9/14, Use By 9/17 Temperature 44.5 FChicken Salad - Prepared 9/13, Use By 9/16 Temperature 46.8 FRefrigeration temperature should be < 41 F. The facility discarded the salads because they were out of an acceptable temperature range. Review of a policy titled Cool Down, dated 2023, showed Food that is prepared from room temperature or refrigerated ingredients also need to be monitored on a cool down log.On 9/15/25 at 11:44 a.m., a document titled Cooling Log, dated September 2025, showed completed cooling logs for the tuna salad and egg salad, but there was no cooling log for the chicken salad prepared on 9/13/25. During observation of Refrigerator #4 on 9/16/25 at 4:07 p.m., there were new batches of egg salad, chicken salad, and tuna salad prepared on 9/16/25. In a concurrent review of the Cooling Log, dated September 2025, there were no cooling logs documented for the chicken salad prepared on 9/13/25, and no cooling logs for any of the salads prepared on 9/15/25 or 9/16/25.During an interview on 9/18/25 at 9:14 a.m., in the kitchen, RD stated We have cooling log, but we have been using it without consistency.

Based on observations, interviews and record reviews the facility failed to ensure the Registered Dietitian (RD) and Certified Dietary Manager (CDM) had the necessary skill sets to carry out the functions of the food and nutrition service when:1. There was not an effective system in place to ensure the sanitation and food safety of the food services areas.2. There was not an effective system in place to ensure adequate training, competence and regular monitoring of dietary staff work practices.During an interview on 9/15/25 at 9:45 a.m., the CDM stated she had been the Director of Food and Nutrition Services since 2021.During an interview with the Registered Dietitian on 9/15/25 at 9:54 a.m., she stated she had worked at the facility for one year. The RD stated she conducted monthly kitchen sanitation inspections where she inspected the equipment, did test trays, observed tray line, and monitored food temperatures. She stated the CDM was responsible for addressing concerns identified during the inspections. The RD pointed out it was an old building.Review of the policy titled Orientation, Inservice & Personnel Management, Subject: Director of Food and Nutrition Services, dated 2023, showed The Director of Food and Nutrition Services effectively manages the operation of the Department of Food and Nutrition Services including .directing and evaluating all aspects of food service. and showed competencies required included conducts weekly/daily sanitation rounds.conducts monthly in-services with staff.prevents cross contamination.cleans and sanitizes surfaces correctly.Review of the policy titled Orientation, Inservice & Personnel Management, Subject: Consultant Registered Dietitian Nutritionist (RDN) Job Description, dated 2023, showed the RD was responsible to evaluate and participate in implementing in-service programs for the Department of Food and Nutrition Services, monitor and recommend food service standards for sanitation, safety, and infection control.advises and counsels Director of Food and Nutrition Services in all areas of food service and nutritional care. 1. There was not an effective system in place to ensure the sanitation and food safety of the food services areas.During the initial tour on 9/15/25 from 9:45 a.m. to 11:10 a.m., the kitchen and its equipment were not sanitary. The interior and exterior of refrigerators and freezers were not clean. Counters, stoves, ovens, plate warmer, can opener and mount, and carts were not clean. Knives and serving utensils were put away soiled and/or wet. Dry storage containers were grimy. High-touch surfaces throughout the kitchen, such as light switches, door knobs, door frames, telephone, equipment handles and knobs had a thick build up of grime and/or dust, increasing risk for cross contamination (the process by which bacteria or other microorganisms are unintentionally transferred from one substance or object to another, with harmful effect). Soiled sanitizer rags were frequently left unattended on counters and equipment in all areas of the kitchen - a source of cross contamination. (Cross Reference F812).A review of the RD's past four monthly kitchen inspection reports titled Quality Assessment for Performance Improvement, dated 5/30/25, 6/15/25, 7/28/25 and 8/24/24 communicated repeat sanitation concerns in all four inspections including: Not clean: can opener/mount, carts, black fans, coffee machine, refrigerators and freezers inside and outside (plus refrigerator/freezer maintenance issues cross-reference F908). The plate warmer was not clean 7/28/25, 8/24/24. Unattended soiled sanitizer rags were not included as an area of focus on the kitchen inspection list.During an interview on 9/17/25 at 2:10 pm, CDM stated she read the RD's monthly kitchen inspection reports each month and responded by providing in-service training to staff and instructing staff to follow the cleaning schedule. She added that she ensured staff signed off on cleaning assignments and stated she checked staff work during her daily rounds. Yet the kitchen and its equipment were not found sanitary during the survey.During the continued interview, CDM stated staff followed the facility's policy and procedures for cleaning the refrigerator. When asked what that process was, she stated she didn't remember the specific policy and procedures and would need to look them up. When asked if staff performed any other cleaning in the refrigerator, CDM replied that she would have to check.During the continued interview, the CDM stated their food vendor's delivery person cleaned the refrigerator during his delivery time on Tuesdays and Fridays when there was less food inside it. When asked how the delivery person cleaned the refrigerator, the CDM stated that he washed and sanitized the refrigerator. Yet the interior of the refrigerators and freezers were found unsanitary (Cross-reference F812).During an interview with CDM on 9/17/25 at 2:10 p.m., she stated cleaning rags should be kept in the sanitizer bucket when not in use. She stated she was unaware of rags being left unattended throughout the kitchen (Cross-reference F812).Review of four position specific (AM Cook, PM Cook, AM Aide, PM Aide) documents titled Cleaning Schedule, dated August 2025 showed the forms were not updated or clear. The cook's cleaning schedules included a mixer that was no longer in the kitchen. It showed Walk-in refrigerator label/date when the kitchen had no walk-in refrigerator. The forms did not indicate which of the five refrigerators and freezers each position was to clean. The form also directed staff to wipe off rather than clean equipment such as the grill, steam table, oven/range, ingredient bins, juice machine, carts, garbage cans, refrigerator doors, and all these pieces of equipment were found not clean.Further review of the Cleaning Schedules showed: AM [NAME] had 14 daily tasks excluding mixer (434/434 signed off), two weekly tasks (1/8 signed off), and one monthly task (0/1 signed off). PM [NAME] had 14 daily tasks excluding mixer (434/434 signed off), two weekly tasks (4/8 signed off), and one monthly task (0/1 signed off). AM Aide had 11 daily tasks (341/341 signed off), two weekly tasks (0/8 signed off) and one monthly task (0/1 signed off). PM Aide had 11 daily tasks (341/341 signed off), two weekly tasks (4/8 signed off) and one monthly task (0/1 signed off). Yet the kitchen was not found clean. *2. There was not an effective system in place to ensure adequate training, competence and regular monitoring of dietary staff work behaviors.During an interview with CDM on 9/17/25 at 2:10 p.m., she stated the kitchen was fully staffed. For new staff training they had a skill check, the same as was done annually for staff. New staff did hands-on training with a peer, the CDM shadowed them, and they trained for at least two weeks or until they were skilled enough to do the job.Review of a policy titled Employee Orientation Program, dated 2023, showed New employees will be trained on the job and competence will be verified before performing assigned duties. During the survey beginning 9/15/25 at 9:10 a.m., through 9/18/25 at 5:00 p.m., concerns identified in the kitchen included issues such as the kitchen and equipment weren't clean; staff did not clean equipment according to policy or manufacturer's instructions; staff increased risk of cross contamination when they did not wash hands, wear aprons, and left soiled sanitizer rags on food production surfaces rather than in sanitizer buckets.Review of in-services provided by the CDM for 2025 included topics such as Handwashing (2/27/24); Sanitation & Cleaning Freezer (2/26/24); Staff will not work off the clock (1/3/25); and Sanitizer Buckets (1/16/25 and 1/28/25). The outline of an in-service titled Cleaning and Sanitizing, provided 7/10/25 showed that all work areas and equipment must be cleaned and sanitized to avoid cross contamination and foodborne illness, but it did not indicate that the wash, rinse, sanitize and air dry process described in the 2022 Food and Drug Administration (FDA) Food Code S4-603.15, S4-603.16, S4-702.11, and S4-901.11 (Cross Reference F802).A review of the [NAME] Competency Skills Checklist, for Food Service Worker 1 (FSW1) dated 8/18/25, FSW 2 dated 8/20/25, FSW 7 dated 8/18/25 , and FSW 6 dated 5/30/24 showed they were all competent in Cleans and sanitizes work surfaces, equipment, and utensils before and after use. Yet the kitchen was not clean. The FSW 1, FSW2, and FSW7 were evaluated to not meet competency requirements in 2 to six areas despite having worked there for a period of time: FSW1 - 20 years, FSW 2 - two years, FSW 7 - two years.During an interview with the RD on 9/18/25 at 10:55 a.m., she stated the CDM did all the in-services for the department, but if she (RD) saw a concern in the kitchen she addressed it with the staff right away.

Based on interview and record review, the facility failed to follow its Abuse policy and procedures to investigate, and report to local, state, and federal agencies suspected incident of resident allegation of abuse for one (Resident 14) of three sampled residents when Resident 14 screamed out during a visit with three facility staff and Resident 14 called 911. This failure had the potential to place Resident 14 at risk for emotional distress, mistreatment, neglect or abuse. During a review of Resident 14's Annual Minimum Data Set (MDS- a federally mandated resident assessment and care guide tool), dated 4/23/25, the MDS indicated Resident 14's Basic Interview of Mental status (BIMS, a scoring system used to determine the resident's cognitive status regarding attention, orientation, and ability to register and recall information. A BIMS score of thirteen to fifteen is an indication of intact cognitive status.) Resident 14's score was 15 meaning intact cognition. Resident 14 had clear speech, usually understand, and understood others. MDS indicated Resident 14 had no potential indicator of Psychosis, no hallucination or delusion. Resident 14 had verbal and other behavioral symptoms directed toward others e.g., screaming at others, threatening others, cursing directed towards others. MDS indicated Resident 14 exhibited rejection of care occurred daily. Resident 14's behavioral symptoms significantly put Resident 14 at risk for physical illness or injury. Resident 14's diagnosis included Schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly).During an interview on 9/15/25 at 11:05 a.m. with Resident 14, in her room. Resident 14 stated three staff came to her room. Resident 14 identified three staff as Social Services Assistant (SSA), Activities Director (AD) and Licensed Vocational Nurse/Infection Preventionist (IP). Resident 14 stated SSA told Resident 14 that they do not want her in the facility anymore and Resident 14 had to leave. Resident 14 said SSA swung her around in her wheelchair. Resident 14 said SSA hurt her left arm. Resident 14 stated that she called 911.During an interview on 9/16/25 at 4:46 p.m. with SSA, SSA stated together with AD and IP, a meeting was held with Resident 14 in Resident 14's room. SSA stated discharge plan was discussed. SSA stated Resident 14 was told that if she was not happy with care at the facility to consider another placement. SSA stated she did not tell Resident 14 that Resident 14 had to leave facility. SSA said she did not swing Resident 14 around in her wheelchair.During an interview on 9/17/25 at 8:27 a.m. with Registered Nurse/Unit Manager (RN1), RN1 stated Resident 14 was one of her residents. RN 1 stated she heard Resident 14 screamed out and saw SSA, AD and IP came out of Resident 14's room and closed the door. RN1 stated that she did not inquire about what happened. RN1 said Resident 14 did not like RN1. RN1 stated Resident 14 did not want RN1 in Resident 14's room. During an interview on 9/17/25 at 8:37 a.m. with Administrator (Admin), Admin stated he heard Resident 14 screamed because Resident 14's room is next to Admin's office. Admin stated Police came to the facility and met with him. Admin said the police came to follow up with Resident 14's 911 call. Admin stated he took the police to Resident 14's room and shortly police left after Resident 14 became agitated. Admin stated he did not investigate further because Resident 14 did not like him. Admin said he did not investigate or report because there were no abuse and no need for investigation.During an interview on 9/17/25 at 2:55 p.m. with Resident 14's Medical Doctor (MD1), MD1 stated Resident 14 has capacity to make decisions. MD1 stated Resident 14 was not in medical distress. During a review of the facility's policy and procedure (P&P), Abuse Investigation & Reporting, dated 4/22/24, the P&P indicated, If an incident or suspected incident of resident abuse, mistreatment, neglect or injury of unknown source is reported, the Administrator will assign the investigation to an appropriate individual.

Based on interview and record review, the facility failed to ensure the Preadmission Screening and Resident Review (PASRR - mental health assessment tool) was completed for one resident out of two sampled residents (Resident 36)This failure placed Resident 36 at risk of not receiving care and services appropriate to her needs.During a review of Resident 36's admission record undated, the admission record indicated Resident 36 was originally admitted on [DATE] and readmitted on [DATE]. During a review of the Minimum Data Set (MDS - an assessment tool to guide care) dated 6/12/25, the MDS section I indicated Resident 36 had a diagnosis of psychotic disorder. During a review of Resident 36 's care plan dated 2/21/25, the care plan indicated Resident 36 with mental illness/psychosis Dx (diagnosis) of schizophrenia with behavioral management interventions.During a concurrent interview and record review on 9/18/25 at 10:06 a.m. with Director of Nursing (DON), DON stated the PASRR level I dated 5/20/23 indicated Resident 36's screening result was positive and required level II evaluation and had a serious diagnosed mental disorder. DON stated the letter dated 5/25/23 from Department of Health Care Services (DHCS) titled Unable to Complete Level II Evaluation indicated, Individual currently has a duplicate PASRR on file. The case is closed now. To reopen, please submit a new Level I Screening. Also reviewed was the PASRR level I dated 2/1/23 and with a letter and Individualized Determination Report dated 2/14/23 indicating recommended specialized services. DON stated these PASRRs were closed, and the last one was in May 2023, and a new request needed to be submitted. DON stated Resident 36 had schizophrenia (a serious mental condition that affects how people think, feel and behave) and depression diagnoses and currently on psychotropic medications - Mirtazapine (used to treat depression) and Olanzapine (used to treat schizophrenia). DON acknowledged Resident 36 was supposed to have a current PASRR. DON stated the PASRR is important so they can assess the resident for referral to the specialized services, so that the mental illness can be managed.During a review of the facility's policy and procedure (P&P) titled, PASSR (Preadmission Screening and Resident Review), undated, the P&P indicated, The Admissions department will secure from the referring hospital the PASRR prior to admission at the facility, the facility's designated staff will review the PASRR and determine if there is a required follow-up-i.e., Level II referral, etc.Level I screening.Level II Evaluation.If the Screening is positive for possible SMI (Serious mental Disorder).then a Level II Evaluation will be performed.helps determine placement and specialized services.

Based on observation, interview, and record review, the facility failed to ensure staff followed the infection prevention and control policy to prevent spread of infection when: 1) Clean personal clothing of residents was not covered and were stored exposed in the laundry room. 2) Housekeeping Staff (HSK) 1 did not perform hand hygiene after cleaning resident rooms and did not perform hand hygiene before entering and exiting room and touched multiple high touch surface areas in resident rooms. These deficient practices had the potential to transmit infectious microorganisms and increase the risk of infection for residents and staff. Findings: 1. During a concurrent interview and observation on 2/28/24 at 8:46 a.m., with Laundry Staff (LS), a blue container for residents personal clothing was open and exposed to air towards the back side of the dryer and washer. LS stated that clean clothing should always be covered, and it is not considered clean when it is open and exposed to air. LS also stated the clothes can get dusty and cause itchiness and coughing for residents. During an interview on 2/28/24 at 3:16 p.m. with Infection Preventionist (IP), IP stated the clean linen and clothes should be covered to protect from getting contaminated with bacteria and dust. During a review of the facility's undated Policy and Procedures (P&P) titled, Linen storage, printed on 3/1/24, the P&P indicated, Purpose- Store linen in a manner that prevent cross-contaminated. 2. During an observation on 2/28/24 at 9:16 a.m., HSK 1 was observed to exit room [ROOM NUMBER] after cleaning the room and discarded the gloves and without performing hand hygiene took the mop from housekeeping cart and swept waste from the floor on the hallway. HSK 1 then entered room [ROOM NUMBER] again without performing hand hygiene and put mini waste collection plastic bags on the two tray tables in room [ROOM NUMBER]. HSK 1 then exited room [ROOM NUMBER] and without hand hygiene entered room [ROOM NUMBER]. HSK 1, without donning gloves, proceeded to mop the floor of room [ROOM NUMBER] and clean the room. HSK 1 then touched the door handle without performing hand hygiene. HSK 1 then exited room [ROOM NUMBER] with waste bag and discarded waste and without performing hand hygiene entered room [ROOM NUMBER] again. HSK 1 then continued to grab supplies from HSK cart and entered room [ROOM NUMBER] without performing hand hygiene. During an interview on 2/28/24 at 9:49 a.m., with HSK 1, HSK 1 stated she should always use gloves when cleaning inside the room and must discard and sanitize hands after removing gloves. HSK 1 stated it is important to do hand hygiene as she can get germs. During an interview on 2/28/24 at 9:50 a.m., with Maintenance Supervisor (MS), MS stated it is important to do hand hygiene to prevent bringing germs to other rooms. During an interview on 2/28/24 at 3:22 p.m. with IP, IP stated staff should perform hand hygiene before entering and exiting resident rooms to prevent spread of infection through direct person to person transmission and through indirect transmission. During a review of the facility's, undated P&P titled, Standard precautions, printed on 2/29/24, the P&P indicated, Purpose- All employees are expected to practice standard precautions to reduce both the risk of transmitting infections and the likelihood of exposure to bloodborne pathogens .4 .Remove gloves promptly after use, and wash hands immediately before touching non- contaminated items and environmental surfaces, and before going to another resident.

Based on observation, interview, and record review, the facility failed to store, distribute, and serve food under sanitary conditions when: 1. Multiple food items in freezer #1 and freezer #2 were opened and undated. 2. Food items in freezers #1 and #2 had expired. 3. Multiple individually packaged food items in an opened box in the dry storage had expired. 4. Freezer #3 was not clean. 5. The three-compartment sink was not clean. 6. One scoop from the clean drawer for scoops was not clean. This failure had the potential to cause cross contamination and an outbreak of food borne illness to 90 residents who received food from the kitchen. Findings: During a concurrent observation and interview on [DATE] at 9:20 a.m. accompanied by the Dietary Manager (DM) and Registered Dietician (RD), Freezer #1 had brown patties in a plastic package and light brown patties in another plastic package that were not labeled with open dates. There was diced, cooked chicken in a plastic package with no open date. There were two Sysco stuffed cabbage rolls with beef and sauce in the box with date [DATE]. DM confirmed the stuffed cabbage rolls had expired. Freezer #2 had one plastic package of potato wedge not labeled with an open date, one plastic package of French toast with no open date or use by date. Freezer # 2 also had garlic bread in a plastic package with label dated [DATE], and ice cream in a box with received date of [DATE]. DM acknowledged the French toast, garlic bread, and ice cream were outdated. Freezer #3 was dirty with brown paper from the bottom of one of the Original Cakerie, a frozen dessert, stuck to the surface of the freezer. Also, on the surface of the freezer were whitish particles. DM acknowledged the freezer was dirty. The three-compartment sink near the cooking area was dirty with water and white particles on the right top counter. On the counter, were the red and green buckets with towels soaked in solution in the red bucket. In the middle sink of the three-compartment sink were two deep pans stacked together, with white substance around the sides of the pan stacked inside, filled with some water. Inside the sink was some brownish particles. DM stated they do not use the three-compartment sink and acknowledged it was dirty. One scoop with blue handle in the clean drawer for scoops was dirty with yellowish green substance at the back, between the scoop and handle. DM stated it needed to be rewashed. During a concurrent observation and interview on [DATE] at 8:14 a.m. with DM and RD in the dry storage room, there were multiple individual use half and half milk in an open box with a use by date [DATE]. DM stated they needed to be thrown away. During an interview on [DATE] at 2:45 p.m. with RD, RD stated the food items should always have received date and open date. RD stated the three-compartment sink area should be clean and dry. RD stated it was not okay for the scoop to be dirty and put in the drawer. During a review of the facility's policy and procedure (P&P) titled, Food receiving and storage of cold foods, dated 2023, the P&P indicated, .All open food items will have an open date and use-by date per manufacturer's guidelines .cold food storage will be clean, dry, and free of contamination by condensation, stored following proper storage hierarchy, . During a review of the facility's P&P, titled, Suggested Freezer Storage Guidelines, the P&P indicated Ice Cream Recommended Maximum Storage Period 3 months. During a review of the facility's P&P titled, Cleaning and Defrosting Freezers, dated 2023, the P&P indicated Reach-In freezers will be cleaned and sanitized once a week .or more often as necessary. According to the Federal Food Code (2022), Warewashing Equipment, Cleaning Frequency. A Warewashing machine; the compartments of sinks, basins, or other receptacles used for washing and rinsing equipment, utensils, or raw foods, or laundering wiping cloths; . shall be cleaned: (A) Before use; (B) Throughout the day at a frequency necessary to prevent recontamination of equipment and utensils and to ensure that the equipment performs its intended function; and (C) If used, at least every 24 hours .Warewashing Sinks, Use Limitation. If the wash sink is used for functions other than warewashing, such as washing wiping cloths or washing and thawing foods, contamination of equipment and utensils could occur.

Based on observation, interview, and record review, the facility failed to ensure three of seven sampled residents (Resident 35, Resident 69, and Resident 5) were assisted with Activities of Daily Living (ADLs, Activities of daily living are those needed for self-care and mobility and include activities such as bathing, dressing, grooming, oral care, ambulation, toileting, eating, transferring, and communicating.) when: 1. Resident 35 had long and chipped fingernails; 2. Resident 69 had long fingernails with black matter underneath; 3. Resident 5 did not received showers as scheduled. These failures resulted in Resident 5 feeling upset; and placed Resident 69 and Resident 35 at risk for getting infections from lack of proper hygiene and injuring themselves with long fingernails. 1. During a review of Resident 35's Face Sheet, undated, the Face Sheet indicated Resident 35 was admitted to the facility in August 2022, with medical diagnoses to include 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) and 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 35's Minimum Data Set (MDS, a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan.), dated 12/03/23, the MDS indicated Resident 35'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 seven (7) out of 15, indicating severely impaired in mental status. The MDS assessment also indicated that Resident 35 required maximum assistance with personal hygiene. During a concurrent observation and interview on 2/28/24 at 10:05 a.m. with Certified Nursing Assistant (CNA) 6, Resident 35 had long and chipped fingernails about 1/4 inch in length on both hands. CNA stated that Resident 35's fingernails needed trimming however he did not provide it. During concurrent observation and interview on 2/28/24 at 2:55 p.m. with Registered Nurse (RN) 2, RN 2 stated Resident 35's fingernails were due for trimming. RN 2 also stated that Resident 35 did not have a diagnosis of diabetes (a long-term chronic disease in which the body cannot regulate the amount of sugar in the blood), so CNAs could trim Resident 35's fingernails. RN 2 stated, if long fingernails were left untrimmed, it could cause Resident 35 to suffer from infection and skin injury. During a review of facility's policy and procedure (P&P) titled Fingernail Care, undated, the P&P indicated, Care of fingernails promotes circulation to the hands and helps prevent small tears around the nails that could lead to infections .use nail clippers to cut fingernails. 2. During a review of Resident 5's Face Sheet, indicated, Resident 5 was admitted to the facility in June 2021, with medical diagnoses to include cerebral infarction and hemiplegia (the loss of muscle function on one side of the body). During a review of Resident 5's MDS, dated [DATE], the MDS indicated Resident 5's BIMS score was 14 out of 15, indicating an intact mental status. The MDS assessment also indicated that Resident 5 required maximum assistance with showers. During a review of Resident 5's Self-Care Deficit Care Plan, dated December 2023, the care plan indicated, Resident will be provided with needed assistance in ADL. During an interview on 2/26/24 at 10:00 a.m. with Resident 5, Resident 5 stated her shower schedule was every Wednesday and Saturday, however, she did not receive three showers as scheduled two weeks ago. Resident 5 also stated that it made her very upset to not received her showers as scheduled. During a review of facility's Daily Shower Schedule, the schedule indicated, Resident 5's showers were every Wednesdays and Saturdays in the morning. During an interview on 3/1/24 at 8:09 a.m. with Director of Staff Development (DSD), DSD stated that CNAs should filled out the Shower Day Skin Inspection and complete the Point of care ADL Report on the electronic health record for shower task completion. During a concurrent interview and record review on 3/1/24 at 8:12 a.m. with DSD, facility's form titled Shower Day Skin Inspection, dated 2/21/24 was reviewed. The form had a section that includes Resident 5's name and Room number. Additionally, there were checklists provided to document shower, tub baths and bed baths if rendered or if refused. The form indicated Resident 5 was provided bed bath on that 2/21/24. DSD stated he interviewed Resident 5 and she confirmed that she also received shower on 2/17 and 2/24, however, DSD did not find the forms for those dates. During a concurrent interview and record review on 3/1/24 at 8:16 a.m. with DSD, Resident 5's Point of care ADL report on bathing, dated 2/12/24 through 2/25/24 was reviewed. The Point of care ADL report indicated there was no documentation for Resident 5 bathing for morning shift on Wednesdays/Saturdays falling on 2/17/24, 2/21/24 and 2/24/24. DSD stated if shower completion was not documented on that shift, it was not provided. During a telephone interview on 3/1/24 at 9:08 a.m. with CNA 7, CNA 7 stated she did not provide a shower to Resident 5 on 2/17/24. During a review of the facility's policy and procedure (P &P) titled, Tub Bath and Shower, undated, the P&P indicated, The purpose of this procedure are to promote cleanliness, provide comfort to the resident. 45875 3. During a review of Resident 69's Admission Record, printed on 2/29/24, the Admission Record showed Resident 69 was admitted to the facility in February 2024 and is deaf and mute. During a record review of Resident 69's MDS, dated [DATE], Resident 69's BIMS score was 13 out of 15, indicating intact mental status. Review of section GG (Functional Abilities and Goal) indicated Resident 69 was dependent on staff for self-care. During a concurrent observation and interview on 2/26/24 at 11:30 a.m. with Certified Nursing Assistant (CNA) 8, Resident 69 had long fingernails with black matter underneath. CNA 8 stated the Nurses and CNA's can trim resident 69's nails. During a concurrent observation and interview on 2/26/24, at 11:32 a.m., with CNA 8 and Resident 69, CNA 8 stated Resident 69 is deaf and mute. Resident 69 indicated through gestures and facial expression that she would like to have her nails trimmed and cleaned. During an interview on 2/29/24, at 9:38 a.m. with Unit Manager (UM)2, UM2 stated Resident 69 is Diabetic and Licensed Nurses are responsible to trim resident 69's fingernails. Stated it is important to maintain the dignity of resident. During an interview on 2/29/24 at 10:35 a.m. with Director of Nursing (DON), DON stated the risk of not providing nail care is that food materials, and other dirt can get stuck, and resident can scratch themselves which can lead to skin issues and can be a source of infection. During a review of Resident 69's Care Plan-Self-care deficit dated 2/10/24, the care plan indicated to assist resident 69 in ADL (Activities of daily living) to maintain comfort and dignity. During a review of the facility's undated Policy and Procedure (P&P) titled, Fingernails/Toenails, Care of, printed on 2/29/24, the P&P indicated, Purpose-Care of fingernails promotes circulation to the hands and helps prevent small tears around the nails that could lead to infections.

Based on observation, interview and record review, the facility failed to protect the dignity and privacy of one of 28 sampled residents (Resident 92), when Resident 92's entire back side of body was exposed in the hallway while Certified Nursing Assistant was transferring Resident 92 from shower room. This failure had the potential to negatively affect Resident 92's self-esteem and cause embarrassment. Findings: During a review of Resident 92's Face Sheet, printed on 2/29/24, the Face Sheet showed Resident 92 was originally admitted to the facility in January 2024 with a 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). During a record review of Resident 92's Minimum Data Set (MDS- a resident assessment instrument used to identify resident care problems to be addressed in an individualized care plan), dated 1/8/24, Resident 92'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. A BIMS score of eight to twelve is an indication of moderate cognitive impairment.) was 11 out of 15. Review of section GG (Functional Abilities and Goal) indicated Resident 92 was dependent on staff for shower and toileting. During an observation on 2/28/24 at 9:05 a.m., Certified Nursing Assistant (CNA )4 brought Resident 92 out of the shower room into the hallway in the shower chair. CNA 4 did not cover Resident 92's back for privacy and was exposed in the hallway. During an interview on 2/28/24 at 9:27 a.m. with CNA 4, CNA 4 stated Resident 92 is confused, and she forgot to cover Resident 92s back as she was rushing. CNA 4 also stated it is important to cover residents for privacy and dignity. During an interview on 2/29/24 at 10:35 a.m. with Director of Nursing (DON), DON stated staff should always make sure residents are covered fully to prevent exposure when taken for a shower. DON stated when residents are exposed it affects their dignity and privacy. During a review of the facility's undated Policy and Procedure (P&P) titled, Resident Dignity and Privacy, printed on 2/29/24, the P&P indicated, Procedure .3. Drape and dress residents appropriately at all times to avoid exposure and embarrassment. 4.Maintain resident privacy during toileting, bathing, and other activities of personal hygiene .a. Use a top sheet or blanket as a cover-up during bedside care. B. Cover resident during transfer to shower or toilet.

Based on observation, interview, and record review, the facility failed to ensure two of five sampled residents (Resident 70 and Resident 42) environment remained free of accident hazards when housekeeping staff placed a bedsheet in the bathroom floor in front of the toilet. This deficient practice had the potential to place Resident 70 and Resident 42 at risk for falls and possible injury. Findings: During a concurrent observation and interview on 2/27/24 at 11:07 a.m., with Certified Nursing Assistant (CNA) 1, a folded white bedsheet was observed on the bathroom floor in front of the toilet under the raised toilet seat in the shared bathroom in Resident 70's and Resident 42's room. CNA 1 stated Resident 42 urinates all over the floor and the housekeeping staff (HSK) placed the bedsheet on the floor. During an interview on 2/27/24 at 11:10 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated she does not know who placed the bedsheet on the bathroom floor and this situation is not safe for residents and can cause falls. During a concurrent observation and interview on 2/27/24 at 11:15 a.m., with HSK 2, the shared bathroom in Resident 70 and Resident 42 room was observed to have the bedsheet on the floor. HSK 2 stated Resident 42 urinates all over the floor and Resident 70 puts paper towel on the floor to prevent his sock from getting wet. HSK stated she cleans the bathroom in the morning and puts the bedsheet on the floor. During an interview on 2/29/24 at 10:43 a.m. with Director of Nursing (DON), DON stated putting bedsheet on the toilet floor is a hazard as residents can trip and fall. During an interview on 2/29/24 at 12:24 p.m. with CNA 2, CNA 2 stated Resident 70 and Resident 42 are able to independently go to the bathroom and use the toilet. During a review of Resident 70's Face Sheet, printed on 2/29/24, the Face Sheet showed Resident 70 was originally admitted to the facility on [DATE] with a diagnosis of sepsis (a potentially life-threatening condition that arises when the body's response to infection causes injury to its own tissues and organs). During a record review of Resident 70'S Care Plan on fall prevention, initiated 4/12/23, the Care Plan indicated to keep the environment free of hazards and clutter. During a review of Resident 42's Face sheet, printed on 2/29/24, the Face Sheet showed Resident 42 was originally admitted to the facility in January 2020 with a diagnosis to include 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). During a record review of Resident 42's Care Plan on fall prevention, initiated on 4/11/23, the Care Plan indicated to keep environment free of hazards and clutter. During a review of the facility's undated policy and procedure (P&P) titled, Safety Supervision of Residents, the P&P indicated, Individualized, Resident -Centered Approach to Safety .1. Our individualized, resident -centered approach to safety addresses safety and accident hazards for individual residents. 3.The care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices. During a review of the facility's undated P&P titled, Fall management, the P&P indicated, Purpose- Based on previous evaluations and current date, the staff will identify interventions related to the resident's risks and causes to try to reduce the risk of the resident falling and try to minimize complications from falling.

Based on interview and record review the facility failed to ensure one of three sampled residents (Resident 1) received PRN (as needed) medications as ordered by the physician. The failure to monitor Resident 1's bowel movements resulted in no administration of ordered PRN bowel regimen medications (a regimen of medications designed to promote bowel movement) even though Resident 1 had no bowel movements for five days. This contributed to Resident 1's development of a fecal impaction (a hard, dry mass of stool which cannot be moved or excreted from the intestines with a normal bowel movement, also known as bowel impaction) which caused compression of internal organs, prevented normal urination, and required critical care treatment to prevent life-threatening urinary obstruction and severe constipation. Findings: A review of Resident 1's Hospital After Visit Summary (a summary of Resident 1's hospitalization history immediately prior to admission to the skilled nursing facility), dated 8/28/2020-9/15/2020, showed Resident 1 had included diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's Face Sheet, undated, indicated Resident 1 was admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's Minimum Data Set (MDS, an assessment tool used to guide care), dated 9/22/20, indicated Resident 1 was able to understand others and sometimes was able to be understood. The MDS indicated Resident 1 was always incontinent of bowel and bladder and was totally dependent on assistance from one person for toilet use. A review of Resident 1's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's care plan titled, Risk of Constipation, dated 9/16/20, indicated the goal of, will have a bowel movement at least every three days. Resident 1's updated care plan intervention dated 10/2/20, indicated, Dulcolax suppository rectally daily x1 as needed if Senna is ineffective and no bowel movement in 24 hours after Senna was administered .Review medication regimen with the physician to help minimize risk of constipation. A review of Resident 1's care plan titled, Incontinence, dated 10/2/20, indicated the goal of, regain/maintain bowel and bladder function and to decrease risk of developing complications from incontinence . Resident 1's care plan indicated the intervention of, Inform Medical Doctor (MD) and responsible party for any abnormal changes . A review of Resident 1's Vitals Results, Intake and Output, dated 9/15/20-10/31/20, indicated Resident 1 had no bowel movements during night shift (11 p.m. to 7 a.m. the following morning), day shift (7 a.m. to 3 p.m.), or evening shift (3 p.m. to 11 p.m.) on 10/6/20, 10/7/20, 10/8/20, 10/9/20, or 10/10/20. During a concurrent record review and telephone interview with the Director of Nursing (DON), on 1/5/22, at 1:35 p.m., Resident 1's MAR, care plans, physician orders, and Vitals Results, Intake and Output dated 10/6/20-10/10/20, were reviewed. The DON was unable to provide documentation Resident 1 had received any of the PRN bowel regimen meds (Senna and Dulcolax suppository). The DON confirmed the Vitals Reports showed Resident 1 had no bowel movement for five consecutive days from 10/6/20 through 10/10/20. The DON stated the computer charting system-generated alerts for such items as no bowel movement for three days, and the charge nurses were supposed to check the alert messages every shift. The DON stated nursing must have failed to check the system-generated alerts, and therefore nursing staff had not notified the physician about Resident 1's lack of bowel movement for five days. During a telephone interview on 2/8/22, at 12:05 p.m., with Resident 1's facility attending Physician 1 (Physician 1), Physician 1 stated Resident 1 was admitted with a bowel regimen and if the resident had not had a bowel movement for more than three days, the nurses should have given PRN [MEDICATION(S)] medications as ordered and informed the physician of the lack of bowel movement. During a telephone interview on 2/24/22, at 12:45 p.m., with Resident 1's facility assigned attending Physician 2 (Physician 2), Physician 2 stated he shared responsibility with Physician 1 for residents at the facility. Physician 2 stated he was familiar with Resident 1's medical history and was aware of her previous fecal impaction; he had written her facility admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Physician stated he had no recollection of receiving a call about Resident 1's lack of bowel movement for five days. Physician 2 stated it was important for Resident 1 to not go for more than two to three days without a bowel movement due to her history of constipation and fecal impaction. A review of Resident 1's Hospital Emergency Department (ED) Notes, dated 10/29/20, indicated Resident 1 was transferred from the facility and admitted to the acute care hospital on 10/29/20, with, .a massive fecal impaction distending the rectum and sigmoid colon. (The large intestine's lowest parts are the sigmoid colon, which turns sharply down at the rectosigmoid junction, the area where the sigmoid colon becomes the rectum, into the rectum, which terminates at the anus.) The distended rectum compressed the uterus and urinary bladder where there was abundant stool in the remainder of the large bowel .A rectosigmoid fecal ball (also called a fecal impaction) measures approximately 24.4 x (by) 13.6 centimeters (cm). This occupies the majority of the pelvis. The uterus and the urinary bladder are compressed anteriorly (toward the front of the body) .Abundant stool in the remainder of the large bowel to a lesser extent. Mild bilateral hydronephrosis (bilateral hydronephrosis is the swelling of both kidneys due to a back-up of urine that is unable to drain properly through the ureters, the tubes that lead from the kidney to the bladder) secondary to compression of the ureters by the distended rectum The ED Notes further indicated, Critical care was necessary to treat or prevent life-threatening deterioration of the following conditions including dehydration, acute urinary obstruction, and severe constipation .

Based on observation, interview, and record review, the facility failed to ensure one resident in a sample of four (Resident 2) was free from physical abuse when Resident 1, who required monitoring for physical aggression and was observed to have escalating behaviors, attacked Resident 2, and ten minutes later attacked Resident 2 again, which caused an eight-centimeter (cm, a length of measurement; eight cm equals 3.15 inches) laceration (open wound) on Resident 2's forearm. The failure of facility staff to monitor Resident 1 after the first attack on Resident 2 resulted in Resident 2 being sent to the emergency room where her laceration needed stitches to close the wound. Resident 2 expressed feeling afraid Resident 1 would come back and kill her. Findings: A review of Resident 2's Face Sheet indicated Resident 2 was admitted to the facility in 2015 with dementia without behavioral disturbances and difficulty walking. The Face Sheet indicated Resident 2 had a non-English preferred language and was her own responsible party. During an interview on 1/21/20 at 12:55 p.m., with Resident 2 and an interpreter, seated in a chair in the hallway outside her room, the interpreter translated Resident 2 stated she did not want to talk. Review of a letter from Resident 2's family member dated 2/13/20, indicated, since the incident, she [Resident 2] is continuing telling us she is scared. She says the person may come back to kill her. A review of Resident 1's History and Physical dated 9/29/14, indicated Resident 1 was admitted in 2014 with included diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] .), amputation (surgical removal) of the right arm below the elbow joint, depression, and non-specific psychological disorders. A review of Resident 1's Face Sheet indicated Resident 1 had dementia (a brain disorder that affects the ability to remember, think clearly, communicate, and perform daily activities and that may cause changes in mood and personality) with behavioral disturbance, and was his own responsible party. A review of Resident 1's care plan with the listed problem, Behavioral Symptoms, dated 12/21/19, indicated Resident 1 manifested the problem by hitting and grabbing others. The care plan approaches for the long term goal of less occurrence with interventions included: encourage resident to verbalize feelings and offer understanding and empathy; identify situation that might have caused behavioral problem and assist resident in resolving identified issues; monitor for behavior not easily altered and refer to MD [physician]; remove from triggering environment to a calm and quite [sp] place with supervision; inform responsible party for untoward changes in behavior; observe for pain or discomfort that might trigger negative behavior; medicate with prn [as needed] anti-anxiety as needed. During an observation and interview in Resident 1's room on 1/21/20, at 10:43 a.m., with Resident 1, Resident 1 sat in a wheelchair with a staff member seated in the room providing one on one supervision. Resident 1 had no right arm below the elbow joint. Resident 1 stated he had been upset because Resident 2 had been making noise. Resident 1 stated he did not tell anyone he wanted her to be quiet, he just went to her room and pulled her by the arm, off the bed onto her buttocks. During an interview on 1/23/20, at 9:35 a.m., with LVN 1, LVN 1 stated she remembered on New Year's night shift (12 a.m. to 7 a.m.) she had found Resident 1 and Resident 2 on the floor together. She stated Resident 1 said he had pulled Resident 2 out of the bed and into the hallway. LVN 1 stated she escorted him to his room and tried to provide one on one supervision but Resident 1 kept walking around, so she brought him with her to the nurse station. LVN 1 stated she noticed Resident 1 had disappeared; she found him in Resident 2's room with a CNA trying to protect Resident 2 from Resident 1 by blocking him with her body. During an interview on 1/23/20 at 10:35 a.m., with Registered Nurse 1 (RN 1), RN 1 stated she remembered the incident between Resident 1 and Resident 2. Around 3 a.m. she heard Resident 1 talking, so she went to check on him and saw Resident 1 and Resident 2 on the floor in the hallway, with Resident 1 holding Resident 2's forearm. RN 1 stated she separated them, asked Resident 1 to step back, and asked what happened. RN 1 stated Resident 1 said he had dragged Resident 2 out of the bed. RN 1 stated Resident 1 had said he had pulled her out of bed because he was sick. RN 1 stated she checked Resident 2's right arm and noticed a discolored area. RN 1 stated Resident 2 was not ambulatory, so RN 1 and two CNAs assisted her back into her bed; Resident 1 was taken to the nurse station with another nurse. During an interview on 1/23/20 at 8:55 a.m., with Certified Nursing Assistant 1 (CNA 1), CNA 1 stated on 1/1/20, she and another co-worker saw Resident 1 walk into the hallway by Resident 2's room. CNA 1 stated she tried to block Resident 1 from entering Resident 2's room, but Resident 1 pushed his way into the room. CNA 1 stated she shouted for help but Resident 1 quickly grabbed Resident 2's arm and held it very tightly before other staff arrived to help. CNA 1 stated after Resident 1's hand was released from Resident 2, there was a cut on Resident 2's forearm. A review of Resident 1's nurse progress notes by Licensed Vocational Nurse 1 (LVN 1) dated 1/1/20, at 4:12 a.m., reflected the following: At 3:00 am .we found out both Resident 1 . and Resident 2 .lying on the floor on the hallway in front of Resident 2's room .Resident 2 was crying .Resident 1 was lying calmly and getting up to sit down .Resident 1 stated 'I grabbed her out of the bed' and he said 'because I am sick'. We separated them, found that Ms. Lam's right forearm with light reddish disc. (discoloration) .I heard one CNA calling for help at 3:10 am .I and other 2 CNAs .ran from station 1 to the room .trying for help them. We saw that one CNA was protecting Resident 2 with her body from pulling down by Resident 2 from the bed. At that time Resident 2 was being assisted by 2 CNAs-CNA 1 and .for ADLS (activities of daily living) when Resident 1 managed to get into Resident 2's room .CNAs tried to stop him, from entering the room, however he pushed them to the sides. Resident 2 was on the half way of the bed .I removed Resident 1's fingers one by one from Resident 2's right forearm. Resident 1 was very strong even with one hand. Found that Resident 2's right forearm got skin tear . A review of Resident 2's acute care hospital record, Trauma and Critical Care Surgery Consultation, date of service 1/1/20 at 4:32 a.m., indicated Resident 1 was assaulted by another resident at her skilled nursing facility which resulted in a laceration of the right upper extremity. A review of Resident 2's acute care hospital record, Laceration Repair Note, showed Resident 2 had an eight centimeter wound of the right upper forearm which was cleaned, irrigated, and closed with sutures (surgical thread used to stitch wound edges together). The facility policy titled, Abuse Prevention Program, dated 5/28/19, indicated Our residents have the right to be free from abuse As part of the resident abuse prevention, the administration will: Protect our residents from abuse by anyone including, but not necessarily limited to facility staff, other residents . The facility policy titled, Resident-to-Resident Abuse, dated 2/2017, indicated, Facility staff will monitor residents for aggressive/inappropriate behavior towards other residents

Based on observation, interview, and record review the facility failed to ensure one of two sampled residents (Resident 1) was securely fastened in the wheelchair during transportation in a facility van. For Resident 1, this failure resulted in dislodgement from the wheelchair during transportation. The dislodgement caused a fracture (broken bone) of the left leg, which led to a two-day hospitalization , and had the potential to have caused more severe injury and death. Findings: During a review of Resident 1's Face Sheet, the Face Sheet indicated Resident 1 was admitted to the facility in 2019 with a diagnosis of [CONDITION(S)] ([CONDITION(S)], loss of blood supply to the brain, commonly known as stroke), which caused a left sided [CONDITION(S)] (paralysis of one side of the body) and [CONDITION(S)] (loss of strength). Resident 1 also had a diagnosis of [CONDITION(S)] (CKD), and required [CONDITION(S)] ([CONDITION(S)] is the process of removing excess water and toxins from the blood in people whose kidneys can no longer perform these functions). During a review of Resident 1's Minimum Data Sheet (MDS, a resident assessment tool use to guide care) dated 2/15/21, the MDS indicated Resident 1 had a score of 14 on the Brief Interview for Mental Status test. (BIMS, a scoring system used to determine the resident's cognitive status regarding attention, orientation, and ability to register and recall information. A BIMS score of thirteen to fifteen is an indication of intact cognitive status.) The MDS also indicated Resident 1 required total assistance from one or two staff for transfer between surfaces, had limited mobility of one side of her body, and was wheelchair bound (required use of a wheelchair for all locomotion.) During a review of Resident 1's nursing progress notes dated 2/5/21, the notes indicated Resident 1 had eye surgery on 2/5/21, for a retinal tear (a tear in the tissue that lines the inner surface of the eyeball and is responsible for providing sight), and would require a follow-up visit on Saturday 2/6/21. During an interview on 2/22/21 at 15:20 p.m., with Resident 1, Resident 1 stated she had an appointment on a Saturday morning to follow-up after her eye surgery. Resident 1 stated she was transported to her appointment in the facility van driven by Licensed Vocational Nurse 1 (LVN 1). Resident 1 stated while in the van she was seated in her wheelchair, facing forward, in the passenger section of the van. Resident 1 stated LVN 1 had attempted three times to use the built-in seat belt attached to the left wall of the facility van but LVN 1 was unable to fasten the seat belt around the wheelchair. After LVN 1 was unable to secure the vehicle seat belt, LVN 1 used a cloth belt, placed around Resident 1's chest, under her armpits, and tied in a knot behind the backrest of the wheelchair. During the transport, Resident 1 stated the driver had to stop quickly because of traffic, which caused her to fall, not slide, out of the wheelchair toward the front of the vehicle. Resident 1 stated immediately after falling, her foot began to hurt. Resident 1 stated she had to wait on the floor of the vehicle until LVN 1 could find a place to stop and pull the van over. After the van stopped, LVN 1 lifted Resident 1 back into her wheelchair, and they drove back to the facility. Resident 1 stated the pain got worse during the drive back to the facility. When she arrived at the facility, she received pain medication, and the pain improved. Resident 1 stated she was sent to the emergency room the next day and was treated for a broken left leg. Resident 1 stated since the accident, she was unable to move her left foot and toes and has occasional pain of the left leg. During an observation and interview with LVN 1 on 2/22/21 at 13:10 p.m., the facility transport van had four metal hooks on the floor of the van, behind the driver seat. LVN 1 used an empty wheelchair to demonstrate how the wheelchair legs locked into the metal hooks on the floor to prevent the wheelchair from moving. On a shelf in the back-passenger area of the facility van was a cloth strap, and a shoulder harness (a set of straps worn around the torso and shoulders). A seat belt was attached to the van wall behind the driver's seat. LVN 1 stated that the four hooks on the floor were where he had locked Resident 1's wheelchair to the facility van floor, and he had used the cloth strap to secure Resident 1 to the wheelchair during transport. LVN 1 stated on Saturday morning 2/6/21, Resident 1 needed transportation to the eye doctor for an eye appointment. LVN 1 stated he had been trained on how to safely transport residents using the facility wheelchair transport van, so he volunteered to transport Resident 1, since the regular transport company was not available. LVN 1 stated he had placed Resident 1 in her wheelchair behind the driver's seat, with her wheelchair secured in the metal hooks. LVN 1 stated he had used the cloth strap as a lap belt to secure Resident 1 in the wheelchair. LVN 1 had tied the cloth strap around Resident 1's chest, under her arms, and tied the belt in a knot behind the wheelchair backrest. LVN 1 stated the shoulder harness was an alternate system for securing the resident to a wheelchair during transport in the van, but he thought the harness was inappropriate for Resident 1's size, so he had not used it. LVN 1 stated during Resident 1's transport, he had to make a sudden stop due to traffic, which caused Resident 1 to slide out of the lap belt, off the wheelchair, and down to the floor toward the front of the vehicle. LVN 1 stated it took him a couple of minutes to pull the vehicle to the side of the road so he could park and help Resident 1 back into the wheelchair. LVN 1 stated he noticed Resident 1 had a small skin tear on her left forearm, which was bleeding, and she complained of leg pain at a level of four on a pain scale of zero to ten (zero means no pain, ten means the highest pain). After the incident, LVN 1 decided to drive Resident 1 back to the facility, as they were too late for the eye appointment and Resident 1 was complaining of pain. LVN 1 stated Resident 1 continued to complain of increasing pain during the drive back to the facility. LVN 1 stated when they arrived back at the facility, Resident 1 said her leg pain level was at a score of nine. During a review of Resident 1's nursing progress notes dated 2/6/21, at 4:14 p.m., by Licensed Vocational Nurse 3 (LVN 3), the notes indicated Resident 1 had returned to the facility at 1 p.m. and received pain medication for a complaint of left leg pain. The notes indicated Resident 1 left the facility at 1:15 p.m. for her routine [CONDITION(S)] treatment. A review of Resident 1's progress note by LVN 3 dated 2/6/21 at 4:34 p.m. indicated, LN [licensed nurse] contacted RP [responsible party], aware eye appointment not done .also aware patient had a skin tear 1 X 1 on right forearm, no active bleeding, cleansed with normal saline and dry dressing applied. During an interview on 4/21/21 at 3:25 p.m. with Licensed Vocational Nurse 2 (LVN 2), LVN 2 stated on 2/6/21 between 4:00 p.m. and 4:30 p.m., he notified Resident 1's physician about her fall in the vehicle, and that she had received pain medication for a complaint of leg pain. LVN 2 further stated the physician ordered neuro checks every 4 hours and to monitor the skin tear. LVN 2 stated he informed the physician Resident 1 was currently at [CONDITION(S)]. During an interview on 4/23/21 at 7:51 a.m. with Registered Nurse 1 (RN 1), RN 1 stated on 2/7/21 at around 3:00 a.m., a certified nursing assistant informed her Resident 1 was complaining of left leg pain and had swelling in her left leg. RN 1 stated she went into Resident 1's room and examined Resident 1's left leg. Resident 1 told RN 1 she was in pain and rated her pain as a three to four on the zero to ten pain scale. RN 1 offered pain medication to Resident 1, but Resident 1 refused and told her she had been given pain medication the day before [2/6/21]. RN 1 further stated Resident 1 appeared stable and went back to sleep. RN 1 stated she notified Resident 1's physician of the left leg swelling on 2/7/21 around 7:00 a.m., and the physician ordered an Xray. During a review of Resident 1 Radiology Report, date of service 2/7/21 at 11:42 a.m., the report indicated Resident 1 had a recent fracture (broken bone) of the left leg; the Report indicated the results were sent to the facility at 2:50 p.m. the same day. During a review of nursing progress notes dated on 2/7/21, at 4:30 p.m., the notes indicated the physician ordered Resident 1 be sent to the acute care hospital. During a review of Resident 1's acute care hospital after visit summary dated 2/9/21, the notes indicated Resident 1 was admitted to the hospital from the emergency roiagnom on [DATE] at 6:21 p.m., for a broken left leg. Resident 1 was discharged back to the facility on [DATE] at 4:30 p.m. The after-visit summary indicated Resident 1 should have no weight bearing on the left leg for 6 to 12 weeks and should use a continuous left immobilizer (a fabric full leg brace and support) for 6 to 12 weeks. During an interview on 2/22/21, at 3:30 p.m., with Resident 1, Resident 1 stated since the accident she was not able to move her left leg or feel her toes, and the left leg was painful most of the time. Resident 1 stated she wished she had not lost function and abilities in her left leg. During a review of the facility document, Van Owner's Manual [brand name], the Manual indicated, to use a tie down retractor or manual belts, occupant lap belt, occupant shoulder belt and hardware when transporting wheelchair occupants. The Manual also indicated, Warning, that wheelchair occupants (person or passenger in the wheelchair) should be properly restraint (tie down in place) during transport. And in the case of a collision a restraint wheelchair and its occupant could become a projectile (ejected or pulled out) in the vehicle and be seriously injured or killed if the passenger was not restrained securely following recommendations of the manual. During a review of Facility Van Safety Policy and Procedure (P & P) dated 8/15/2001, the P & P indicated the van be maintained in good condition, equipped with safety devices, and drivers be trained in the use of such devices. The P & P indicated the designated driver must ensure securing station are properly equipped with straps, lap, and shoulder belts and should check belt buckles and hardware functions properly before and during transportation with wheelchair occupants.