Every finding on record at Grand Valley Health Care Center

Based on observation, interview, and record review, the facility failed to implement and revise a comprehensive person-centered care plan (a document that summarizes a resident's needs, goals, and care/treatment) addressing residents' low air loss mattress (LALM - a specialty bed that alternates pressure to help heal and prevent pressure ulcer/injuries [PU/PI- injuries that breakdown the skin and underlying tissue when an area of skin is placed under pressure]) use for three of three sampled residents (Resident 1, Resident 2, and Resident 3). This deficient practice had the potential to negatively affect the delivery of care and services and miscommunication among the care team for residents with the LALM use.Findings: a. During a review of Resident 1's admission Record, the admission Record indicated that the facility originally admitted the resident on 2/2/2024 and readmitted the resident on 4/30/2025 with diagnoses that included diabetes mellitus (disorder characterized by difficulty in blood sugar control and poor wound healing) with foot ulcer, history of transient ischemic attack (TIA - known as a mini-stroke, and happens when a blood clot temporarily blocks blood flow to a part of the brain) and cerebral infarction (CI - a serious medical condition that occurs when blood flow to the brain is blocked, leading to brain cell death), and osteoarthritis (a degenerative joint disease where the cartilage that cushions the ends of bones gradually wears away, leading to pain, stiffness, and reduced movement) both ankles and feet. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 5/2/2026, the MDS indicated Resident 1 had intact cognition (ability to think and make decisions) and was dependent on staff for oral/toileting/personal hygiene, showering, upper/lower body dressing and transferring, and required maximal assistance on staff for bed mobility (movement). The MDS further indicated that Resident 1 was at risk of developing PUs/PIs. During a review of Resident 1's Order Summary Report, the Order Summary Report indicated an order for LALM with bolsters (raised, pillowy air edges on the sides that act as gentle bumpers to keep a resident from rolling out of bed) for skin management, ordered 2/27/2026. During a concurrent observation and interview on 6/12/2026 at 8:36 a.m., in Resident 1's room, with Treatment Nurse 1 (TN 1), observed Resident 1 lying in bed with a LALM. TN 1 stated that Resident 1's LALM use is for skin management. During a concurrent interview and record review on 6/12/2026 at 12:24 p.m., with Licensed Vocational Nurse 1 (LVN 1), reviewed Resident 1's physician orders for LALM use and Resident 1's care plans. LVN 1 stated that the licensed nurses did not implement or revise Resident 1's care plans for the LALM use for skin management currently. b. During a review of Resident 2's admission Record, the admission Record indicated that the facility admitted the resident on 2/18/2025 with diagnoses that included left femur (thigh bone) and tibia (the shinbone that located in the lower half of the leg) fractures (broken bone), and osteoarthritis on left hip. During a review of Resident 2's MDS dated [DATE], the MDS indicated Resident 2 had intact cognition. The MDS further indicated Resident 2 required moderate assistance on staff for toileting and personal hygiene, showering, upper and lower body dressing, bed mobility, and transferring. During a review of Resident 2's Order Summary Report, the Order Summary Report indicated an order for LALM for skin management, ordered 3/5/2026. During a concurrent interview and record review on 6/12/2026 at 8:52 a.m., with TN 1, reviewed Resident 2's physician order for LALM use and care plans. TN 1 stated that there were no care plans for the LALM use for a skin management currently, and no information either about Resident 2's LALM setting mode. c. During a review of Resident 3's admission Record, the admission Record indicated that the facility admitted the resident on 10/10/2025 with diagnoses that included diabetes mellitus, dysphagia (difficulty swallowing) and aphasia (a disorder that makes it difficult to speak) following cerebral infarction, and anemia (a condition where the body does not have enough healthy red blood cells). During a review of Resident 3's MDS dated [DATE], the MDS indicated Resident 3 had moderately impaired cognition, and Resident 3 required maximal assistance on staff for toileting hygiene, showering, lower body dressing and transferring, and required moderate assistance on staff for eating, oral hygiene, and bed mobility. The MDS further indicated that Resident 3 was at risk of developing PUs/PIs. During a review of Resident 3's Order Summary Report, the Order Summary Report indicated an order for LALM for skin and wound management, monitor for functional settings every shift, ordered 3/27/2026. During a review of Resident 3's care plan titled LALM, with an initiated date of 11/3/2025, last reviewed on 5/6/2025, and next evaluation date of 8/6/2026, indicated Resident 3 had impaired skin integrity and needed to use LALM to improve wound healing. The two interventions indicated as follows: Turn and reposition every two (2) hours and/or as needed when in bed, and keep area clean and dry. During a concurrent interview and record review on 6/12/2026 at 12:15 p.m., with LVN 1, reviewed Resident 3's physician orders for LALM use and the care plans. LVN 1 stated the care plan for LALM use was not indicating about the setting levels or mode, or how to manage the LALM use with linen, and not indicating specific interventions, and was not individualized or person-centered care plan. During an interview on 6/12/2026 at 4:28 p.m., with the Director of Nursing (DON), the DON stated that staff should revise and update the care plans when a resident's condition changes, and the purpose of the care plans was to provide proper interventions and care needed for each resident. During a review of the facility's policy and procedure (P&P) titled, Comprehensive Care Planning, last reviewed on 8/28/2025, the P&P indicated, The care plan must be reviewed and revised periodically, at least quarterly, and on an ongoing basis to reflect changes in the resident and the services provided or arranged must be consistent with each resident's written plan. The care plan must be reviewed and revised periodically, at least quarterly, and on an ongoing basis to reflect changes in the residents and the services provided or arranged must be consistent with each resident's written plan.

Based on observation, interview, and record review, the facility failed to ensure the proper use of low air loss mattress (LALM - a specialty bed that alternates pressure to help heal and prevent pressure ulcers/injuries [PU/PI- injuries that break down the skin and underlying tissue when an area of skin is placed under pressure]) by: Failing to maintain the LALM in the appropriate operating mode while a resident was in bed for one of three sampled residents (Resident 2).Applying multiple layers of linens over the LALM for two of three sampled residents (Resident 2 and Resident 3), which could interfere with the LALM's pressure-redistribution function. These failures had the potential to compromise the effectiveness of the LALM, increasing the resident's risk of skin breakdown and/or delaying the healing of existing PU/PI.During a review of Resident 2's admission Record, the admission Record indicated that the facility admitted the resident (Resident 2) on 2/18/2025 with diagnoses that included left femur (thigh bone) fracture (broken bone), left tibia (the shinbone that located in the lower half of the leg) fracture, and left hip osteoarthritis (a degenerative joint disease where the cartilage that cushions the ends of bones gradually wears away, leading to pain, stiffness, and reduced movement). During a review of Resident 2's Minimum Data Set (MDS - a resident assessment tool) dated 5/25/2026, the MDS indicated Resident 2 had intact cognition (ability to think and make decisions). The MDS further indicated Resident 2 required moderate assistance from staff with toileting hygiene, personal hygiene, showering, upper and lower body dressing, bed mobility (movement), and transfers. During a review of Resident 2's Order Summary Report, the Order Summary Report indicated the following physician orders:Sacrococcyx (the tailbone area at the bottom of the spine, right between the buttocks) area scar tissue, apply skin barrier cream (used to reinforce the skin's physical barrier, lock in moisture and protect against external irritants) and leave open to air every shift for preventative skin management, ordered 3/19/2025. LALM for skin management, ordered 3/5/2026. During a review of Resident 3's admission Record, the admission Record indicated that the facility admitted the resident (Resident 3) on 10/10/2025 with diagnoses that included diabetes mellitus (disorder characterized by difficulty in blood sugar control and poor wound healing), dysphagia (difficulty swallowing) and aphasia (a disorder that makes it difficult to speak) following cerebral infarction (CI - a serious medical condition that occurs when blood flow to the brain is blocked, leading to brain cell death), and anemia (a condition where the body does not have enough healthy red blood cells). During a review of Resident 3's MDS dated [DATE], the MDS indicated Resident 3 had moderately impaired cognition. The MDS indicated Resident 3 required maximal assistance from staff with toileting hygiene, showering, lower body dressing and transfers and required moderate assistance with eating, oral hygiene, and bed mobility. The MDS further indicated that Resident 3 was at risk for developing PUs/PIs. During a review of Resident 3's Order Summary Report, the Order Summary Report indicated the following orders: Sacrococcyx area, cleanse with soapy water, pat dry, apply barrier cream and leave open to air every shift to maintain skin integrity and as a preventive measure, ordered 4/22/2026. LALM for skin and wound management, monitor functional settings every shift, ordered 3/27/2026. 1. During a concurrent observation and interview on 6/12/2026 at 8:45 a.m., in Resident 2's room, with Treatment Nurse 1 (TN 1), observed Resident 2 lying in bed on a LALM that was set to static mode (function that stops the mattress from alternating pressure [a feature of some devices that inflate and deflate in sections, such as air mattresses, redistributes pressure across the body, which can help prevent PU and improve circulation]). TN 1 stated that the setting may have been the resident's (Resident 2) preference but needed to verify Resident 2's medical records. During a concurrent interview and record review on 6/12/2026 at 8:52 a.m., in the nurse station, with TN 1, TN 1 reviewed the Physician Order for LALM use and care plans for Resident 2 and stated there were no care plan regarding LALM use for skin management, and that there was no information either about Resident 2's LALM setting mode. TN 1 further stated the LALM should be in alternating-pressure mode while the resident was in bed, because static mode provides constant pressure to the same areas of the body. During a concurrent interview and record review on 6/12/2026 at 3:08 p.m., with the Director of Nursing (DON), the DON stated the LALM should be set to alternating pressure mode when a resident is in bed. The DON further stated that if the mattress were temporarily placed in static mode to meet a resident's immediate needs or preferences, staff should return it to alternating-pressure mode unless the resident specifically request continuous use of static mode. During a concurrent interview and record review on 6/12/2026 at 3:18 p.m., with the DON, the DON reviewed Resident 2's Physician Order for LALM use and care plan and stated there were no care plans developed addressing LALM use or LALM settings. 2. a. During a concurrent observation and interview on 6/12/2026 at 9:05 a.m., in Resident 3's room, with TN 1, observed Resident 3 lying on a LALM while wearing an incontinence (loss of bowel or bladder control) brief over a disposable absorbent pad and spread sheet resulting in multiple layers between the resident and the mattress surface. TN 1 stated that the nursing staff should not use more than two layers of linen with a LALM. TN 1 stated staff should use one spread sheet and either one disposable absorbent pad or one incontinent brief depending on the resident's condition and preferences. TN 1 further stated that the purpose of LALM for Resident 3 was PUs/PIs prevention and that using more than two (2) layers could reduce the effectiveness of the LALM. 2. b. During a concurrent observation and interview on 6/12/2026 at 9:14 a.m., in Resident 2's room, with Certified Nursing Assistant 1 (CNA 1), observed Resident 2 lying on a LALM while wearing an incontinent brief over a disposable absorbent pad and spread sheet resulting in multiple layers between the resident and the mattress surface. CNA 1 stated that a night shift nurse (did not specify) placed the additional layer (three layers) at around 7:50 a.m. that morning, and that CNA 1 planned to remove one layer during morning care, because staff should not use more than two layers with a LALM. CNA 1 further stated that multiple layers could trap moisture and interfere with pressure ulcer prevention. During a concurrent interview and record review on 6/12/2026 at 3:50 p.m., with the DON, the DON stated that staff should use only one sheet with a LALM and that the use of multiple layers defeats the purpose of the LALM by reducing its effectiveness. During a review of the facility's policy and procedure (P&P) titled, Low Air Loss Mattress last reviewed on 8/28/2025, the P&P indicated, It is the policy of the facility to provide for the proper placement and management of a low air loss mattress when utilized by a resident. The manufacturer's guidelines should be reviewed for each individual mattress to ensure that this policy is what is recommended. If this policy is not in agreement with manufacturer's guidelines, the manufacturer's guidelines will be followed. During a review of the LALM's manual provided by the facility, titled, Alternating Pressure Mattress Replacement System with Low Air Loss copyrighted 2005, the LALM manual indicated, it was intended to reduce the incidence of PUs while optimizing patient comfort.Installation. may place a thin cotton sheet over the quilted mattress top cover. Operation. In static mode, the mattress provides a firm surface that makes it easier for the patient to transfer or reposition. The static mode prevents the patient from bottoming out when in a sitting position,

Based on interview and record review, the facility's licensed nurses failed to accurately assess and complete fall risk evaluations for one of four sampled residents (Resident 1).These deficient practices had the potential to place the residents at increased risk for injury related to falls.During a review of Resident 1's admission Record, the admission Record indicated that the facility originally admitted Resident 1 on 3/18/2026 and readmitted on [DATE] with diagnoses that included metabolic encephalopathy (ME - a disorder that affects brain function), dehydration (when the body uses or loses more fluid than it takes in), diabetes mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing), anemia (a condition where the body does not have enough healthy red blood cells), dementia (a progressive state of decline in mental abilities), hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (paralysis or weakness on one side of the body) following cerebral infarction (stroke, loss of blood flow to a part of the brain resulting in damage to brain tissue), chronic kidney disease (a long-term condition where the kidneys are damaged and cannot effectively filter waste and extra fluid from the blood), and repeated falls.During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 3/24/2026, the MDS indicated Resident 1's cognition (ability to think, reason, and function) was severely impaired. The MDS further indicated that Resident 1 was dependent on staff for toileting hygiene, showering/bathing, and lower body dressing, and required maximal assistance with eating, oral and personal hygiene, upper body dressing, bed mobility (movement), and transfers.During a review of Resident 1's Situation-Background-Assessment-Recommendation (SBAR - a communication tool used by healthcare workers when there is a change of condition among the residents) communication form dated 4/6/2026, timed at 6:50 p.m., the SBAR indicated that Resident 1 had an unwitnessed fall in the resident room, sustained a laceration to the back right side of the head, and was transferred to the hospital for further evaluation.During a review of Resident 1's SBAR communication form dated 4/9/2026, timed at 9:04 p.m., the SBAR indicated that Resident 1 had an additional fall.During a review of Resident 1's Nursing Progress Notes dated 4/9/2026 timed at 7:50 p.m., the Nursing Progress Notes further indicated that Resident 1 was found lying on the left lateral side next to the bed in the resident room.During a review of Resident 1's Fall Risk Evaluation dated 4/6/2026, the Fall Risk Evaluation indicated the following: Instructions: Evaluate the resident status in the eight clinical condition parameters listed below (A-H) by assigning the corresponding score which best describes the resident in the appropriate evaluation column. Add the column of numbers to obtain the Total Score. If the total score is 10 or greater, the resident should be considered at HIGH RISK for potential falls. A prevention protocol should be initiated immediately and documented on the care plan. To evaluate the resident's gait (a person's particular manner, style, or pattern of walking or running) and balance, have him/her stand on both feet without holding onto anything; walk straight forward; walk through a doorway; and make a turn. If nonapplicable (N/A), do not check any other boxes. The Fall Risk Evaluation dated 4/6/2026, the history of falls sections indicated that Resident 1 had no falls in the past three months despite the SBAR (dated 4/6/2026) documentation of a fall on the same date. The Fall Risk Evaluation further indicated the gait and balance section of the 4/6/2026 evaluation did not indicate decreased muscular coordination, changes in gait pattern when walking through a doorway, or gait problems. However, it was marked with a score of one (1) for balance problem while standing, balanced problem while walking, and requires use of assistive devices. The Fall Risk Evaluation dated 4/9/2026, under the gait and balance section did not indicate decreased muscular coordination, changes in gait pattern when walking through a doorway, or gait problems. However, it was marked with a score of one (1) for balance problems while standing, balance problems while walking, and requires use of assistive devices (specialized tools, equipment, or technologies used to help residents maintain or improve their functional independence, safety, and mobility [movement]). During a concurrent interview and record review on 4/29/2026 at 5:10 p.m., with the Director of Nursing (DON), the DON reviewed Resident 1's Fall Risk Evaluations dated 4/6/2026 and 4/9/2026 and stated that the DON completed the Fall Risk Evaluations after the fall incidents occurred. The DON stated that the fall that occurred on 4/6/2026 was not reflected in the response to the history of falls section for the past three (3) months. The DON further stated that the gait and balance items - decreased muscular coordination, change in gait pattern, or gait problems were not marked because the resident had been transferred to the hospital via paramedics (a highly trained healthcare professional who provides advanced emergency medical care, stabilization, and transportation for patients in crisis situations, usually outside of a hospital), and the DON was unable to personally assess the resident's gait and balance at that time. The DON further stated that when completing Resident 1's Fall Risk Evaluation dated 4/9/2026, following the second fall, the DON obtained information from the rehabilitation therapy personnel that Resident 1 did not demonstrate issues related to decreased muscular coordination, change in gait pattern, or gait problems therefore, those items were not marked on the evaluation, and the DON left those items blank. When the DON was asked about the purpose of accurately completing the Fall Risk Evaluations, the DON stated that the assessments should be completed correctly to establish the development of individualized, person-centered care plans and to reduce each resident's risk for falls.During a review of the facility's policy and procedures (P&P) titled, Fall Risk and Prevention of Injury to include Pathological Fracture (broken bone caused by disease) last reviewed on 8/28/2025, the P&P indicated, It is the policy of the facility to identify that are at risk for falls to implement a plan of care in an attempt to prevent falls. Upon admission, a Fall Risk Assessment will be completed for all residents. The Fall Risk Assessment will be reviewed quarterly and after each fall. The incident report and the investigation will be reviewed by the Interdisciplinary Team (IDT - a group of different health professionals-such as doctors, nurses, therapists, and social worker who meet regularly to create a single, coordinated care plan for a resident) with recommendations for additional approaches to prevent further falls.

Based on interview and record review, the facility's licensed nurses failed to accurately assess and complete dehydration (a condition that occurs when the body loses too much water and other fluids that it needs to work normally) risk assessments for one of four sampled residents (Resident 1).These deficient practices had the potential to place the residents at increased risk for dehydration.During a review of Resident 1's admission Record, the admission Record indicated that the facility originally admitted Resident 1 on 3/18/2026 and readmitted on [DATE] with diagnoses that included metabolic encephalopathy (ME - a disorder that affects brain function), dehydration, diabetes mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing), anemia (a condition where the body does not have enough healthy red blood cells), dementia (a progressive state of decline in mental abilities), hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (paralysis or weakness on one side of the body) following cerebral infarction (stroke, loss of blood flow to a part of the brain resulting in damage to brain tissue), chronic kidney disease (a long-term condition where the kidneys are damaged and cannot effectively filter waste and extra fluid from the blood), and repeated falls.During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 3/24/2026, the MDS indicated Resident 1's cognition (ability to think, reason, and function) was severely impaired. The MDS further indicated that Resident 1 was dependent on staff for toileting hygiene, showering/bathing, and lower body dressing, and required maximal assistance with eating, oral and personal hygiene, upper body dressing, bed mobility (movement), and transfers.During a review of Resident 1's Dehydration Risk assessment dated [DATE], the Dehydration Risk Assessment indicated that the oral intake section was marked 75 percent (% - a way to express a part of a whole as a fraction out of 100) to 50%, and the total score was six (6), indicating Resident 1 was at moderate risk for dehydration.During a review of Resident 1's Dehydration Risk assessment dated [DATE], the Dehydration Risk Assessment indicated that the oral intake section was marked 100% to 75%, and the total score was two (2), indicating Resident 1 was at low risk for dehydration.During a concurrent interview and record review on 4/29/2026 at 4:20 p.m., with Registered Nurse 4 (RN 4), RN 4 reviewed Resident 1's Dehydration Risk assessment dated [DATE]. When asked how RN 4 obtained the information for the food intake and marked 75% to 50%, RN 4 stated that RN 4 based solely on observation of one meal consumed on the day of admission. RN 4 stated that this did not represent the resident's overall usual intake and that the additional information should have been obtained from the hospital records, or from the resident (if alert and oriented), or from family members. RN 4 stated that the documented intake was not accurate, as it was based on an assumption obtained from a single meal rather than comprehensive data. RN 4 stated that dehydration risk assessment should be completed using accurate and complete information in order to develop an appropriate plan of care and reduce the resident's risk for dehydrationDuring a concurrent interview and record review on 4/30/2026 at 3:57 p.m., with Registered Nurse 3 (RN 3), RN 3 reviewed Resident 1's Dehydration Risk assessment dated [DATE]. When asked how RN 3 obtained the information for the food intake and marked for 100% to 75% on the day of readmission, 4/23/2026, with a dehydration diagnosis, RN 3 stated that the intake range of 100% to 75% was documented without verification of the resident's actual intake. RN 3 stated that hospital records were not reviewed to obtain intake information, family members were unable to provide details regarding the resident's consumption during hospitalization, and the resident was unable to report intake amounts. RN 3 further stated that the accuracy of the documented oral intake could not be confirmed. The total score of the assessment was two (2), indicating a low risk for dehydration. RN 3 stated that accurate assessment of oral intake is necessary to establish an appropriate baseline and to develop and implement an individualized plan of care to reduce the risk of dehydration. During a review of the facility's policy and procedures (P&P) titled, Dehydration Risk Assessment last reviewed on 8/28/2025, the P&P indicated, It is the policy of the facility to ensure that each resident is assessed for their hydration status on admission, within the assessment period, and at least quarterly. Each resident will be individually assessed to ensure sufficient intake to prevent dehydration.During a review of the facility's P&P titled, Hydration Management last reviewed on 8/28/2025, the P&P indicated, Residents will be screened on admission, quarterly, annually, and when there is a significant change of status for their hydration and nutritional status. While there is no reliable calculation to determine a resident's fluid needs, an assessment should take into consideration characteristics pertinent to each resident, such as age, medical diagnoses, activity level, etc. Residents identified with the potential for, or actual dehydration will be assessed for risk factors and appropriate recommendations shall be made. These risk factors and interventions will be documented on the plan of care.

Based on observation, interview, and record review, the facility failed to:1. Ensure one of seven (7) sampled residents (Resident 56), who had an order for modified liquid consistency (liquids that have been thickened [drinks such as water, juice, coffee, modified with powders or gels to be easier and safer to swallow] to a specific level to improve swallowing safety per the International Dysphagia Diet Standardization Initiative [IDDSI - framework that provides a common terminology to describe food textures and drink thickness]), was not provided thin (water-like) liquids. The facility failed to: a. Ensure that Resident 56, who has a diagnosis of dysphagia (swallowing difficulties) and was at risk for aspiration (when food, liquid or other material enter a resident's airway and eventually the lungs), and who was placed on a restorative dining program (a nursing intervention designed to help residents maintain or regain their highest level of independence and safety during mealtime) requiring supervision and/or assistance during meals, was not served unthickened coffee with a straw during lunch, at approximately 12 p.m. on 12/29/2025. Resident 56 was observed coughing while drinking the unthickened coffee through a straw. b. Implement Resident 56's physician's diet order dated 10/10/2025, to provide Resident 56 liquids with nectar/mildly thick liquid consistency (refers to liquids that are thicker than water but still pourable, liquid will flow/pour from a spoon, quickly, but is slower that thin drinks). c. Ensure Licensed Vocational Nurse 1 (LVN 1), who was monitoring residents in the activity/dining room, verified that Resident 56's coffee was of the correct liquid consistency, in accordance with the facility's policy and procedure (P&P) titled, Thickened Liquids, last reviewed on 8/23/2025, which indicated that thickened liquids are to be served at the appropriate consistency as ordered by the physician and that hot beverages are to be mixed on the tray line (an assembly line used in healthcare settings to prepare and distribute meals to residents) or by nursing staff. d. Ensure Restorative Nursing Assistant 1 (RNA 1) and Restorative Nursing Assistant 2 (RNA 2), who were assisting residents in the activity/dining room, verify Resident 56's diet order with LVN 1 to ensure Resident 56's coffee was provided at the correct liquid consistency, in accordance with the facility P&P titled, Restorative Dining Program, last reviewed on 8/23/2025, which indicated the RNA dining program to be performed as ordered and care planned to allow residents to safely and effectively consume food and fluids. e. Implement Resident 56's Nutrition care plan related to dietary concerns/problems dated 10/14/2025, which identified Resident 56 as being at risk for aspiration, dehydration (a condition that occurs when the body does not have enough fluids to function properly), malnutrition (a condition that happens when the body does not get enough nutrients) and included interventions to provide Resident 56 with the diet as ordered. f. Implement Resident 56's Dysphagia care plan related to oropharyngeal dysphagia (a resident has trouble starting the swallow in the mouth or throat, leading to issues like coughing, choking [a life-threatening event where food, liquid or another object becomes lodged in a resident's airway obstructing their ability to breathe], food getting stuck or aspiration) dated 10/16/2025, which identified Resident 56 as at risk for aspiration and required aspiration precautions (a set of care strategies to prevent food or liquids from entering the airway [lungs]), including not using straws when consuming fluids. On 12/29/2025 during lunch, at approximately 12 p.m., Resident 56 was provided with unthickened coffee with a straw. These deficient practices placed Resident 56 at risk for life threatening complications such as choking and aspiration pneumonia (a lung infection from inhaling foreign substances like food into the lungs), which could result in hospitalization and or death. 2. Prepare food in a form designed to meet individual needs by failing to:a. Ensure puree (foods that are smooth with pudding like consistency) three (3) bean chili held its shape and was not served watery on the plate and passed the spoon tilt test (a test used to determine the stickiness of the sample and the ability of the sample to hold together).b. Ensure puree green tossed salad was not watery and did not fall off easily during the spoon tilt test. These failures had the potential to result in difficulty in swallowing, chewing, decrease in food intake and nutrient intake to 19 of 82 residents on puree diet, resulting in unintended (not planned) weight loss and choking (when food gets stuck in your airway, blocking the flow of air to your lungs). On 12/30/2025 at 2:52 p.m., while onsite at the facility, the State Survey Agency (SSA) called an Immediate Jeopardy (IJ- a situation in which the facility's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death of a resident) in the presence of the Administrator (ADM) and the Director of Nursing (DON), due to the facility's failure to provide food and drink prepared in a form designed to meet individual needs in accordance with S483.60(d)(3) by failing to provide Resident 56 coffee with nectar/mildly thick liquid consistency as ordered by the physician. On 1/1/2026 at 12 p.m., the ADM provided an IJ Removal Plan (a plan that identifies all actions the facility will take to immediately address the noncompliance that has resulted in the IJ situation) which included the following summarized actions: 1. On 12/29/2025, LVN 1 completed a Situation, Background, Assessment, Recommendation (SBAR - a structured communication tool used primarily in healthcare to provide concise, clear, and essential information about a resident's condition) regarding Resident 56's consumption of thin fluids. 2. On 12/29/2025, the DON assessed Resident 56 for any adverse (harmful or undesired) reactions or side effects related to Resident 56's consumption of thin liquids through a straw, no adverse findings were noted. 3. On 12/29/2025 the facility notified Resident 56's attending physician's nurse practitioner (NP) and Resident 56's family of the incident involving the provision (action of providing) of thin coffee with a straw. The NP ordered a stat (immediate) chest X-radiation (x-ray - a type of medical imaging that uses radiation to take pictures of the inside of the body). 4. On 12/29/2025, the Speech Therapist (ST - a person qualified to treat people with conditions that affect the production of speech, communication and swallowing problems) evaluated Resident 56 to assess oral (mouth) and pharyngeal (throat) swallowing function. The evaluation identified mild to moderate weakness of orofacial myofunctional (refers to disorders of the muscles in the face and mouth including the tongue, lips, and jaws), with a mild delay in swallow initiation, oral phase impairments characterized by delayed and incomplete bolus (a small, rounded mass of a substance) formation. The ST recommended continuation of a mildly thick liquid and pureed diet. 5. On 12/29/2025, the DON, Social Service Director (SSD) and Case Management scheduled an Interdisciplinary Team (IDT- a collaborative group of healthcare professionals working together with the resident and family member to create a unified, holistic care plan to address all of resident's needs) meeting with Resident 56's family member to discuss preferences related to the use of straws when consuming liquids and the prescribed fluid consistency. The risks and benefits of these preferences were to be discussed during the meeting. 6. On 12/29/2025, the Director of Staff Development (DSD) provided one-on-one (1:1) in-service (- refers to individualized, one-on-one education provided to a single individual by a staff member or professional) training to RNA 1 and RNA 2: a. Certified Nursing Assistant(s) (CNAs) are to verify the diet order on the diet list, which will be maintained in Nursing Station 1, the Dining Room, and the Activity Room. b. Liquids served to residents with modified liquid consistencies will be visually checked by a licensed nurse prior to serving. c. CNAs must verify with licensed nurses the use of straws before serving liquids to residents. 7. On 12/30/2025, the DON and designee conducted a review of residents on thickened liquids. The DON and designee verified that the liquids served at the bed side (place next to a resident's bed) matched the physician's orders. No other residents were affected by this deficient practice. 8. Starting 12/30/2025, the Registered Nurse (RN) Supervisor will print the diet list daily. The LVN or the RN Supervisor is responsible for updating the diet list whenever a new diet order is placed or whenever there is a new admission. The updated diet list will be available in Nursing Station 1, the Dining Room, and the Activity Room. A copy of the diet list will also be provided to the dietary department daily. 9. On 12/30/25, licensed staff and CNAs present in the facility received an in-service from the Registered Dietitian (RD - an expert on diet and nutrition) and DON on the importance of providing residents with liquids of the appropriate consistency as ordered by the physician. a. Licensed nurses are responsible for verifying that liquids supplied to residents match the physician's order, especially for residents requiring modified liquid consistencies, before serving to residents. b. All beverages requiring modified textures will be prepared in the kitchen. 10. On 12/30/2025, DON provided a one-on-one in-service training to LVN 1, emphasizing verification of fluid consistency with the diet list before serving liquids. LVN 1 was instructed to verify the diet order on the diet list maintained in Nursing Station 1, Dining Room, and the Activity Room. 11. On 12/30/2025, the DON provided a one-on-one in-service training to the CNAs on the importance of verifying liquid consistency and straw use with licensed nurses prior to serving drinks/liquids to residents. The training included the following: a. CNAs to verify the residents' diet order using the diet list maintained in Nursing Station 1, the Dining Room, and the Activity Room. b. Liquids served to residents requiring modified liquid consistencies will be visually verified by a licensed nurse prior to serving. c. CNAs to verify with licensed nurses whether the use of straws is permitted before serving drinks/liquids to residents. Thickening agents (powders or gels added to liquids such as water, juice, and milk to increase their viscosity [thickness], making them easier and safer to swallow) are controlled dietary items and are not to be provided to or used by nursing staff. From 12/30/2025 until delivery, dietary services are responsible for preparing and labeling moderately thickened liquids. Education on the different types of thickened liquids and their proper preparation was provided. 12. On 12/30/2025, the RD provided in-service training to dietary staff based on the IDDSI guidelines to ensure resident safety, reduce aspiration risk, and maintain compliance with physician diet orders and swallowing precautions. Dietary staff on leave will receive in-service training upon return, provided by the Dietary Supervisor. 13. On the evening (time not specified) of 12/30/2025, licensed staff and CNAs received in-service training from the DON and the RD on the importance of providing residents with liquids of the appropriate consistency as ordered by the physician. a. The 7-3 RN Supervisor or designee will print the diet list daily. The LVN or the RN Supervisor is responsible for updating the diet list with any new diet orders or admissions. The diet list will be available in the Nursing Station 1, the Dining Room, and the Activity Room. A copy of the diet list will be provided to the dietary department daily. b. Licensed nurses will be responsible for verifying that fluids supplied to residents match the physician's order, particularly for residents requiring modified liquid consistencies, prior to serving.c. It was discussed with the licensed nurses the different liquid consistencies based on IDDSI, and they were given a copy of the IDDSI chart (Drinks/Liquids). All beverages requiring modified textures will be prepared in the kitchen. CNAs to verify the diet order using the diet list that will be in Nursing Station 1, Dining Room, and Activity Room prior to serving drinks/fluids. CNAs to verify liquid consistency and straw use with licensed nurses before serving residents requiring modified textures. 14. On 12/31/2025, the ST conducted an in-service training to licensed nurses present in the facility on the different types of 1DDS1 fluid consistencies and testing methods. Staff on leave will receive in-service training upon return, provided by the ST or RD. 15. On 12/31/2025, the Assistant Administrator and the DSD conducted in-service training for non-nursing staff on the prohibition of providing food or fluids to residents. Non-nursing staff were instructed to communicate resident needs to licensed nursing staff. Non-nursing staff on leave will receive in-service training upon return, provided by the Assistant Administrator or designee. 16. Starting on 1/1/2026 the DON/Designee will conduct observations during breakfast, lunch, dinner, and snack times for residents requiring modified liquid consistencies daily for 30 days; then four times per week for four weeks; and then weekly for the remainder of the next three months to ensure residents are served liquids in accordance with prescribed physician orders. On 1/1/2026 at 5:57 p.m., while onsite at the facility, the SSA verified and confirmed the facility's full implementation of the IJ Removal Plan through observations, interviews, and record reviews, and determined the IJ situation regarding the facility's failure to provide food and drink prepared in a form designed to meet individual needs by failing to provide Resident 56 coffee with nectar/mildly thick liquid consistency as ordered by the physician on 12/29/2025 was no longer present. The SSA removed the IJ situation, while onsite, on 1/1/2026 at 5:57 p.m. in the presence of the ADM and DON. Findings: 1. During a review of Resident 56's admission Record, the admission Record indicated the facility admitted Resident 56 on 10/10/2025 with diagnoses including dysphagia following cerebral infarction (known as stroke, loss of blood flow to a part of the brain), aphasia (a language disorder caused by brain damage [often from stroke or injury] that impairs the ability to communicate) and gastro-esophageal reflux disease (GERD - when stomach acid frequently backs up into your esophagus [food pipe], causing irritation, often felt as persistent heartburn.) During a review of Resident 56's History and Physical (H&P- a comprehensive assessment of a resident's medical condition), dated 10/13/2025, the H&P indicated that Resident 56 had dysphagia requiring aspiration precautions and follow up with an ST. During a review of Resident 56's Minimum Data Set (MDS – a resident assessment tool), dated 10/16/2025, the MDS indicated Resident 56 was able to make herself understood and could understand others. The MDS further indicated Resident 56 required supervision during meals and substantial assistance from facility staff for activities of daily living (ADLs- essential self-care tasks for daily functioning such as bathing, dressing and toileting). The MDS indicated Resident 56 had a swallowing disorder as evidenced by coughing or choking during meals. During a review of Resident 56's Physician's Order dated 10/10/2025, the Physician's Order indicated a diet order for no added salt (NAS), pureed (to crush, grind, or blend food into a smooth, thick, pudding-like consistency, free of lumps, requiring no chewing and easy to swallow) texture; nectar/mildly thick liquid consistency. During a review of Resident 56's Nutrition Care Plan (CP) dated 10/14/2025, the CP includes a focus on dietary concerns and problems, as well as the resident's therapeutic diet (a specialized meal plan, prescribed by a doctor and planned by a dietitian, that modifies a normal diet to treat a medical condition and manage symptoms) and mechanically altered textures. The CP indicated that Resident 56 was at risk for aspiration and included an intervention to ensure that Resident 56's diet was administered and served according to the Physician's Order. During a review of Resident 56's Dysphagia CP dated 10/16/2025 and completed by the ST, the CP indicated Resident 56 had oropharyngeal dysphagia, and was at risk for aspiration, and required aspiration precautions, including an intervention not to use straws when consuming fluids. During a dining observation on 12/29/2025 at 12:15 p.m., in the activity/dining room, Resident 56 was observed seated at a table eating lunch with RNA 1, RNA 2 and LVN 1 present. On one side of the room, there was a coffee service cart and a meal tray (refers to the complete, assembled plate of food, drinks, utensils and condiments delivered to a resident) cart for residents. On top of the coffee service cart was a burgundy cup with a plastic lid labeled moderate thick milk, containing a white powder. On 12/29/2025 at 12:22 p.m., Resident 56 was observed holding a coffee cup with a straw and coughing after drinking from that coffee cup through a straw. The liquid in the cup was light brown and had a thin, water-like consistency. Resident 56's meal tray contained three cups: a clear liquid labeled mildly thickened water, a white liquid labeled mildly thickened milk, and a red liquid labeled mildly thickened juice. The food on the tray was pureed and consistent with the diet indicated on the meal ticket. Resident 56's meal ticket indicated that Resident 56 was on a pureed diet with mildly thickened consistency liquids. During a concurrent observation and interview on 12/29/2025 at 12:23 p.m., in the activity/dining room, with RNA 1, RNA 1 stated Resident 56 is on a pureed diet with thickened liquids and should not use a straw due to the risk of choking. RNA 1 stated Resident 56 continuously requests a straw, and staff (did not specify) sometimes provide it. Observed RNA 1 look inside Resident 56's coffee cup and identified the light brown liquid as coffee. RNA 1 further stated Resident 56 should not have been given coffee with a thin, watery consistency and served with a straw. During a concurrent observation and interview on 12/29/2025 at 12:45 p.m., in the activity/dining room, with the Dietary Supervisor (DS), observed the DS look inside Resident 56's coffee cup and described the light brown liquid in Resident 56's cup as thin, water-like coffee, and stated the liquid should have been mildly thick, nectar-like in consistency. The DS stated that it was dangerous for Resident 56 to receive thin coffee with a straw because her (Resident 56) diet order required mildly thick liquids, putting her (Resident 56) at risk for aspiration and choking. The DS further stated that whenever a resident with a thickened liquid diet requests coffee, the RNA or any licensed staff must go to the kitchen to request it. The DS stated only kitchen staff are authorized to prepare thickened liquids, and the cup containing the thickener should never have left the kitchen. During an interview on 12/29/2025 at 12:55 p.m., RNA 1 stated that prior to lunch, a coffee service is provided, and while residents wait for their meal trays, she (RNA 1) and RNA 2 distribute coffee. RNA 1 stated the cup labeled moderate thick milk contained thickener, but she (RNA 1) did not know where the cup came from or who brought it into the dining room. RNA 1 stated she (RNA 1) was aware Resident 56 cannot drink with a straw, but sometimes she (RNA 1) and other RNAs (did not specify) provide a straw because the resident repeatedly requests for a straw. During an interview on 12/29/2025 at 1:05 p.m., RNA 2 stated that she and RNA 1 typically work together in the dining room during coffee service and lunch. RNA 2 stated she (RNA 2) was handed the cup labeled moderate thick milk, by dietary staff (did not specify) in the kitchen but she (RNA 2) did not give Resident 56 the unthickened coffee and straw that day (12/29/2025). RNA 2 stated she did not know who provided the unthickened coffee with straw to Resident 56 during lunch on 12/29/2025. During an interview on 12/29/2025 at 1:14 p.m., with LVN 1, LVN 1 stated his (LVN 1) role during lunch was to supervise residents. LVN 1 stated he (LVN 1) does not serve coffee to residents and that coffee is served by the RNAs. LVN 1 stated meals are checked by licensed staff once the trays leave the kitchen and are checked again upon arrival in the activity/dining room by verifying the trays against the meal tickets. LVN 1 stated he did not observe who provided Resident 56 with the coffee or the straw. During a telephone interview on 12/29/2025, at 3:04 p.m., with facility's RD, the RD stated that it is extremely important to verify Resident 56's diet order to ensure the resident receives the correct diet to meet nutritional needs. The RD stated she (RD) has only observed the tray line and was not familiar with the coffee service process in the activity/dining room. The RD stated that in October (specific date not mentioned) of 2025, the facility transitioned to the IDDSI and that only dietary staff or licensed staff who have been trained are permitted to prepare thickened liquids. The RD further stated that not all licensed staff have currently received training on proper preparation of thickened liquids and that providing thin liquids to Resident 56 posed a danger due to the risk of aspiration. During a concurrent telephone interview and record review on 12/29/2025 at 4:01 p.m., with the ST, the ST reviewed Resident 56's care plan titled, Dysphagia Short Term Care Plan, dated 10/16/2025 and ST Evaluation notes from 10/16/2025 to 11/11/2025. The ST stated Resident 56 had a history of cerebrovascular accident (CVA – a medical emergency where blood flow to a part of the brain is suddenly interrupted, causing brain cells [building blocks of the brain] to die from lack of oxygen [colorless, odorless reactive gas and the life-supporting component of the air], leading to potential brain damage, disability or death) and upon evaluation on 10/16/2025, required a pureed diet with mildly thickened liquids, described as having a consistency similar to cooking oil or apricot juice. The ST stated she (ST) recommended safe swallowing and aspiration precautions, including sitting upright, taking small bites and sips, consuming food and liquids of the correct consistency and texture, utilizing a chin tuck (gently moving your head and bringing your chin toward your chest), and not using straws. The ST stated that without these precautions, Resident 56 was at risk for aspiration and aspiration pneumonia. The ST further stated that Resident 56 should not have been given thin liquids and a straw on 12/29/2025 during lunch. The ST stated she screened Resident 56 again on 12/11/2025 at the family's request and determined Resident 56 was not ready for a diet upgrade to thin liquids due to continued coughing after consuming thin liquids. During an interview on 12/29/2025 at 6:10 p.m., with the DON, the DON stated that licensed and unlicensed nursing staff are not permitted to prepare thickened liquids because they have not yet been trained to do so. The DON stated all thickened liquids must be prepared by kitchen staff only prior to being served to residents on thickened liquid diets. The DON also stated Resident 56 should not have been given unthickened liquids and a straw on 12/29/2025 during lunch, until cleared by the ST and determined to be safe. During an interview on 12/30/2025 at 8:48 a.m., [NAME] 3 stated that cold liquids are pre-thickened, but hot liquids require preparation by adding thickener to achieve the appropriate consistency. [NAME] 3 stated that it had been the kitchen's practice to review residents' diet orders, measure thickener using a measuring cup, and place the dry powder into a coffee cup for non-kitchen staff to mix and prepare the coffee. [NAME] 3 stated this had been their longstanding practice and that he (Cook 3) was not aware that only kitchen staff were permitted to mix or prepare thickened liquids. During a concurrent interview and record review on 12/30/2025 at 9:45 a.m., with the DON, the facility's P&P titled, Thickened Liquids, last reviewed on 8/23/2025, was reviewed. The P&P indicated thickened liquids will be served at the appropriate consistency as ordered by the physician and the mixing of the thickened meals will be done by Food and Nutrition Services during trayline or made up prior to trayline.Exception: Hot beverages will be mixed on trayline or by nursing. The DON stated that none of the facility's licensed nursing staff have been trained to prepare thickened liquids, despite the policy stating, Exception: Hot beverages will be mixed on tray line or by nursing. The DON further stated that only dietary/kitchen staff are permitted to prepare all thickened liquids. During an interview on 12/30/2025 at 11:22 a.m., with Nurse Practitioner 1 (NP 1), NP 1 stated she works directly with Resident 56's physician. NP 1 stated Resident 56 has a history of CVA and has a physician order for mildly thickened liquids due to dysphagia. NP 1 stated Resident 56 was not ready for thin/watery liquids due to risk for aspiration and that staff should follow all prescribed interventions and precautions. NP 1 stated the ST evaluated Resident 56 on 12/30/2025, and although Resident 56 was able to clear her throat, she (Resident 56) continued to demonstrate a delayed cough and would require a Video Fluoroscopic Swallow Study (a test that shows what happens when you swallow food or liquid). NP 1 stated Resident 56 would continue on her current diet orders of no added salt, pureed texture, nectar/mildly thick liquid consistency. During a review of the facility's P&P titled, Healthcare Menus Direct, LLC. IDDSI Framework, last reviewed on 8/23/2025, the P&P indicated level #2 Mildly Thick Liquids: flows off spoon; pours slower than drinks. During a review of the facility's P&P titled, Restorative Dining Program, last reviewed on 8/23/2025, the P&P indicated the RNA dining program must be performed as ordered and care planned for with the purpose for residents to effectively and safely take in food and fluids. During a review of the facility's P&P titled, Diet Orders, last reviewed on 8/23/2025, the P&P indicated diet orders prescribed by the physician will be provided by the Food and Nutrition Department. During a review of the facility's P&P titled, Thickened Liquids, last reviewed on 8/23/2025, the P&P indicated thickened liquids will be served at the appropriate consistency as ordered by the physician.hot beverages will be mixed on tray line or by nursing. 2. a. During a review of the facility's menu spreadsheet (a sheet containing the kind and amount of food each diet would receive) titled Winter Menus, dated 12/29/2025, the spreadsheet indicated residents on puree diet/International Dysphagia Diet Initiative ([IDDSI] a framework for categorizing food textures and drink thickness) Level 4 would include the following foods on the tray: Puree three (3) bean chili 1 cup (c, a household measurement) Puree tossed green salad 1/3 c Puree cornbread with green chili 1/4 c Margarine with puree bread Pudding 1/3 c Milk 4 fluid ounces (oz, a unit of measurement) During a concurrent observation and interview on 12/29/2025 at 11:35 a.m. of the trayline (an area where foods were assembled from the steamtable to resident's plate) with [NAME] 2, observed [NAME] 2 pouring liquid on the puree three bean chili without measuring it. [NAME] 2 stated she added a mixture of water, butter and chicken base to the puree bean chili. [NAME] 2 stated she checked the puree food every 15 minutes and added more liquid because it was too thick. [NAME] 2 added a total of 4 ¾ cups of liquid to the puree 3 bean chili. During a concurrent observation and interview on 12/29/2025 at 11:45 a.m. with [NAME] 2, observed the preparation of the 3-bean chili. The puree 3 bean chili was observed to be flat on the plate. [NAME] 2 performed a spoon tilt test and added more liquid to the puree 3 bean chili. During an observation on 12/29/2025 at 12:01 p.m. of the puree 3 bean chili on the plate, the puree bean chili was observed to be flat on the tray when plated. During an observation on 12/29/2025 at 12:05 a.m. of [NAME] 1 mixing the puree 3 bean chili, observed [NAME] 1 adding water and thickener to the puree 3 bean chili. During an observation on 12/29/2025 at 12:08 p.m. of the first cart, five (5) puree diet trays with puree chili and puree season green beans were observed to be flat and had thin texture on the trays. During a concurrent observation and interview on 12/29/2025 at 12:11 p.m. of the puree 3 bean chili on trayline with the DS and [NAME] 2, observed the Dietary Supervisor (DS) telling the staff that the puree 3 bean chili was too thin when served on the plate. [NAME] 1 stated they would be adding slurry on the puree 3 bean chili and the DS was preparing it. The DS stated she prepared slurry which is composed of hot water and thickener. The DS stated they added a slurry to the puree 3 bean chili so that the puree consistency would be correct and not too thin. b. During a concurrent test tray (a process of tasting, temping, and evaluating the quality of food) observation and interview on 12/29/2025 at 12:40 p.m. with the DS, observed the DS performing a spoon tilt test on puree 3 bean chili and it had a thick puree food left on the spoon after tilting. The DS stated there was a thick film left on the spoon, but she needed to check her notes of the criteria when puree food passed the spoon tilt test. Observed the DS performed a spoon tilt test on the puree tossed green salad and it fell off the spoon quickly. The DS stated the puree tossed green salad was too watery and too thin. The DS stated a standardized recipe was available for puree foods and the staff are supposed to follow it and not add liquid and thickener without measuring it. The DS stated if puree food was not in proper texture and consistency, residents would be unsatisfied with the food and would not eat it resulting in weight loss and choking as a potential outcome. During a review of the facility's diet manual titled IDDSI Framework reviewed on 8/25/2025, the manual indicated the facility has incorporated the IDDSI framework on its menus, recipes, spreadsheets, and supporting books. The IDDSI diet that will be available on facility's spreadsheets and recipe are as follows: IDDSI Level #4/Pureed- the pureed diet will consist of food that have been prepared in a manner to ensure the items served are smooth and free of lumps, hold their shape, without being too firm or sticky, and will not weep. The finished pureed food items, including sauces and gravies, must pass IDDSI level #4 testing requirements. IDDSI testing requirements: appearance, fork drip, and spoon tilt test. During a review of the facility's policies & procedure titled Food Preparation reviewed on 8/25/2025, the P&P indicated, the facility will use approved recipes, standardized to meet the resident census. This count is to be kept current so that an accurate amount of food is prepared. During

Based on observation, interview, and record review, the facility failed to ensure the confidential personal information of residents were protected by failing to ensure documents (diet tickets) containing protected information ([PHI]- any health information that can be used to identify specific individual which must remain confidential to prevent harmful consequences) were shredded prior to disposing in the waste container. This failure had the potential to violate 80 of 82 residents' rights for privacy and confidentiality of personal and medical records. Findings: During an observation on 12/30/2025 at 3:36 p.m. of the dishwashing process with Dietary Aide 2 (DA 2), observed DA 2 sorting food and diet tickets from the soiled residents' tray in different trash containers. DA 2 threw the menu tickets in the trash. During an interview on 12/30/2025 at 3:43 p.m. with DA 2, DA 2 stated he separated food from diet tickets and napkins as they have a separate dumpster container. DA 2 stated the food goes to the food dumpster and the diet tickets and napkins go to trash dumpster. DA 2 stated he throws the diet tickets in the trash dumpster after washing dishes. During an interview on 12/30/2025 at 4:10 p.m. with the Dietary Supervisor (DS), the DS stated they have different dumpsters outside and one is for organic (food) and other one for plastic and paper. The DS stated they throw the diet tickets in the dumpster outside designated for paper and plastic. The DS stated the diet ticket contains information about residents' name, menu, diet, diet consistency, room number, food likes and dislikes and these are protected information. The DS stated it was not appropriate to throw the diet ticket in the trash because of Health Insurance Portability and Accountability Act ([HIPPA], a law that sets national standard to protect sensitive health information, making sure it stays private and secure) law and protection of data of privacy of residents. During a review of the facility's policy and procedure (P&P) titled Health Information Record dated 8/25/2025, the P&P indicated The facility will maintain systems/platforms that are secure, encrypted, and minimize the risk to resident privacy and confidentiality as per HIPPA/HITECH regulations and the Condition of Participation or Conditions of Coverage.

Based on observation, interview, and record review, the facility failed to ensure that its medication error rate was less than five (5) percent (%). Three (3) medication errors out of 34 total opportunities contributed to an overall medication error rate of 8.82% affecting two of three residents (Resident 21 and 22) observed for medication administration. The medication errors were as follows: 1. For Resident 21: a. The facility failed to ensure that lidocaine 4% gel (a topical [applied to the skin] pain medication) was applied to Resident 21's left shoulder as ordered. b. The facility failed to ensure diclofenac sodium gel (a topical pain medication) was applied to the correct site when it was applied to Resident 21's left shoulder which was not a site indicated in the physician's order. 2. The facility failed to ensure Resident 22's metformin (medication to treat high blood sugar) medication was administered on time and with a meal per physician (MD) order. These failures had the potential to result in Resident 21 and 22 receiving suboptimal (less than standard) care, experiencing adverse effects (unwanted, uncomfortable, or dangerous effects that medication may have) and resulting in Residents 21 and 22's health and well-being negatively impacted. Findings: 1. During a review of Resident 21's admission Record, the admission Record indicated the facility originally admitted the resident on 6/9/2022 and most recently readmitted the resident on 3/7/2025 with diagnoses including, but not limited to, urinary tract infection (UTI- an infection in the bladder/urinary tract), type 2 (chronic) diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and unspecified dementia (a progressive state of decline in mental abilities). During a review of Resident 21's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 11/18/2025, the MDS indicated the resident had moderately impaired cognition (trouble with thinking, learning, and remembering clearly). The MDS also indicated Resident 21 required moderate to substantial assistance with most activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 21's Order Summary Report, the Order Summary Report indicated the following medications: a. Diclofenac sodium 1% external gel. Apply topically to bilateral knees two times a day for pain management. Apply four grams, dated 10/18/2023. b. Lidocaine 4% external gel. Apply to left shoulder, left arm topically two times a day for pain management, dated 3/14/23. During a concurrent observation and interview on 12/30/2025 at 8:07 a.m. with Licensed Vocational Nurse (LVN) 3, LVN 3 prepared diclofenac sodium 1% external gel and brought it into Resident 21's room. LVN 3 proceeded to apply the diclofenac sodium to Resident 21's bilateral knees and left shoulder. During an interview on 12/30/2025 at 12:02 p.m. with LVN 3, LVN 3 stated she thought diclofenac sodium was ordered to be applied to the resident's bilateral knees and the left shoulder, but after reviewing the resident's orders she stated diclofenac sodium should have been applied to the knees only and lidocaine gel to the left shoulder. During an interview on 12/31/2025 at 3:04 p.m. with the Director of Nursing (DON), the DON stated the doctor's orders should have been followed and lidocaine applied to the left shoulder instead of diclofenac sodium. The DON stated Resident 21 would not get the efficacy of lidocaine to her shoulder and applying diclofenac sodium to the shoulder may cause skin irritation and dermatitis (irritated, inflamed skin). During a review of the facility's policy and procedure (P&P) titled, Medication Administration, last reviewed 8/28/2025, the P&P indicated it is the policy of the facility that medications for residents be administered in a safe and timely manner, and as prescribed. The P&P indicated the licensed nurse administering the medication must check the label to verify the right resident, the right medication, the right dosage, the right time, and route of administration before giving the medication. 2. During a review of Resident 22's admission Record, the admission Record indicated the facility originally admitted on [DATE] and readmitted the resident on 4/30/2025 with diagnoses including sepsis (a life-threatening condition that arises when the body's response to infection causes injury to its own tissues and organs) and diabetes mellitus (DM-a chronic condition that affects the way the body processes blood sugar [glucose]). During review of Resident 22's Minimum Data Set (MDS - a comprehensive standardized assessment and care-screening tool), dated 11/5/2025, the MDS indicated Resident 22 had intact cognition (mental action or process of acquiring knowledge and understanding) for daily decision-making and required maximal assistance from staff for activities of daily living (ADLs-bed mobility, surface transfer, eating, walk in room, dressing, toileting, and personal hygiene). The MDS also indicated Resident 22 was receiving hypoglycemic (types of medication that treats high blood sugar) medications. During a review of Resident 22's Order Summary Report, the Order Summary Report indicated an order dated 9/26/2025, for metformin hydrochloride (medication that helps control high blood sugar levels) extended release (ER) 500 milligrams (mg) by mouth (PO) two times a day for DM with meals. During a review of Resident 22's Administration History Report (AHR), metformin was scheduled to be administered daily at 7:15 a.m. and 5:15 p.m. The AHR indicated that metformin was administered on 12/30/2025 at 8:44 a.m. During a medication pass observation, and interview on 12/30/2025 at 8:27 a.m., with Licensed Vocational Nurse 1 (LVN 1), LVN 1 was observed administering metformin to Resident 22. LVN 1 confirmed that metformin was supposed to be administered with meals at 7:15 a.m. LVN 1 also stated that providing metformin late and without a meal could affect how the medication works and alter its absorption in the body. During an interview on 1/2/2026 at 11:01 a.m., with the Director of Nursing (DON), the DON stated that it was important to provide metformin at the right time and with meals as prescribed, since taking it at a different time or without food can affect absorption and cause significant changes in blood sugar levels. During a review a review of facility's policy and procedures (P&P) titled, Medication Administration, reviewed on 8/28/2025, the P&P indicated, the facility will administer medications for residents in a safe and timely manner. medications must be administered in accordance with the physician orders, including any required time frame.

Based on observation, interview, and record review the facility failed to follow the menu and meet the nutritional needs of the residents when [NAME] 1 did not follow the recipe for Puree 3 bean chili. This failure had the potential to result in decrease in food flavor, decrease in food and nutrient intake to 19 of 19 residents on Puree (foods that are smooth with pudding like consistency) /International Dysphagia Diet Standardization Initiative ([IDDSI] a framework for categorizing food textures and drink thickness) Level 4, and puree consistent carbohydrate diet (diet consisting of the same amount of carbohydrates per meal for blood sugar management), resulting in increased blood sugar levels and unplanned weight loss. Findings: During a review of the facility's menu spreadsheet (a sheet containing the kind and amount of food each diet would receive) titled Winter Menus, dated 12/29/2025, the spreadsheet indicated residents on puree diet/IDDSI Level 4 would include the following foods on the tray: Puree three (3) bean chili 1 cup (c, a household measurement) Puree tossed green salad 1/3 c Puree cornbread with green chili 1/4 c Margarine with puree bread Pudding 1/3 c Milk 4 fluid ounces (oz, a unit of measurement) During a concurrent observation and interview on 12/29/2025 at 11:35 a.m. of the trayline (an area where foods were assembled from the steamtable to resident's plate) with [NAME] 2, observed [NAME] 2 pouring liquid on the puree three bean chili without measuring it. [NAME] 2 stated she added a mixture of water, butter and chicken base to the puree 3 bean chili. [NAME] 2 stated she checked the puree food every 15 minutes and added more liquid because it was too thick. [NAME] 2 added a total of 4 3/4 cups of liquid to the puree 3 bean chili. During a concurrent observation and interview on 12/29/2025 at 11:45 a.m. of the preparation of the 3-bean chili with [NAME] 2, the puree 3 bean chili was observed to be flat on the plate. [NAME] 2 performed a spoon tilt test and added more liquid to the puree 3 bean chili. During an observation on 12/29/2025 at 12:01 a.m. of the puree 3 bean chili on the plate, the puree bean chili was observed to be flat on the tray when plated. During an observation on 12/29/2025 at 12:05 a.m. of [NAME] 1 mixing the puree 3 bean chili, observed [NAME] 1 adding water and thickener to the puree 3 bean chili. During an observation on 12/29/2025 at 12:08 p.m. of the first cart, observed five (5) puree diet trays had puree chili and puree season green beans were flat and had thin texture on the trays. During a concurrent observation and interview on 12/29/2025 at 12:11 p.m. of the puree 3 bean chili on trayline with the DS and [NAME] 2, observed the Dietary Supervisor (DS) telling the staff that the puree 3 bean chili was too thin when served on the plate. [NAME] 1 stated they would be adding slurry on the puree 3 bean chili and the DS was preparing it. The DS stated she prepared slurry which is composed of hot water and thickener. The DS stated they added a slurry to the puree 3 bean chili so that the puree consistency would be correct and not too thin. During an interview on 12/29/2025 at 1:07 p.m. with the DS, the DS stated it was important to follow standardized recipe and measure ingredients to ensure residents were not getting extra calories and carbohydrates for residents on puree, CCHO diet. The DS stated cooks kept adding extra thickener and chicken base with butter, CCHO diet was not followed and they are not compliant with the diet orders. The DS stated there would be changes in flavor resulting in residents not eating the food and weight loss. The DS stated possible weight gain would be the potential outcome of not following standardized recipes. During a review of the facility's policies & procedure titled Food Preparation dated 8/25/2025, the P&P indicated, the facility will use approved recipes, standardized to meet the resident census. This count is to be kept current so that an accurate amount of food is prepared. During a review of the facility's standardized recipe titled Recipe: 3 Bean Chili dated 2025, the recipe indicated there were no chicken base and butter in the recipe list. During a review of the facility's standardized recipe titled Recipe: Pureed (IDDSI Level #4) Soup dated 2025, the recipe indicated, ingredients: soup per recipe, crackers (saltine), if needed, stabilizer: instant potato, non-fat dry milk, breadcrumbs, toast, instant cream of rice or farina, or commercial instant food thickener. The recipe further indicated to prepare 24 servings would use 3/4 - 1 1/2 cups of thickener and chicken broth with butter and water were not included on the recipe list.

Based on observation, interview, and record review, the facility failed to prepare food by methods that conserved appearance, flavor and temperature for lunch when: Puree (foods that are soft with pudding like consistency) chili was flat on the plate and puree tossed salad was too watery. Puree tossed green salad's temperature was at 61 degrees Fahrenheit ( F, a degree of temperature), puree Jello's temperature at 51 F, tossed green salad's temperature at 61 F, and citrus chiffon delight's temperature at 55 F during test tray (a process of tasting, temping, and evaluating the quality of food) These failures had potential to result in 80 of 82 facility residents at risk of unplanned weight loss, a consequence of poor food intake, from receiving getting food from the kitchen. Findings: During a review of the facility's menu spreadsheet (a sheet containing the kind and amount of food each diet would receive) titled Winter Menus, dated 12/29/2025, the spreadsheet indicated residents on puree diet/International Dysphagia Diet Initiative ([IDDSI] a framework for categorizing food textures and drink thickness) Level 4 would include the following foods on the tray: Puree three (3) bean chili 1 cup (c, a household measurement) Puree tossed green salad 1/3 c Puree cornbread with green chili 1/4 c Margarine with puree bread Pudding 1/3 c Milk 4 fluid ounces (oz, a unit of measurement) During a concurrent observation and interview on 12/29/2025 at 11:35 a.m. of the trayline (an area where foods were assembled from the steamtable to resident's plate) with [NAME] 2, observed [NAME] 2 pouring liquid on the puree three bean chili without measuring it. [NAME] 2 stated she added a mixture of water, butter and chicken base to the puree bean chili. [NAME] 2 stated she checked the puree food every 15 minutes and added more liquid because it was too thick. [NAME] 2 added a total of 4 3/4 cups of liquid to the puree 3 bean chili. During a concurrent observation and interview on 12/29/2025 at 11:45 a.m. with [NAME] 2, observed the preparation of the 3-bean chili. Observed the puree 3 bean chili lay flat on the plate. [NAME] 2 performed a spoon tilt test and added more liquid to the puree 3 bean chili. During an observation on 12/29/2025 at 12:01 p.m. of the puree 3 bean chili on the plate, the puree bean chili was observed to be flat on the tray when plated. During an observation on 12/29/2025 at 12:05 p.m. of [NAME] 1 mixing the puree 3 bean chili, observed [NAME] 1 adding water and thickener to the puree 3 bean chili. During an observation on 12/29/2025 at 12:08 p.m. of the first cart, five (5) puree diet trays with puree chili and puree season green beans were observed to be flat and had thin texture on the trays. During a concurrent observation and interview on 12/29/2025 at 12:11 p.m. of the puree 3 bean chili on trayline with the DS and [NAME] 2, observed the Dietary Supervisor (DS) telling the staff that the puree 3 bean chili was too thin when served on the plate. [NAME] 1 stated they would be adding slurry on the puree 3 bean chili and the DS was preparing it. The DS stated she prepared slurry which is composed of hot water and thickener. The DS stated they added a slurry to the puree 3 bean chili so that the puree consistency would be correct and not too thin. During a concurrent test tray (a process of tasting, temping, and evaluating the quality of food) observation and interview on 12/29/2025 at 12:40 p.m. with the DS, observed the DS performing a spoon tilt test on puree 3 bean chili and it had a thick puree food left on the spoon after tilting. The DS stated there was a thick film left on the spoon, but she needed to check her notes of the criteria when puree food passed the spoon tilt test. Observed the DS performed a spoon tilt test on the puree tossed green salad and it fell off the spoon quickly. The DS stated the puree tossed green salad was too watery and too thin. The DS stated a standardized recipe was available for puree foods and the staff are supposed to follow it and not add liquid and thickener without measuring it. The DS stated if puree food was not in proper texture and consistency, residents would be unsatisfied with the food and would not eat it resulting in weight loss and choking as a potential outcome. During a review of the facility's diet manual titled IDDSI Framework dated 8/25/2025, the manual indicated the facility has incorporated the IDDSI framework on its menus, recipes, spreadsheets, and supporting books. The IDDSI diet that will be available on facility's spreadsheets and recipe are as follows: IDDSI Level #4/Pureed- the pureed diet will consist of food that have been prepared in a manner to ensure the items served are smooth and free of lumps, hold their shape, without being too firm or sticky, and will not weep. The finished pureed food items, including sauces and gravies, must pass IDDSI level #4 testing requirements. IDDSI testing requirements: appearance, fork drip, and spoon tilt test. 2. During a review of Resident 42's admission Record, the admission Record indicated the facility initially admitted Resident 42 on 12/2/2025 and readmitted on [DATE] with diagnosis including, but not limited to, dysphagia (difficulty swallowing), type 2 diabetes (too much sugar in the blood because the body cannot use insulin right away), and essential hypertension (high blood pressure). During a review of Resident 42's Minimum Data Sheet (MDS- a federally mandated resident assessment tool) dated 12/8/2025, the MDS indicated Resident 42 understood others and can make self-understood. The MDS indicated Resident 42 needed set up and clean up assistance (helper sets up or cleans up; resident completes activity. Helper assists only prior to or following the activity) when eating. During a review of Resident 42's Order Summary Report, dated 1/20/2025, the Order Summary report indicated Resident 43 was ordered no added salt (NAS, no salt packet on the tray), consistent carbohydrate (CCHO, diet containing the same amount of carbohydrate each meal to manage blood sugar), easy to chew IDDSI Level 7 (diet that included food that are soft and tender in textures with the exclusion of hard, tough, chewy, fibrous, stingy, crunchy bits, pits, seeds, fibrous part of the fruit) regular texture, Level 0, thin liquid consistency. During a concurrent test tray observation and interview on 12/29/2025 at 12:23 p.m. of the puree diet tray with the DS at Station three (3), observed DS taking the temperature of the foods using the facility thermometer. The DS stated the following food had the following temperatures: Puree green tossed salad at 61 F, Puree Jello at 51 F During a concurrent test tray observation and interview on 12/29/2025 at 12:26 p.m. of the regular diet (diet with no restrictions) tray with the DS at Station 3, observed DS taking the temperature of the foods using the facility thermometer. The DS stated the following food had the following temperatures: Tossed green salad at 61 F Citrus chiffon delight at 55 F. During an interview on 12/30/2025 at 7:58 a.m. with Resident 42, Resident 42 stated the eggs and toast were cold this morning and he thinks they were the last ones to get their meals, so it was often cold. Resident 42 stated breakfast was the worst when it comes to cold foods, but lunch and dinner also come cold at times. During an interview on 12/30/2025 at 8:58 a.m. with the DS, the DS stated cold food should stay cold at 41 f and below before serving but when it comes out to the residents the acceptable temperature is 45 F and below for acceptability and palatability of food. The DS stated if temperatures are not acceptable, residents would not be acceptable to eat and residents would not eat the food resulting in decrease in food intake and weight loss. During a review of the facility's P&P titled Dietary- Menus, Food and Drink dated 8/25/2025, the P&P indicated It is the policy of the facility to meet needs of residents in accordance with established national guidelines. The facility will provide food and drink that is palatable, attractive and at safe and appetizing temperatures. The facility will prepare foods by methods that conserve nutritive value, flavor and appearance. During a review of the facility's P&P titled Dietary- Food and Nutrition Preparation and Service dated 8/25/2025, the P&P indicated It is the policy of the facility to provide each resident with nourishing, palatable, well-balanced diet that meets the daily nutritional and dietary needs.

Based on observation, interview and record review, the facility failed to ensure Resident 20 received and consumed food in appropriate nutritive content as prescribed by a physician. This deficient practice had the potential to result in ineffective therapeutic diet, decreased in nutrient intake to one (Resident 20) of 82 residents, resulting in weight loss, getting food from the kitchen. Findings: During a review of Resident 20's admission Record, the admission record indicated the facility initially admitted Resident 20 on 9/16/2022 and readmitted on [DATE] with diagnosis including, but not limited to, moderate protein-calorie malnutrition (body lacks protein and energy for basic functions leading to noticeable weight loss, fatigue and muscle loss), type 2 diabetes (too much sugar in the blood because the body cannot use insulin right away), and essential hypertension (high blood pressure). During a review of Resident 20's Minimum Data Sheet (MDS - a federally mandated resident assessment tool) dated 11/15/2025, the MDS indicated Resident 20's usually understood others and rarely/never made self-understood. The MDS indicated Resident 20 needed supervision and touching assistance when eating (helper provides verbal cues and or touching/steadying and/or contact guard assistance as a resident completes the activity. Assistance maybe provided throughout the activity or intermittently). During a review of Resident 20's Order Summary Report, dated 11/18/2025, the Order Summary Report indicated Resident 20 was ordered no added salt (NAS, no salt packet on the tray), consistent carbohydrate diet (CCHO, diet containing the same amount of carbohydrate each meal to manage blood sugar), soft and bite sized texture (foods that are soft, tender and moist with no liquid separation that could be mashed or broken down with pressure from fork, spoon or chopstick), thin liquid consistency. During an observation on 12/29/2025 at 12:15 p.m. of the trayline (an area where foods were assembled from the steamtable to resident's plate), observed Resident 20 diet ticket indicated a diet of CCHO, NAS, soft bite sized (SB6), small portion. Observed an extra plate of chopped quesadilla had been prepared for Resident 20. During an interview on 12/29/2025 at 1:02 p.m. with the Dietary Supervisor (DS) the DS stated small portion diets received less portion compared to the regular portion diets and it depends what was indicated on the spreadsheet. The DS stated small portion diets are given to residents who were transitioning from tube feeding (tube that delivers nutrition, fluids, and medicine directly into the stomach through a tube placed through the abdomen) to regular food and those residents needing to lose weight. The DS stated if a resident was on small portion diet and got additional food on the plate, it could result in unplanned weight gain. During a review on 12/30/2025 at 10:39 a.m. of the Resident 20's physician diet order, the diet order indicated Resident 20's diet was NAS, CCHO, soft bite sized, regular thin liquid diet. During an interview on 12/30/2025 at 3:47 p.m. with the Registered Dietitian (RD), the RD stated that diet orders are ordered by a physician, nursing staff would fill up the duplicate slip indicating the diet of the resident and kitchen will get the original copy. The RD stated the diet order is placed by nursing in the order management system and it gets printed on the menu ticket every meal. The RD stated the diet order must match the menu ticket to avoid the risk of serving the wrong food to the residents and to ensure therapeutic diets are provided to residents as ordered. The RD stated a small portion diet is ordered by a physician for Resident 20's weight control and for some residents who stated meals are overwhelming. The RD stated if residents on regular portions received a small portion diet there could be a decreased in calorie intake necessary for maintenance of resident's nutritional status and weight loss, malnutrition and skin issues could result in decreased intake. During an interview on 12/30/2025 at 4:06 p.m. with the RD, the RD stated she changed the meal ticket of Resident 20 to match the diet order and the right portion was regular portion. The RD stated she changed meal ticket for dinner to avoid giving the wrong portion sizes of food to Resident 20. During a review of the facility's policies and procedures (P&P) titled Dietary-Menus, Food and Drink dated 8/25/2025, the P&P indicated, Each resident will receive food in the appropriate form an/or the appropriate nutritive content as prescribed by their physician. During a review of the facility's P&P titled Diet Orders dated 8/25/2025, the P&P indicated Policy: Diet orders as prescribed by the physician will be provided by the Food and Nutrition Services department. Procedure: Nursing will send a Diet Order Communication slip to the food and Nutrition Services department. The FNS Director or [NAME] in charge will make or adjust the diet profile and tray card as prescribed. The diet count is also to be adjusted as needed. The diet profile and tray card will be removed upon discharge or transfer. Any discrepancy in the diet order slip will be clarified by the FNS director or cook in charge with nursing. During a review of the facility's P&P titled Portion Sizes dated 8/25/2025, the P&P indicated, Policy: Various portion sizes of the food served will be available to better meet the needs of the residents. Procedure: The small and large portion servings will be served as printed on the cook's spreadsheets for every meal. 1/2 size portions are to be given to those residents who request smaller portions than the small portion diet provides. This portion size is not recommended except with fortifications, as it may not meet the nutritional needs of most residents. The food server is to give the 1/2 size portion of the regular diet for the food on the main plate-entree, vegetable, and starch. Regular portions will be given for the soup, bread, salad, dessert, and beverage, unless otherwise stated by the Dietitian.

Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen when: 1, Kitchen equipment and utensils were not free from dirt, dust and food debris. a. Reach in refrigerators one (1), two (2), near the trayline (an area where foods were assembled from the steamtable to resident's plate) and four (4) had dirt, food, dust debris and buildup, juice spills on the shelves and gaskets. b. The toaster had breadcrumbs and burnt bread debris. c. The ice machine side bins had dirt buildup. 2. Milk in two (2) cups at 44 degrees Fahrenheit ( F, a degree of temperature) and 43 F in the Reach in refrigerator 2. 3. The gasket on Reach-in refrigerator 2 was torn. 4. The Reach in refrigerator by trayline had no internal thermometer. 5. The dry storage floor had dirt, food and dust debris. 6. Four (4) dented cans were not separated with non-dented cans. 7. Chopping boards were stored along with red and green buckets containing chemical (sanitizer). 8. Fifty (50) of 80 residents' tray for dinner service on 12/30/2025 had no glaze and had cracks and chips. These failures had the potential to result in harmful bacterial growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to foodborne illness (a disease caused by consuming food or drinks that are contaminated by germs or chemicals) in 80 of 82 medically compromised residents who received food and ice from the kitchen. Findings: 1.a. During an observation on 12/29/2025 at 8:06 a.m. of the Reach-in refrigerator one (1), observed a food container with food debris and the side shelving on the reach in refrigerator had food debris. During an observation on 12/29/2025 at 8:15 a.m. of the Reach-in refrigerator two (2), observed gasket with dirt residues. During a concurrent observation and interview on 12/29/2025 at 8:22 a.m. of the Reach in-refrigerator 1 with the Dietary Supervisor (DS), the DS stated the cream cheese container and the side of the refrigerator had food debris and it could be sugar or bread. The DS stated the staff clean the refrigerator every Tuesday and Friday during the delivery of food and deep-clean it once a month. The DS stated last time it was cleaned was Friday. The DS stated it was not okay to have food debris in the refrigerator due to cross contamination of food. During a concurrent observation and interview on 12/29/2025 at 8:34 a.m. of the Reach-in refrigerator 2 with the DS, the DS stated the gasket had dirt and food debris and it was important to clean it to avoid cross-contamination. During an observation on 12/29/2025 at 8:40 a.m. of the reach-in refrigerator by trayline, observed dirt and food debris around the gasket. During a concurrent observation and interview on 12/29/2025 at 8:43 a.m. of Reach-in refrigerator four (4), observed the gasket with dirt and food debris. The DS stated the gasket needed to be clean as it had dirt and food debris to prevent cross-contamination. During an observation on 12/29/2025 at 8:54 a.m. of the Reach-in freezer 1, observed dirt debris on the freezer shelves. During an observation on 12/29/2025 at 8:57 a.m. of the Reach-in freezer 2, observed dirt and food debris on the shelves and gasket. During an interview on 12/29/2025 at 9:02 a.m. with the DS, the DS stated two (2) employees were assigned to clean the refrigerators and freezers, but they were not focused on cleaning the refrigerator and gaskets. The DS stated Reach-in freezer 1 and Reach-in freezer 2 had dirt buildup, food debris and spill and it was not okay because it could cause cross-contamination. The DS stated foodborne illnesses to the residents could be the potential outcome of cross-contamination. During a review of the facility's policies and procedures (P&P) titled Procedure for Refrigerated Storage dated 8/25/2025, the P&P indicated Refrigeration equipment should be routinely cleaned. During a review of the facility's P&P titled Refrigerator and Freezer dated 8/25/2025, the P&P indicated Maintaining a clean refrigerator and freezer can improve the safety and quality of your foods. Food the best cleaning results, always refer to your owner's manual. (1) Refrigerator and freezer should be on a weekly cleaning schedule (2) Wipe up spills immediately. (5) Wipe down gaskets with soapy water. (6) Remove all items and clean shelves. Wipe with sanitizer. b. During an observation on 12/30/2024 at 3:17 p.m. of the toaster, observed breadcrumbs debris and a burnt piece of bread inside the toaster. During a concurrent observation and interview on 12/30/2025 at 3:17 a.m. of the toaster with [NAME] 2, [NAME] 2 stated the toaster should be cleaned after each use and she needed to remove the screw so they could clean the toaster as it had breadcrumbs inside it. [NAME] 2 stated it is important to maintain the cleanliness of the toaster to prevent cross-contamination. During an interview on 12/30/2025 at 4:06 p.m. with the DS, the DS stated they clean the toaster once a week and every after use. The DS stated the paint from the toaster was coming off and it is time to change it due to physical hazard and contamination. The DS stated bacteria can grow in the food and residents could get sick from it. During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated, 4-601.11 (A) Equipment Food Contact Surfaces and utensils shall be cleaned: (1) Except as specified in (B) of this section, before use with a different type of raw animal food such as beef, fish, lamb, pork or poultry; (2) Each time there is a change from working with raw foods to working with ready-to-eat food; (3) Between uses with raw fruits and vegetables and with time/temperature control for safety food. (4) Before using or storing a food temperature measuring device, and (5) At the time during the operation when contamination may have occurred. c. During a concurrent observation and interview on 12/31/2025 at 11:08 a.m. of the ice machine internal parts in the room across room [ROOM NUMBER] with the DS, the ice machine internal parts had dirt residue on the side. The DS stated dirt in the ice machine was not good as it could contaminate the ice and residents could get illness from the dirt and mold. During a concurrent observation and interview on 12/31/2025 at 11:20 a.m. of the internal part of the ice machine with the Maintenance Supervisor (MS), the MS stated the side of the ice machine internal part had dirt debris and it needed to be removed and clean. The MS stated the ice machine should be free from dirt and mold debris to keep the residents safe as they could get upset stomachs as a potential outcome. During a review of the facility's P&P titled Cleaning the Ice Machine dated 8/25/2025, the P&P indicated The ice machine shall be cleaned for maintenance of sanitary conditions in order to prevent food contamination and the growth of disease disease-producing organisms and toxins. The ice machine shall be cleaned in accordance with the manufacturer's requirements. The ice machine shall be cleaned using a nickel safe ice machine cleaner and sanitized every month per manufacturer's guidelines. During a review of Food Code 2022, the Food Code 2022 indicated, 4-601.11 (E) Except when dry cleaning methods are used as specified under S 4-603.11, surfaces of utensils and equipment contacting food that is not time/temperature control for safety food shall be cleaned: (1) At any time when contamination may have occurred; (2) At least every 24 hours for iced tea dispensers and consumer self-service utensils such as tongs, scoops, or ladles; (3) Before restocking consumer self-service equipment and utensils such as condiment dispensers and display containers; and (4) In equipment such as ice bins and beverage dispensing nozzles and enclosed components of equipment such as ice makers, cooking oil storage tanks and distribution lines, beverage and syrup dispensing lines or tubes, coffee bean grinders, and water vending equipment: (a) At a frequency specified by the manufacturer, or (b) Absent manufacturer specification, at a frequency necessary to preclude accumulation of soil or mold. During a review of Food Code 2022, the Food Code 2022 indicated, 4-602.12 Cooking and Baking Equipment. (A) The food contact surfaces of cooking and baking equipment shall be cleaned at least every 24 hours. This section does not apply to hot oil cooking and filtering equipment if it is cleaned as specified subparagraph 4-602.11 (D)(6). During a review of Food Code 2022, the Food Code 2022 indicated,4-602.13 Nonfood-Contact Surfaces. Nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues. 2. During an observation on 12/29/2025 at 8:15 a.m. of the milk in the cup in the Reach-in refrigerator 2, observed the temperature of the milk was at 44 F. During a concurrent observation and interview on 12/29/2025 at 8:28 a.m. of the milk in the cups with the DS, observed DS took the temperature of the milk in the cups. The DS stated the milk temperature was 44.4 F for one cup and 45 F for the other cup. The DS stated the milk was poured in the cup in the preparation area at 7:15 a.m. The DS stated the milk would not be acceptable to serve to the residents, but the staff just prepared the milk, and the temperature should go down to 40 F and below at 9:15 a.m. The DS stated it was important for the milk not to be in the danger zone ([41 F-135 F], the range of temperature where bacteria multiply and grow rapidly), to avoid the growth of microorganisms and foodborne illnesses. During a concurrent observation and interview on 12/29/2025 at 9:22 a.m. of the milk temperature in the Reach-in refrigerator 2 with the DS, the DS took the temperature of the milk in the cup. The DS stated the cups of milk were at 43 F and 44 F and it would not be okay to serve the milk as it was in the danger zone, and the temperature did not go down in 2 hours. The DS stated they will toss the milk in the cups and prepare a new one. During review of the facility's P&P titled Food Temperatures dated 8/25/2025, the P&P indicated Cold food should be served at 41 F or below. Potentially hazardous food has been held above proper temperatures for more than two hours; they should be discarded. During a review of Food Code 2022, the Food Code 2022 indicated, 3-501.16 Time/Temperature for Safety Food, Hot and Cold Holding. (A) Except during preparation, cooking, or cooling, or when time is used as a public health control as specified under 3-501.19, and except as specified under (B) and in (C) of this section, Time/Temperature Control for safety food shall be maintained: (2) At 5 C (41 F) or less. 3. During an observation on 12/29/2025 at 8:15 a.m. of the Reach-in refrigerator 2, observed the bottom gasket was torn. During a concurrent observation and interview on 12/29/2025 at 8:34 a.m. of the Reach-in refrigerator 2's gasket with the DS, the DS stated the gasket was torn and needed to be replaced. The DS stated the expectation was to have a good fitting refrigerator gasket so that the refrigerator could be close to ensure the inside temperature is correct. The DS stated if the inside refrigerator's temperature was not kept in the acceptable temperature, the refrigerator would be in the danger zone, and the food could spoil. The DS stated there would be a potential foodborne illness upon consumption of spoiled food for the residents. During a review of the facility's P&P titled Refrigerator and Freezer dated 8/25/2025, the P&P indicated How to keep your refrigerator and freezer working efficiently: (2) Periodically, check door gaskets and replaced if damaged. 4. During an observation on 12/29/2025 at 8:40 a.m. of the Reach-in refrigerator by trayline, observed no thermometer inside the refrigerator. During an interview on 12/29/2025 at 8:43 a.m. with the DS, the DS stated there should be two (2) thermometers in all the refrigerators, one for in the inside and one external to make sure the refrigerator works for temperature maintenance. During a review of the facility's P&P titled Procedure for Refrigerated Storage dated 8/25/2025, the P&P indicated (2) Two thermometers, placed to be easily visible for checking, should be inside all walk-in, reach-in refrigerators. The second thermometer is check against the first thermometer for accuracy. A temperature will be logged twice daily by a designated employee upon opening of the kitchen and upon closing of the kitchen. During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated 4-204.112 Temperature Measuring Devices. (A) In a mechanically refrigerated or hot FOOD storage unit, the sensor of a temperature measuring device shall be located to measure the air temperature or a simulated product temperature in the warmest part of a mechanically refrigerated unit and in the coolest part of a hot FOOD storage unit. (B) Except as specified in (C) of this section, cold or hot holding equipment used for time/temperature control for safety food shall be designed to include and shall be equipped with at least one integral or permanently affixed temperature measuring device that is located to allow easy viewing of the device's temperature display. 5. During an observation on 12/29/2025 at 9:04 a.m. of the dry storage area, observed dirt, food, dust on the floor under the storage shelves. During an interview on 12/29/2025 at 9:09 a.m. with the DS, the DS stated storage floors had dirt and food debris and staff needed to clean all the way at the back of the shelves. The DS stated it was important to maintain cleanliness of the food storage area due to cross-contamination and growth of pathogens that could cause foodborne illnesses to the residents and for pest control. During a review of the facility's P&P titled Storeroom dated 8/25/2025, the P&P indicated The general cleanliness and care of the storeroom and supplies are important to ensure safe wholesome food. (1) The floor, walls, ceiling, lights, shelves and equipment must be kept clean by setting up, maintaining, and monitoring a regular cleaning schedule. Routine inspection must be made to ensure cleanliness and high standards of sanitation. (Refer to shelves, walls, ceiling and floor cleaning). During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated,4-602.13 Nonfood-Contact Surfaces. Nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues. 6. During an observation on 12/29/2025 at 9:04 a.m. observed four (4) dented cans stored with non-dented cans. During an interview on 12/29/2025 at 9:12 a.m. with the DS, the DS stated dented cans are separated and placed in the bottom shelves to be returned to vendor. The DS stated the cans are considered dented if your thumb can fit in the dent or if the dent is inside or in the can opening where bacteria could go in. The DS stated they separate dented cans because they could not use them due to bacteria oxidizing food for bacterial growth. The DS stated if residents consume the dented can food, they could get foodborne illnesses as a potential outcome. The DS stated there were 4 dented cans on the shelves where undented cans were stored and it should not be there. During a review of the facility's P&P titled Food Storage-Dented Cans dated 8/25/2025, the P&P indicated Policy: Food in unlabeled, rusty, leaking, broken containers or cans with side seam dents, rim dents or swells shall not be retained or used by the facility. Procedure: All dented cans (defined as side seam or rim dents) and rusty cans are to be separated from remaining stock and placed in a specified labeled area for return to purveyor for refund. All leaking cans are to be disposed of immediately. During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated, 3-101.11 Safe Unadulterated, and Honestly Presented. Food shall be safe, unadulterated, and, as specified under 3-601.12, honestly presented. 3-201.11 Compliance with Food Law. A primary line of defense ensuring that food meets the requirements of S3-101.11 is to obtain food from approved sources, the implications of which are discussed below. However, it is also critical to monitor food products to ensure that, after harvesting, processing, they do not fail victim to conditions that endanger their safety, make them adulterated, or compromise their honest presentation. The regulatory community, industry, and consumers should exercise vigilance in controlling the conditions to which foods are subjected and be alert to signs of abuse. FDA considers food in hermetically sealed containers that are swelled or leaking to be adulterated and actionable under the Federal Food, Drug, and Cosmetic Act. Depending on the circumstances, rusted, and pitted or dented cans may also present a serious potential hazard. 7. During an observation on 12/30/2025 at 3:13 p.m. of the chopping board storage area, observed chopping boards were stored along with red and green buckets with chemical without a physical barrier. During a concurrent observation and interview on 12/31/2025 at 10:53 a.m. of the chopping board storage with the DS, the DS stated the green and red buckets should not be close to the clean chopping board because of cross-contamination. The DS stated the buckets contained sanitizer and water that could spill on the clean chopping board hence they have to move the buckets to another area. During a review of the facility's P&P titled Personal Hygiene dated 8/25/2025, the P&P indicated Cross-contamination: Keep food surfaces sanitized. Food surfaces include cutting boards, tableware, knives, and other utensils used to prepare foods. During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated, 3-307.11 Miscellaneous Sources of Contamination. Food shall be protected from contamination that may result from a factor or source not specified under subparts 3-391 - 3-306. 8. During an observation on 12/30/2025 at 3:32 p.m. of the resident's tray assembled in the racks for dinner use, 50 of 80 residents' trays were observed to have no glaze and were cracked and chipped. During an interview on 12/30/2025 at 4:09 p.m. with the DS, the DS stated the trays are chipped and needed to be replaced. The DS stated the trays must be smooth and free of chips to ensure proper meal presentation for residents. The DS stated the chipped surfaces could harbor bacteria, increasing the risk of infection. During a review of Food Code 2022, dated 1/18/2023 the Food Code 2022 indicated, 4-202.11 Food-Contact Surfaces. (A) Multiuse Food-contact surfaces shall be (1) Smooth (2) Free of breaks, open seams, cracks, chips, inclusions, pits, and similar imperfections. (3) Free of sharp internal angles, corners, and crevices, (4) Finished to have smooth welds and joints.

Based on observation, interview, and record review, the facility failed to dispose garbage and refuse properly by failing to ensure: 1. Two (2) of 2 black dumpsters (a movable waste container designed to be brought and taken away by a special collection vehicle, or to a bin that a specially designed garbage truck lifts) were completely closed while not actively being used. 2. There were no soiled gloves, masks, and a bag of trash on the floor area and surroundings of the facility's dumpster. 3. The dumpster designated for food and organic waste was not leaking fluid on the ground. These failures had potential to attract birds, flies, insects, pests, and possibly spread infection to 82 of 82 facility residents. Findings: During an observation on 12/30/2025 at 4:15 p.m., of the dumpster area with the Dietary Supervisor (DS), observed two (2) black dumpsters that were not completely closed and there was a bag of trash, soiled gloves, plastic, mask, and paper on the floor and the surroundings of the dumpster. During an observation on 12/30/2025 at 4:16 p.m., of the dumpster designated for food with the DS, observed liquid drippings on the base of the dumpster. During an interview on 12/31/2025 at 10:56 a.m., with the DS, the DS stated all the trash must be inside the dumpster and they cannot leave a trash bag on the floor and the dumpster lids should always be closed. The DS stated dumpster surroundings must be cleaned and free of trash for infection control and to avoid animals and pests getting into the trash. The DS stated animals and pests could come inside the facility and contaminate the food residents would receive. The DS stated it was not acceptable that the dumpster lids were open yesterday, that there was trash around the surrounding area, and there was a leak of fluid in the dumpster designated for food because it could attract pests and animals. The DS stated the dietary staff are responsible for keeping the dumpster lid close. During a review of the facility's policy and procedure (P&P) titled, Sanitation and Infection Control-Waste Control and Disposal, dated 8/25/2025, the P&P indicated It is the policy of the facility to use proper procedures for waste control and disposal. Procedures: Keep lids of outside trash dumpster closed. Outside trash compactors require a protective cover to prevent pests, animals or debris from falling in. During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated, 5-501.15 Outside receptacles. (A) Receptacles and waste handling units for REFUSE, recyclables, and returnable used with materials containing FOOD residue and used outside the FOOD ESTABLISHMENT shall be designed and constructed to have tight-fitting lids, doors, or covers. During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated, 5-501.116 Cleaning Receptacles. Proper storage and disposal of garbage and refused are necessary to minimize the development of odors, prevent such waste from becoming an attractant and harborage of breeding place for insects and rodents, and prevent the soiling of food preparation and food service areas. Improperly handled garbage creates nuisance conditions, makes housekeeping difficult, and may be possible source of contamination of food, equipment, and utensils. Outside receptacles must be constructed with tight-fitting lids or covers to prevent the scattering of the garbage or refuse by birds, the breeding of flies, or the entry of rodents. Proper equipment and supplies must be made available to accomplish thorough and proper cleaning of garbage storage areas and receptacles so that unsanitary conditions can be eliminated.

Based on observation, interview, and record review, the facility failed to ensure: 1. An unopened box of expired lancets (tiny, sharp needles used to prick the skin to obtain a small blood sample for blood glucose [sugar] monitoring) found in one of one medication storage room was disposed of on the date of expiration This deficient practice had the potential to cause an infection if the expired lancets were used on a resident. 2. One of three sampled resident's (Resident 21) insulin pen (a device used to administer insulin [a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication]) tip was not cleaned with an alcohol pad prior to attaching the needle. This failure had the potential to increase Resident 21's risk of developing an infection at the site of the injection. Findings: a. During a concurrent observation and interview on [DATE] at 4:15 p.m., with Registered Nurse 1 (RN 1), observed inside the medication storage room, one unopened box of expired ACCU-CHEK Softclix lancets on the shelf with the expiration date of [DATE]. RN 1 stated the lancets needed to be disposed of because they could cause infection if not used before the expiration date. RN 1 then disposed of the unopened box of lancets. During an interview on [DATE] at 4:40 p.m., with the Director of Nursing (DON), the DON stated the expired box of lancets could cause infection because there is no way of verifying if the lancets are still sterile and safe to use. During a review of the facility's insert for ACCU-CHEK Softclix lancets, dated 2024, the insert indicated, Risk of Infection . If the use by date of the lancet has expired, the lancet can be unsterile. Insert only lancets that are within the use by date. During a review of the facility's policy and procedure (P&P) titled, Equipment and Supplies for Administering Medications, dated [DATE], the P&P indicated, The facility maintains equipment and supplies necessary for the preparation and administration of medications to residents. b. During a review of Resident 21's admission Record, the admission Record indicated the facility originally admitted the resident on [DATE] and most recently readmitted the resident on [DATE] with diagnoses including, but not limited to, urinary tract infection (UTI- an infection in the bladder/urinary tract), type two (2) diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and unspecified dementia (a progressive state of decline in mental abilities). During a review of Resident 21's Minimum Data Set (MDS, a resident assessment tool) dated [DATE], the MDS indicated the resident had moderately impaired cognition (trouble with thinking, learning, and remembering clearly). The MDS also indicated Resident 21 required moderate to substantial assistance with most activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 21's care plan (a document summarizing a resident's health conditions, care needs, goals, and treatments) titled, Resident Care Plan: Diabetes Mellitus, dated [DATE], the care plan indicated an intervention to practice infection/universal precautions while administering skin punctures. During a review of Resident 21's Order Summary Report, the Order Summary Report indicated an order to inject nine (9) units of Lantus (a type of insulin that works steadily over 24 hours to help the body absorb glucose) subcutaneous (to be injected under the skin) solution two times a day for diabetes mellitus, dated [DATE]. During a concurrent medication administration observation and interview on [DATE] at 8:07 a.m., with Licensed Vocational Nurse 3 (LVN 3), LVN 3 removed Resident 21's insulin Lantus SoloStar pen (a brand name of an insulin pen) from the medication cart and attached a needle to the tip of the pen. LVN 3 did not scrub the end of the insulin pen with alcohol prior to attaching the needle. LVN 3 stated she cleans the vials of insulin with alcohol prior to using a needle to draw up insulin but did not clean the insulin pen. LVN 3 stated she should have cleaned the insulin pen tip with alcohol prior to attaching the needle. LVN 3 stated without cleaning with alcohol first, germs could get to the patient which could cause an infection. During an interview on [DATE] at 3:04 p.m., with the DON, the DON stated insulin pen tips should be wiped with alcohol before putting on the needle as there is a risk of infection to the resident. During a review of the facility's policy and procedure (P&P) titled, Infection Control – Medical Device Safety, last reviewed [DATE], the P&P indicated it is the policy of the facility that staff implement and comply with infection control policies and procedures for medical device safety, which includes administration of medications. The P&P indicated injectable medications should be prepared using aseptic technique (purposeful prevention of microbe contamination from one person or object to another) in a clean area free from potential sources of infection. During a review of the facility-provided Lantus SoloStar pen manufacturer's instructions, (undated), the manufacturer's instructions indicated to wipe the pen tip (rubber seal) with an alcohol swab before screwing on a new needle.

Based on observation, interview, and record review, the facility failed to maintain sanitary conditions in the food services department when one dead cockroach (a type of insect) was observed in the residents' refrigerator in the staff break room. This failure had the potential to result in 80 of 82 residents, who received food from the kitchen, acquiring food borne illnesses (illness caused by consuming contaminated foods or beverages) by consuming potentially contaminated food. Findings: During a concurrent observation and interview on 12/31/2025 at 11:28 a.m., with the Dietary Supervisor (DS), observed the residents' refrigerator in the staff break room. Observed there was a resident's food stored inside the refrigerator and one (1) dead cockroach inside the vegetable bin. The vegetable bin was difficult to remove because a bench chair and another refrigerator were blocking the refrigerator door from completely opening. The DS stated the brown insect looked like a dead cockroach. During a concurrent observation and interview on 12/31/2025 at 11:31 a.m., with the Housekeeping Supervisor (HKS), observed the resident's refrigerator. The HKS stated she (HSK) cleaned the refrigerator in the morning. The HKS stated there were dead cockroaches in the refrigerator and she cannot even clean it because the door would not completely open. The HKS stated it was not acceptable to have dead cockroaches in the residents' refrigerator because there was a resident's food stored in there. The HKS stated it is important to maintain the residents' refrigerator free of pest for infection control. During an interview on 12/31/2025 at 11:47 a.m., with Licensed Vocational Nurse 4 (LVN 4) and Infection Prevention Nurse (IPN), LVN 4 stated they ensure that everything is sanitary and clean in the residents' refrigerator because it could compromise residents' health. The IPN stated the potential outcome for pests in the refrigerator is infection spread to the residents. During a review of the facility's policy and procedure (P&P) titled, Pest Control, dated 8/25/2025, the P&P indicated, It is the policy of the facility that pest will be managed utilizing a pest management company. During a review of the facility's pest control report titled, Service Report, dated 10/10/2025, the report indicated there was German roach inside the employee break room and was treated. During a review of the facility's pest control report titled, Service Report, dated 12/23/2025, the report indicated high activity of fungus gnats (slender and delicate fly) in the breakroom area, and it was treated. During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated 6.501.111 Controlling Pests. The premises shall be maintained free of insects, rodents and other pests shall be controlled to eliminate their presence on the premises by: - Routinely inspecting incoming shipments of food and supplies. - Routinely inspecting the premises for evidence of pests. - Using methods, if pests are found, such as trapping devices or other means of pest control specified under SS 7-202.12, 7-206.12, and 7-206.13. - Eliminating harborage conditions.

Based on interview and record review, the facility failed to draw a resident's hemoglobin (Hgb, is the iron-rich protein in red blood cells that carries oxygen) and hematocrit, (Hct, is the percentage of the total blood volume made up of red blood cells) as indicated in the physician's order for one (Resident 4) of five residents investigated for unnecessary medications. This had the potential for residents to suffer side effects from having low blood counts such as dizziness and syncope (fainting). Findings: During a review of Resident 4's admission Record (or Facesheet, the front page of the chart that contains a summary of basic information about the resident), the admission Record indicated the resident was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included anemia (a condition where the body does not have enough healthy red blood cells). During a review of Resident 4's Census (the document that indicates when a resident goes and returns from a general acute care hospital [or simply hospital]), the census indicated Resident 4 returned from a GACH on 10/25/2025. During a review of Resident 4' s Minimum Data Set (MDS, a resident assessment tool), dated 11/22/2025, the MDS indicated Resident 4 was severely impaired in cognition (the process of acquiring knowledge and understanding through thought, experience, and the senses) with skills required for daily decision making. The MDS indicated Resident 4 required substantial/maximal assistance (helper does more than half the effort) with eating, oral hygiene, and upper body dressing. During a review of Resident 4's Physician's Orders, the Physician's Orders indicated an order to draw the laboratory values for hemoglobin (Hgb, is the iron-rich protein in red blood cells that carries oxygen) and hematocrit, (Hct, is the percentage of the total blood volume made up of red blood cells) level every two weeks on Fridays, dated 10/27/2025. During a review of Resident 4's Physician's Orders, the Physician's Orders indicated an order for epoetin alfa-EPBX (also known as Retacrit, the brand name, which is given to treat anemia) 4000 units per milliliter (unit/ml, a unit of measure for Retacrit), inject 1 ml subcutaneously (to be given by injection into the fat below the skin) one time a day every Monday for anemia until 12/01/2025, hold dose if Hgb is greater than (>) 11 grams per deciliter (g/dL, a unit of measure for measuring red blood cells, normal reference range is 11.0 - 16.0 g/dL). During a review of Resident 4's Laboratory Values (labs), the laboratory values indicated Resident 4's Hgb and Hct were drawn on the following dates: 10/31/2025, 11/14/2025, 11/28/2025, and 12/05/2025. There was no documentation indicating labs were drawn on 12/12/2025 or 12/26/2025. During a review of Resident 4's Care Plan for Anemia, initiated 10/25/2025, the care plan indicated a goal that the Hgb and Hct level will be within normal (sic) when checked. The care plan indicated an intervention to draw the Hgb and Hct levels every two weeks. During a concurrent interview and record review with the Minimum Data Set Nurse (MDSN) on 12/30/2025 at 3:15 p.m., the MDSN reviewed Resident 4's lab values. The MDSN confirmed that there were no labs for Hgb or Hct drawn on 12/12/2025 or 12/26/2025. The MDSN stated the labs should have been drawn, according to the order. The MDSN stated the licensed nurses should have clarified with Resident 4's physician to find out if those labs still needed to be drawn. The MDSN stated it is important to follow-up with the physician because Resident 4 could be at risk for anemia or any internal bleeding. During an interview with the Assistant Director of Nursing (ADON) on 12/30/2025 at 5:16 p.m., the ADON stated Resident 4's physician should have been contacted to see if the resident still needed the labs to be drawn. During an interview with the Director of Nursing (DON) on 1/02/2026 at 10:30 a.m., the DON stated Resident 4's physician should have been contacted prior to the labs that were to be drawn 12/12/2025 to see if Resident 4 still needed them. The DON stated this was important because a low Hgb/Hct lab value could cause anemia with adverse effects of dizziness, syncope, abnormal vital signs, placing them at risk for hospitalization and in need of blood transfusion. During a review of the facility's policy and procedure (P&P) titled, Physician Services, last reviewed on 8/28/2025, the P&P indicated drugs, biologicals, laboratory services, radiology and other diagnostic services shall be administered or performed only upon the written order of a person duly licensed and authorized to prescribe such drugs and services. The policy and procedure indicated this person is a resident's physician.

Based on observation, interview, and record review the facility failed to ensure residents who were incontinent (lacks voluntary control over urination) of bladder (organ in the pelvis that stores urine) received appropriate treatment and services to prevent urinary tract infections (UTI, common infections that happen when bacteria infect the urinary tract) by failing to ensure the urinary catheter (a thin flexible tube that is inserted into the bladder to help drain urine) collection bag tubing was not looped or coiled to allow the urine to flow freely into the collection bag for one of two residents (Resident 79) reviewed under the urinary catheter care area. This failure had the potential to result in the backflow of urine into the resident's bladders, which can cause urinary tract infections (UTI- an infection in the bladder/urinary tract). Findings: During a review of Resident 79's admission record, the admission record indicated, the facility initially admitted Resident 79 to the facility on 1/2/2023 and readmitted the resident on 11/28/2025 with diagnoses including unstageable (Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by dead skin cells) pressure injuries (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) on his sacral (tail bone area) region and left heel, Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), and diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 79's Minimum Data Set (MDS - a resident assessment tool), dated 12/1/2025, the MDS indicated Resident 79's cognition (the process of acquiring knowledge and understanding through thought, experience, and the senses) was moderately impaired. The Bladder and Bowel section of the MDS indicated Resident 79 was using an indwelling urinary catheter appliance. During a review of Resident 79's Care Plan (CP) dated 11/28/2025, the CP indicated Resident 79 has a Foley [specific brand of indwelling urinary catheter] catheter secondary to the presence of sacrococcyx (tail bone area) pressure injury. The goal of the CP is for Resident 79 to be free from signs and symptoms of UTI and will be free of related complications daily for 90 days. The interventions include to monitor and keep tubing patency and below the level of bladder. During a review of Resident 79's Physician Orders, the Physician Orders indicated an order dated 11/28/2025 for a Foley catheter for wound management. During a concurrent observation and interview on 12/29/2025 at 9:30 AM with Certified Nursing Assistant 1 (CNA 1), in Resident 79's room, Resident 79's urinary catheter tubing was observed to be looped preventing the free flow of urine through the tubing and into the collection bag. CNA 1 stated the tubing should not be looped and not have urine building up inside the tubing because this could cause Resident 79 to have an infection. During a concurrent observation and interview on 12/29/2025 at 9:35 AM with Licensed Vocational Nurse 1 (LVN 1) in Resident 79's room, Resident 79's urinary catheter tubing was observed to be looped preventing the free flow of urine through the tubing and into the collection bag. LVN 1 stated, the tubing should not be looped and have urine in the tubing since it can back up into Resident 79's bladder and cause a UTI. LVN 1 then moved the tubing to allow for the drainage of the urine into the drainage bag. During an interview on 12/29/2025 at 3:40 PM with Registered Nurse 1 (RN 1), RN 1 stated, indwelling urinary catheter tubing should never be looped because it could cause a back up urine into the resident and cause infection. RN 1 also stated, if this was ever to be observed, the tubing should be adjusted to allow for gravity to free flow the urine into the collection bag. During a review of the facility's Foley catheter insert for Medline SelectSilicone Foley Catheter Tray, dated 2019, the insert indicated, Directions for use . Hang drainage bag near the foot of the bed and position the tubing to ensure an unimpeded flow . Periodic observations of this system should be made to ensure urine is flowing freely. If standing column of urine is observed, check for correct positioning of bag and tubing. During a review of the facility's policy and procedure titled, Catheter-Associated Urinary Tract Infections, dated 8/28/2025, indicated, An indwelling catheter is attached to a drainage bag to allow for unrestricted flow of urine.

Based on observation, interview, and record review, the facility failed to maintain an environment free from potential accident hazards for one of three residents (Resident 21) observed during medication administration when Resident 21's medications were left unattended at the resident's bedside. This deficient practice had the potential to result in an unsafe medication administration to Resident 21. Findings: During a review of Resident 21's admission Record, the admission Record indicated the facility originally admitted the resident on 6/9/2022 and most recently readmitted the resident on 3/7/2025 with diagnoses including, but not limited to, urinary tract infection (UTI- an infection in the bladder/urinary tract), type 2 (chronic) diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and unspecified dementia (a progressive state of decline in mental abilities). During a review of Resident 21's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 11/18/2025, the MDS indicated the resident had moderately impaired cognition (trouble with thinking, learning, and remembering clearly). The MDS also indicated Resident 21 required moderate to substantial assistance with most activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 21's Order Summary Report, the Order Summary Report indicated the following medications: Amlodipine (a medication that treats high blood pressure and chest pain) 5 milligram (mg) tablet. Give one tablet every morning for hypertension (high blood pressure), dated 3/2/2023. 2. Buspirone (a medication that treats anxiety) 15 mg tablet. Give one tablet every morning for anxiety manifested by expressing excessive worry about health, dated 4/27/2023. 3. Colace (stool softener) 100 mg capsule. Give one capsule two times a day for bowel management, dated 7/31/2024. 4. D-Mannose (a supplement used for urinary tract health) 500 mg capsule. Give two capsules two times a day to prevent UTIs, dated 3/10/2025. 5. Diclofenac sodium (a topical [applied to the skin] pain medication) 1% external gel. Apply topically to bilateral knees two times a day for pain management. Apply four grams, dated 10/18/2023. 6. Drizalma Sprinkle (a medication used for depression and certain types of pain) 60 mg capsule. Give one capsule two times a day for pain management, dated 4/28/2025. 7. Gabapentin (a medication used to treat seizures and pain) 100 mg capsule. Give two capsules three times a day for neuropathic (affects the nerves) pain, dated 8/1/2023. 8. L-Methylfolate (a vitamin) 7.5 mg tablet. Give one tablet in the mornings for anemia (a condition where the body does not have enough healthy red blood cells), dated 10/18/2023. 9. Lantus (a type of insulin [a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication] that works steadily over 24 hours) Subcutaneous (to be injected under the skin) solution. Inject two times a day for diabetes mellitus, dated 9/18/2025. 10. Losartan (a medication used to treat high blood pressure) 100 mg tablet. Take one tablet daily for hypertension, dated 3/1/2023. 11. Namenda (a medication used to treat moderate to severe dementia) 10 mg tablet. Give one tablet two times a day for dementia, dated 6/28/2023. 12. Plavix (a blood thinner) 75 mg tablet. Give one tablet daily for transient ischemic attack (TIA, a mini stroke) prevention, dated 3/1/2023. 13. Refresh Tears 0.5% ophthalmic (to be used in the eyes) solution. Give one drop to both eyes four times a day for dry eyes, dated 10/17/2024. 14. Vitamin B complex Oral Tablet. Give one tablet daily in the morning for supplement, dated 3/21/2024. During a concurrent observation and interview on 12/30/2025 at 8:07 a.m. with Licensed Vocational Nurse (LVN) 3, LVN 3 prepared the following medications and brought them into the Resident 21's room: amlodipine, buspirone, D-Mannose, diclofenac sodium, Drizalma Spinkle, gabapentin, L-Methylfolate, Lantus insulin pen (a device used to administer insulin), losartan, Namenda, Plavix, Refresh Tears, and vitamin B complex. LVN 3 set the medications on the resident's bedside table then left them unattended and out of eyesight while she went back to the medication cart. LVN 3 stated she went back to the medication cart because she forgot to bring in the resident's Colace capsule. LVN 3 stated she should have taken all the medications with her when she left to get the Colace capsule. LVN 3 stated the medications should not be left unattended with the resident because something could happen like the resident knocking the medications over, the resident could take some of the medication and she would not see it and know exactly what she did take, or someone else could come in and take them. During an interview on 12/31/2025 at 3:04 p.m. with the Director of Nursing (DON), the DON stated Resident 21 is not able to safely self-administer medications. The DON stated the best practice is for a licensed nurse to not leave any medications out of eyesight due to safety issues. During a review of the facility's policy and procedure (P&P) titled, Medication Administration, last reviewed 8/28/2025, the P&P indicated it is the policy of the facility that medications for residents be administered in a safe and timely manner, and as prescribed. During a review of the facility's P&P titled, Safety and Supervision of Residents, last reviewed 8/28/2025, the P&P indicated the facility strives to make the environment as free from accident hazards as possible.

Based on observation, interview and record review, the facility failed to implement its policy and procedure titled Residents Who Present with Communication Barriers, by failing to provide a communication device or board (a tool that includes pictures that help residents communicate their healthcare and every-day needs to facility staff) in their preferred language for one of two sampled residents (Resident 55) reviewed under the communication-sensory care area. This deficient practice had the potential to prevent the resident from communicating with the staff and receiving care in a timely manner. Findings: During a review of Resident 55's admission Record, the admission Record indicated that the facility admitted the resident on 7/18/2025, with diagnoses including muscle weakness and dysphagia (difficulty swallowing). During a review of the Minimum Data Set (MDS - a standardized assessment and care screening tool) dated 10/23/2025, the MDS indicated Resident 55`s preferred language is not English and needed an interpreter to communicate with a doctor or health care staff. The MDS indicated that the resident had severely impaired cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and senses). The MDS indicated Resident 55 required substantial/maximal assistance (the resident performed part of the activity, but staff provided more than half of the effort needed to compete the activity or two or more staff were required to assist) with toileting hygiene, shower, lower body dressing, and putting on and taking off footwear. During a concurrent observation and interview on 12/30/25 at 9:26 a.m. with the Infection Preventionist Nurse (IPN), in Resident 55's room, there was no communication board observed at the resident`s bedside. The IPN stated that the social services department is responsible for assisting residents with communication needs when the resident's primary language is not English. During an interview on 12/30/2025 at 12:45 p.m. with the Social Services Director (SSD), the SSD stated that her department is responsible for assessing the communication needs of residents who are non-English speakers. The SSD stated that it is very important for the residents with a language barrier to be able to communicate their needs using a communication board. The SSD stated that if a resident has no way of communicating their needs it can result in frustration and unmet needs. During a review of Resident 55`s Care Plan (CP, a document that outlines how a patient's health care needs will be met) dated 11/06/2025, the CP indicated a problem of impaired communication secondary to language barrier, with a goal that the resident will communicate effectively despite language barrier with the use of translator, gestures and communication board daily. During a review of the facility`s policy and procedures (P&P) titled, Residents Who Presents With Communication Barriers, last reviewed on 8/28/2025, the P&P indicated that It is the policy of this facility to meet the needs of residents who present with communication barriers.Communication boards will be provided at no charge to the resident so that non-English speakers, or aphasic residents can use pictograms to communicate needs and desires.

Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan (a plan of care that summarizes a resident's health conditions, specific care and services facility staff need to provide a resident to promote healing and prevent a worsening of a condition, and current treatments) for one of three residents (Resident 11) reviewed under the accidents care area by failing to indicate in the care plan titled, Impaired Physical Mobility and Self-Care Deficit, dated 1/08/2025, the required level of assistance needed to safely transfer Resident 56 from the bed to the and from wheelchair back to the bed. This deficient practice had the potential to place Resident 11 at risk for injuries. Findings: During a review of Resident 11's admission Record (AR), the AR indicated that the facility initially admitted the resident on 6/21/2024 and readmitted the resident on 4/28/2025 with diagnoses including muscle weakness and presence of artificial knee joint. During a review of Resident 11's Minimum Data Set (MDS - a resident assessment tool) dated 9/25/2025, the MDS indicated that the resident`s cognitive skills (brain's ability to think, read, learn, remember, reason, express thoughts, and make decisions) for daily decision making was intact (decisions consistent/reasonable). The MDS further indicated that Resident 11 was dependent on assistance of two or more helpers for activities of daily living (ADL-activities related to personal care) and totally dependent on staff for chair/bed-to-chair transfer. During a concurrent interview and record review on 12/30/2025 at 1:55 p.m., with the Minimum Data Set Nurse Assistant (MDSNA), reviewed Resident 11`s Care Plan (CP) titled, Impaired Physical Mobility and Self-Care deficit, dated 1/08/2025. The CP indicated an intervention to assist with ADL as necessary and to provide assistance during transfer in and out of bed, wheelchair, toilet and vice versa (the other way around) using appropriate device as needed. The MDSNA stated the CP did not specify the required number of staff necessary to assist the resident with safe transfers in and out of bed. The MDSNA stated that based on the MDS assessment dated [DATE], the resident required two-person assistance with transfers, however, the CP did not indicate this level of assistance. During an interview on 12/30/2025 at 3:58 p.m., with Certified Nurse Assistant 2 (CNA 2). CNA 2 stated that when transferring a resident from the bed to the chair and vice versa, sometimes it is done with one person assistance but when using a mechanical lift (a full body, electric patient lift capable of lifting from the floor), two people should assist the resident to prevent accidental fall. CNA 2 stated that the level of assistance a resident requires with transfers is indicated in the resident`s care plan. During a review of the facility`s policy and procedures (P&P) titled, Fall Risk & Prevention of Injury to include Pathological Fractures, last reviewed on 8/28/2025, the P&P indicated that It is the policy of the facility to identify residents that are at risk for falls and implement a plan of care in an attempt to prevent falls. During a review of the facility`s policy and procedure (P&P) titled, Comprehensive Care Planning, last reviewed on 8/28/2025, the P&P indicated that It is the policy of this facility that a comprehensive resident-centered care plan be developed for each resident that includes measurable objectives and timeframes to meet each resident`s medical, nursing and mental and psychosocial needs that are identified in the comprehensive assessment.

Based on observation, interview and record review, the facility failed to ensure Licensed Vocational Nurse (LVN 5) knocked on a resident's door and requested permission before entering the room for one of two sampled resident (Resident 114) reviewed under the dignity care area. This deficient practice violated the resident`s rights to be treated with respect and dignity, which had the potential to affect the resident's sense of self-worth and self-esteem. Findings: During a review of Resident 114's admission Record, the admission Record indicated the facility admitted the resident on 12/17/2025 with diagnoses including muscle weakness and type 2 diabetes mellitus (a group of diseases that result in too much sugar in the blood). During a review of Resident 114's Minimum Data Set (MDS-a standardized assessment and care screening tool) dated 12/23/2025, the MDS indicated the resident`s cognitive (the mental action or process of acquiring knowledge and understanding through thought, experience, and sense) skills for daily decision making were intact. The MDS indicated that Resident 114 required assistance in performing activities of daily (activities that are fundamental to survival and well-being and include things like eating, bathing, dressing, and toileting). During a concurrent observation and interview on 12/29/2025 9:51 a.m., observed LVN 5 wheel the medication cart outside of Resident 114`s room. LVN 5 then went inside the resident's room without knocking and asking permission from the resident. LVN 5 then stepped out of the resident room, placed a blood pressure machine on top of the medication cart and went back to the resident's room without knocking and asking permission from the resident. LVN 5 then came out of the room and started to pour medications on a medicine cup and went back to the resident room (3rd time) with the medications without knocking and asking permission from the resident. LVN 5 was asked if it was appropriate to go in the resident's room without knocking and asking permission from the resident, LVN 5 stated that he should have knocked, introduced himself and asked permission from the resident before entering the room. LVN 5 stated knocking before entering the room helps prevent the resident from being startled and shows respect for their personal space. During a review of the facility`s policy and procedure (P&P), titled, Resident`s Right to Dignity and Privacy, last reviewed on 8/28/2025, the P&P indicated, It is the policy of the facility that each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality and provides for resident privacy.residents private space and property shall be respected at all times; staff will knock and request permission before entering a resident`s room.

Based on interview and record review, the facility failed to protect the resident's right to be free from physical abuse (deliberately aggressive or violent behavior with the intention to cause harm) for one of four sampled residents (Resident 1) when on 1/8/2025, Resident 2 punched Resident 1 in the face several times with a fist (a person's hand when the fingers are bent in toward the palm and held there tightly). This deficient practice resulted in Resident 1 being subjected to physical abuse by Resident 2 while under the care of the facility. Resident 1 sustained a left periorbital (around the eye) discoloration (change in the color, texture or pigmentation of the skin), abrasion (when the surface layers of the skin have been broken) on the left eyebrow, skin tear (a wound that happens when the layers of skin separate or peel back) on the left forearm (part of the arm between the elbow and the wrist) and skin tear on left dorsal (back portion) hand that needed first aid (initial assistance and care given to a resident who has been injured) and daily wound treatments. Findings: During a review of Resident 1's Admission Record, the Admission Record indicated the facility admitted the resident on 12/5/2024, with diagnoses that included cauda equina syndrome (a rare but serious condition that occurs when the bundle of nerves at the end of the spinal cord becomes damaged), osteomyelitis (bone infection) of the left ankle and foot, cellulitis (a deep infection of the skin caused by bacteria) of the left lower limb (leg). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 12/11/2024, the MDS indicated Resident 1 had intact cognition (ability to think and make decisions). During a review of Resident 1's Initial Psychiatric (relating to the medical specialty of psychiatry [branch of medicine focused on the diagnosis, treatment and prevention of mental, emotional and behavioral disorders]) Evaluation dated 1/8/2025, the Initial Psychiatric Evaluation indicated Resident 1 stated that on the morning of 1/8/2025 at around 9:00 a.m. to 9:30 a.m., he (Resident 1) was trying to sleep when his roommate (Resident 2) hit him (Resident 1) in the face with a fist. During a review of Resident 1's Situation-Background-Assessment-Recommendation (SBAR- a form that provides a framework for communication between members of the health care team about a resident's condition) Communication Form dated 1/8/2025, the SBAR Communication Form indicated on 1/8/2025, Resident 1 was involved in a physical altercation (a confrontation that involves physical force or contact between two or more people) with another resident (Resident 2). The SBAR Communication Form further indicated that as a result of the physical altercation, Resident 1 sustained left periorbital discoloration, left eyebrow abrasion, left forearm skin tear, and left dorsal hand skin tear. During a review of Resident 1's document titled, Nursing Notes for additional information on the Change of Condition (COC- when there is a sudden change in a resident's condition), dated 1/8/2025, the Nursing Notes indicated that on 1/8/2025, Resident 1 told staff that while he (Resident 1) was trying to sleep, his roommate (Resident 2) struck (hit forcibly) him (Resident 1) out of nowhere and he (Resident 1) used his left arm to block the next strikes. The Nursing Notes further indicated a complete body assessment was done and observed Resident 1 with left eyebrow abrasion 0.8 centimeter (cm- unit of measurement) in length by 0.7 cm in width and 0.1 cm in depth (0.8 cm x 0.7 cm x 0.1 cm), left forearm skin tear 0.8 cm in length by 0.5 cm in width (0.8 cm x 0.5 cm), left dorsal hand skin tear 0.5 cm in length by 0.2 cm in width and 0.1 cm in depth (0.5 cm x 0.2 cm x 0.1 cm), and periorbital discoloration. The Nursing Notes also indicated initial treatment (first aid) was rendered by the nurse (Director of Nursing [DON]) on Resident 1's left eyebrow abrasion and left forearm and dorsal hand skin tears and an ice pack was applied to Resident 1's left eyebrow. During a review of Resident 1's Skin & Body assessment dated [DATE], the Skin & Body Assessment indicated on 1/8/2025, the assessment was done due to a physical altercation with another resident (Resident 2) and the following injuries were noted: 1. Left eyebrow skin abrasion measuring 0.8 cm x 0.7 cm x 0.1 cm 2. Left forearm skin tear measuring 0.8 cm x 0.5 cm 3. Left dorsal hand skin tear measuring 0.5 cm x 0.2 cm x 0.1 cm During a review of Resident 1's Order Summary Report, the Order Summary Report indicated there were physician's orders dated 1/8/2025 for the treatment of Resident 1's left eyebrow skin abrasion as follows: 1. Cleanse with normal saline (NS - a liquid solution used to cleanse wounds), pat dry, then, apply steri-strips (thin, sticky bandages applied to the skin to help small cuts or wounds stay closed as they heal) daily, every day shift for seven (7) days. 2. Cleanse with NS, pat dry, then apply xeroform gauze (a medical dressing made of gauze [thin, woven cloth] and petrolatum [skin protectant and moisturizing agent commonly known as petroleum jelly] that is used to treat wounds) and cover with dry dressing (a wound dressing that absorbs moisture from a wound, leaving the area dry) daily, every day shift for seven (7) days. During a review of Resident 1's Order Summary Report, the Order Summary Report indicated there were physician's orders dated 1/8/2025 for the treatment of Resident 1's left forearm skin tear as follows: 1. Cleanse with NS, pat dry, then apply steri-strips daily, every day shift for seven (7) days. 2. Cleanse with NS, pat dry, then apply xeroform gauze and cover with dry dressing daily, every day shift for seven (7) days. During a review of Resident 1's Order Summary Report, the Order Summary Report indicated there were physician's orders dated 1/8/2025 for the treatment of Resident 1's left dorsal hand skin tear as follows: 1. Cleanse with NS, pat dry, then apply steri-strips daily, every day shift for seven (7) days. 2. Cleanse with NS, pat dry, then apply xeroform gauze and cover with dry dressing daily, every day shift for seven (7) days. During a review of Resident 2's Admission Record, the Admission Record indicated the facility admitted the resident on 12/12/2024, with diagnoses that included chronic obstructive pulmonary disease (COPD - a lung disease that causes blocked airflow from the lungs, making it hard to breathe), unspecified dementia (group of symptoms affecting memory, thinking and social abilities severely enough to interfere with daily life), opioid (a class of drugs that can be used to treat pain, but can also be addictive) dependence, and nicotine (an addictive, poisonous chemical found in tobacco) dependence. During a review of Resident 2's MDS dated [DATE], the MDS indicated Resident 2 had severely impaired cognition. During a review of Resident 2's Initial Psychiatric Evaluation dated 1/8/2025, the Initial Psychiatric Evaluation indicated Resident 2 stated that he (Resident 2) had been hearing voices and that on the morning on 1/8/2025, the voice told him (Resident 2) to punch his roommate (Resident 1). The Initial Psychiatric Evaluation further indicated that Resident 2 was agitated (a medical condition that causes a person to feel extremely tense and irritable) and restless (unable to remain still) at times during the evaluation, had impaired insight and judgment, and was having auditory hallucinations (hearing sounds or voices that do not exist in reality). During a review of Resident 2's SBAR Communication Form dated 1/8/2025, the SBAR Communication Form indicated Resident 2 was physically aggressive towards his roommate (Resident 1), hit his roommate (Resident 1) without apparent reason, and was a danger to himself or others. During a review of the facility's undated Final Investigative Report, the Final Investigative Report indicated that on 1/8/2025 Resident 1 was in bed when Resident 2 struck him (Resident 1). The Final Investigative Report further indicated that it was confirmed that Resident 2 physically hit Resident 1. During an interview on 1/21/2025 at 11:30 a.m., with Certified Nursing Assistant 1 (CNA 1), CNA 1 stated on 1/8/2025 he (CNA 1) went to answer the call light in Room A (Resident 1 and Resident 2's room) and upon entering the room, he (CNA 1) found Resident 1 lying in bed and rubbing his (Resident 1) left eye. CNA 1 stated Resident 1 told him (CNA 1) that his roommate (Resident 2) hit him (Resident 1). During an interview on 1/21/2025 at 11:49 a.m., with the Case Manager (CM), the CM stated that on 1/8/2025, he (CM 1) was alerted by CNA 1 that assistance was needed in Room A because there was a resident-to-resident altercation. The CM stated he (CM) assisted in assessing Resident 1 who had told staff that Resident 2 had hit him (Resident 1) while he was sleeping in bed. The CM stated upon assessment of Resident 1, there were skin tears on the left dorsal hand and left forearm, discoloration around the left eye, and an abrasion to the left eyebrow. The CM stated the areas of open skin were not actively bleeding, but the treatment nurse (Licensed Vocational Nurse 1 [LVN 1]) did provide immediate treatment to Resident 1's injuries. During an interview on 1/21/2025 at 12:30 p.m., with LVN 1, LVN 1 stated he (LVN 1) did not perform the actual treatment (cleanse left eyebrow abrasion and left forearm and left dorsal hand skin tears with NS and place steri-strips on left eyebrow, left forearm, and left dorsal hand) on Resident 1 as he only assisted the DON with measuring and providing treatment to Resident 1's injuries caused by Resident 2. During an interview on 1/21/2025 at 12:37 p.m., with the DON, the DON stated that on the morning of 1/8/2025, CNA 1 answered Resident 1's call light and after hearing about the altercation, CNA 1 immediately separated Resident 1 and Resident 2 and called the CM for assistance. The DON stated she (DON) was also made aware of the incident and immediately went to Resident 1 to assess him and provide treatment to his (Resident 1) injuries with the assistance of LVN 1. The DON stated that Resident 1 was interviewed and told staff that he (Resident 1) was in bed sleeping when Resident 2 hit him (Resident 1) in the face with his fist. The DON stated Resident 1 further explained to staff that he (Resident 1) used his left arm to cover his face from the other punches from Resident 2. The DON stated that as a result of the altercation, Resident 1 sustained an abrasion on his left eyebrow and skin tears on his left hand and forearm. The DON stated she (DON) measured and provided treatment to Resident 1's abrasion and skin tears. The DON stated she (DON) cleaned Resident 1's left eyebrow abrasion and left forearm and left dorsal hand skin tears with NS and placed steri-strips on Resident 1's left eyebrow, left forearm, and left dorsal hand. During an interview on 1/21/2025 at 12:55 p.m., with the Social Services Director (SSD), the SSD stated on the morning of 1/8/2025, she (SSD) interviewed Resident 1 after the altercation and Resident 1 told her (SSD) that he was sleeping in bed when Resident 2 charged at him, hitting him in the left eye and left arm. The SSD stated on 1/8/2025, she (SSD) also interviewed Resident 2 after the altercation and Resident 2 admitted to hitting Resident 1, but when asked why he (Resident 2) did it, he did not respond. During an interview on 1/21/2025 at 3:10 p.m., with the Assistant Administrator (AADM), the AADM stated that he (AADM) was aware of the resident-to-resident altercation between Resident 1 and Resident 2. The AADM stated he (AADM) was involved in the investigation process. The AADM stated that Resident 2 punching Resident 1 in the face several times with a fist is a physical abuse. During a review of the facility's policy and procedure titled, Abuse Reporting and Prevention, last revised 4/2024, the policy indicated it is the policy of the facility to ensure that residents rights are protected by providing a method of investigation and reporting of alleged violations involving mistreatment, neglect (fail to care for properly), abuse including injuries of unknown sources, unusual occurrences, unauthorized photographs, unauthorized video recordings, unauthorized postings on social media of nursing home residents and misappropriation (intentional, illegal use of the property or funds of a resident for one's own use or other unauthorized purpose) of resident property. The policy and procedure further indicated that the facility is expected to take any necessary action to prevent resident to resident altercations to every extent possible and should be reviewed as a potential situation of abuse. If, during the investigation it is determined that the resident's actions were willful and deliberate, then abuse has occurred.

Based on interview and record review, the facility failed to ensure that the primary care physician (Primary Medical Doctor 1 [PMD 1]) for one of four sampled residents (Resident 1), who had a history of hypothyroidism (a condition where the thyroid gland doesn't release enough thyroid hormone [plays a role in regulating weight, energy levels, growth and metabolism] into the bloodstream), reviewed Resident 1's General Acute Care Hospital 1 (GACH 1) progress notes, including medications essential to Resident 1's medical treatment. PMD 1 failed to prescribed Resident 1 her (Resident 1) routine medication (medication taken regularly) of Levothyroxine (a medication used to treat an underactive thyroid gland [a gland that makes and stores hormones that help regulate the heart rate, blood pressure, body temperature, growth development and energy) upon admission to the facility on [DATE]. This deficient practice resulted in Resident 1 not receiving 30 doses of Levothyroxine from 5/26/2024 to 6/25/2024. Subsequently, Resident 1 was transferred to General Acute Care Hospital 2 (GACH 2) where Resident 1 was diagnosed with myxedema coma (severe hypothyroidism leading to decreased mental status [mental capacity], hypothermia [dangerously low body temperature], and other symptoms related to slowing of function in multiple organs) requiring Resident 1 to be admitted into the Intensive Care Unit (ICU- a unit in a hospital providing intensive care for critically ill patients) on 6/25/2024. Findings: During a review of Resident 1's Admission Record indicated that Resident 1 was admitted to the facility on [DATE] with diagnoses that included hypothyroidism. During a review of Resident 1's History and Physical (H&P) from GACH 1, completed by PMD 1, dated 5/23/2024, the H&P indicated that Resident 1 was admitted to GACH 1 on 5/23/2024. Listed under Resident 1's medical history was a diagnosis of hypothyroidism. The H&P further indicated that Resident 1's routine home medications included Levothyroxine 100 micrograms (mcg-unit of measure), one tablet to be taken by mouth once a day. During a review of Resident 1's H&P completed by PMD 1 (same physician in charge of Resident 1's care while in the facility), dated 5/26/2024, the H&P indicated that Resident 1 did not have the capacity to understand and make decisions. The H&P further indicated that Resident 1's medical history included a diagnosis of hypothyroidism. During a review of Resident 1's Minimum Data Set (MDS - a comprehensive assessment and screening tool) dated 6/1/2024, the MDS indicated that Resident 1's cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) was intact. The MDS further indicated that Resident 1 required set up assistance with eating; supervision with oral hygiene; moderate assistance with personal hygiene; and maximum assistance with toileting hygiene and bathing. During a review of Resident 1's Physician Orders from 5/26/2024 to 6/25/2024, the Physician Orders for Resident 1 did not indicate an order for Levothyroxine. During a review of Resident 1's Change of Condition (COC- a sudden deviation from a resident's health status) dated 6/25/2024, the COC indicated that on 6/25/2024 at 9:52 a.m., Resident 1 passed out in the shower room. The COC further indicated at 9:54 a.m., Resident 1 regained consciousness (the state of being awake and aware of one's surrounding) and was verbally responsive. On 6/25/2024 at 10:07 a.m., 911 (telephone number to reach emergency services) was called, and on 6/25/2024 at 10:22 a.m., paramedics (a person trained to give emergency medical care to people who are injured or ill, typically in a setting outside of a hospital) arrived at the facility, took over Resident 1's care and transferred Resident 1 to GACH 2. During a review of Resident 1's Discharge Summary (DS) from GACH 2, dated 7/5/2024, the DS indicated that Resident 1 was admitted to GACH 2 on 6/25/2024 with diagnoses that included myxedema coma. The DS indicated that Resident 1 had a history of thyroidectomy (surgical removal of all or part of the thyroid gland) and was previously prescribed Levothyroxine, but Levothyroxine was not continued for the past several months. The DS indicated that Resident 1 had severely elevated thyroid stimulating hormone (TSH- a blood test that measures thyroid stimulating hormone [normal TSH level is 0.5 to 5.0 milli-internal units per liter {mIU/L- unit of measure}]) and low thyroxine test (T4- a blood test that measures the level of thyroxine in the blood [normal T4 level is 0.8 to 1.9 nanograms per deciliter {ng/dL-unit of measure}]) dated 6/26/2024. Resident 1 was found to have profound (to the greatest possible degree) hypothyroidism and myxedema coma with an initial TSH level drawn on 6/26/2024, TSH level greater than 150 mIU/L. Resident 1 was initiated on Levothyroxine intravenous (into the vein). The DS also indicated that Resident 1's thyroid function was noted to be severely affected. During an interview on 7/24/2024 at 11:48 a.m. with PMD 1, PMD 1 stated that he (PMD 1) was the primary care physician for Resident 1 during Resident 1's stays at GACH 1 and at the facility. PMD 1 stated that Resident 1 had a history of hypothyroidism. When PMD 1 was asked if PMD 1 reviewed Resident 1's routine home medications that indicated that Resident 1 was taking Levothyroxine, PMD 1 stated that he (PMD 1) did not review Resident 1's routine home medications list. PMD 1 stated that had if he (PMD 1) reviewed Resident 1's routine home medications list, PMD 1 would have noted that Resident 1 was prescribed Levothyroxine and PMD 1 would have continued Resident 1's previously prescribed Levothyroxine. PMD 1 further stated it's a big problem Resident 1 ended up with myxedema coma as a result of the lack of Levothyroxine, an essential medication needed for Resident 1's diagnosis of hypothyroidism. During an interview and concurrent record review on 7/24/2024 at 12:10 p.m. with the Director of Nursing (DON), the DON reviewed Resident 1's H&P from GACH 1, completed by PMD 1, dated 5/23/2024 and Resident 1's H&P at the facility, completed by PMD 1, dated 5/26/2024, and Resident 1's Physician Orders from 5/26/2024 to 6/25/2024. The DON verified the Physician Orders for Resident 1 did not indicate an order for Levothyroxine. The DON stated PMD 1 did not prescribe Resident 1 Levothyroxine throughout Resident 1's stay at the facility. The DON stated PMD 1 should have reviewed Resident 1's total program of care including the list of medications and treatments upon admission to GACH 1 and upon admission to the facility vital to Resident 1's health and well-being. During a review of the facility policy and procedure (P&P), titled Physician Services and Orders dated January 2017, last reviewed on 8/17/2023, the P&P indicated that it is the policy of the facility that each resident remain under the care of a physician. Drugs, biologicals, laboratory services, radiology and other diagnostic services shall be administered or performed only upon the written order of a person duly licensed and authorized to prescribe such drugs and services .The physician must review the resident's total care at each visit, write, sign and date progress notes and sign and date all orders. This includes reviewing medications and treatments.

Based on observation, interview, and record review, the facility failed to protect resident ' s right to be free from physical abuse (deliberately aggressive or violent behavior with the intention to cause harm) by: 1. Resident 1 for one of two sampled residents (Resident 2). On 4/28/2023, Resident 1 threw a water pitcher (container) which hit Resident 2 ' s head. 2. Resident 2 for one of two sampled residents (Resident 1). On 4/28/2023, Resident 2 threw his cane which hit Resident 1 ' s head. These deficient practices resulted in Resident 1 having to go to the General Acute Care Hospital (GACH) to receive sutures (a stitch or a row of stitches holding together the edges of a wound) for a laceration (a deep cut or tear in the skin) caused by Resident 2 hitting him with his cane; and Resident 2 sustaining a mid-forehead and left eyebrow skin tear (a wound that happens when the layers of skin separate) caused by Resident 1 hitting him with a water pitcher. Findings: A review of Resident 1 ' s Admission Record indicated the facility admitted the resident on 4/17/2023 with diagnoses including syncope (fainting or passing out) and collapse, history of falling, and fracture (a broken bone) of nasal bones (bones located in the nose). A review of Resident 1 ' s Long-Term Care (LTC) Skilled Initial History and Physical (H&P-the starting point of the resident ' s ' story ' as to why they sought medical attention or are now receiving medical attention), dated 4/18/2023, indicated that Resident 1 did not have the capacity to understand and make decisions. A review of Resident 1 ' s Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 4/24/2023, indicated that Resident 1 had the ability to make himself understood and to understand others. The MDS indicated that Resident 1 had moderately impaired cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) and required limited one-person assistance from staff for bed mobility, transfers, walking in the room and corridor, locomotion on and off the unit, and eating. A review of Resident 1 ' s Situation-Background-Assessment-Recommendation (SBAR) Communication Form (a tool used to facilitate prompt communication regarding a change in a resident ' s health condition), dated 4/28/2023, indicated that Resident 1 was involved in a resident-to-resident physical altercation on 4/28/2023. The SBAR indicated that on 4/28/2023 at approximately 12:00 p.m., the case manager witnessed Resident 1 throw his cane at Resident 2 after Resident 2 had thrown a pitcher at Resident 1 ' s head. The SBAR indicated that Resident 1 was then noted with a laceration to his left eyebrow as a result of being hit with Resident 2 ' s cane. A review of Resident 1 ' s Physician ' s Orders, dated 4/28/2023, indicated to transfer Resident 1 to the GACH for a left eyebrow laceration needing sutures. A review of Resident 1 ' s GACH Summary (a document given to a resident after a medical appointment intended to summarize the resident ' s health), dated 4/28/2023, indicated the Resident 1 was seen at the GACH for a head injury and left eyebrow laceration, which was repaired with sutures. A review of Resident 1 ' s Skin and Body Assessment, dated 4/28/2023 at 8:00 p.m., indicated this was an assessment done upon the resident ' s return from the hospital. The resident was noted to have a left eyebrow laceration with sutures. A review of Resident 2 ' s Admission Record indicated the facility admitted the resident on 4/1/2023 with diagnoses including metabolic encephalopathy (a disorder that causes brain dysfunction) and dementia (a condition characterized by progressive or persistent loss of intellectual functioning). A review of Resident 2 ' s History and Physical Examination form, dated 4/3/2023, indicated the resident can make his needs known but cannot make medical decisions. A review of Resident 2 ' s MDS, dated [DATE], indicated the resident had the ability to make himself understand and to understand others. The MDS also indicated that Resident 2 had severely impaired cognition and required extensive one-person assistance from staff for bed mobility, transfers, dressing, eating, toilet use, and personal hygiene. A review of Resident 2 ' s SBAR Communication Form, dated 4/28/2023, indicated that after Resident 1 threw his cane at Resident 2, Resident 2 sustained a mid-forehead and left eyebrow skin tear. A review of Resident 2 ' s Skin and Body Assessment, dated 4/28/2023, indicated the resident sustained a skin tear to the mid-forehead and left eyebrow. On 5/1/2023 at 3:05 p.m., during a concurrent observation and interview, Resident 1 was sitting on a chair at his bedside reading a book. Resident 1 had dark red laceration with sutures on the left eyebrow. When Resident 1 was asked if he was able to recall the incident with Resident 2 on 4/28/2023, Resident 1 stated no. Resident 1 then stated that he did not want to answer any further questions. On 5/1/2023 at 3:34 p.m., during an interview, Case Manager 1 (CM 1) stated that on 4/28/2023 at around 12:00 p.m., he was passing by the nurses ' station when he heard yelling coming from Resident 1 and Resident 2 ' s room. CM 1 stated that he saw Resident 2 throw a water pitcher at Resident 1. CM 1 stated that, in response to being hit in the head with a water pitcher, Resident 1 threw his cane at Resident 2 ' s head. CM 1 stated he immediately grabbed Resident 1 to separate the two residents. On 5/1/2023 at 4:44 p.m., during an interview, the Administrator (ADM) stated that he was the facility ' s abuse coordinator. ADM stated that the incident on 4/28/2023 between Resident 1 and Resident 2 could be considered abuse since both residents threw things (cane and water pitcher) at each other. When ADM was asked if the incident on 4/28/2023 between Resident 1 and Resident 2 where both residents were throwing objects at each other would be physical abuse even though no fists were involved, the ADM stated, Yes, they abused each other. It ' s resident-to-resident abuse. When asked if he considered both residents ' actions to be deliberate, ADM stated, Was it deliberate that they threw things at each other? Yes, it was. I would say that was deliberate. A review of the facility ' s policy and procedure titled, Abuse Reporting and Prevention, last reviewed on 1/2023, indicated that a resident-to-resident altercation should be reviewed as a potential situation of abuse. The policy further stated that if the resident ' s actions were willful or deliberate then abuse has occurred. The policy indicated that Abuse means the willful infliction of injury. The policy indicated that physical abuse is a willful physical action that is meant to inflict physical harm, pain, or mental anguish.

Based on observation, interview, and record review, the facility failed to implement infection control measures to prevent and control the spread of Coronavirus Disease 2019 (COVID-19, highly contagious [CONDITION(S)] infection that affects the respiratory system and transmit from person to person) in accordance with the facility's infection control policies, the facility's Mitigation Plan (MP, a plan to reduce loss of life and impact of COVID-19 in the facility) policy, and state and national standards for the residents in Rooms 16, 19, 21, 23, 26, 28, 30, 32, 34, 36, 38, 40 and 42 and the total census of 54 residents residing in the facility, staff, and visitors. The facility failed to: 1. Ensure there was air circulation in the residents' rooms located in Red Zone cohort (is an infection prevention and control strategy that includes physical and procedural controls to separate infectious residents and decrease risk of transmission to uninfected residents) designated area for residents with laboratory-confirmed COVID-19), Rooms 26, 28, 30, 32, 34, 36, 38, 40 and 42, and in rooms [ROOM NUMBER] located in the Yellow Zone cohort (mixed quarantine [period or place of isolation in which people that have arrived from elsewhere or been exposed to infectious or contagious disease are placed], COVID-19 symptomatic residents and Persons Under Investigation [PUI] for 14 days since admission to rule out COVID-19). 2. Ensure laundry staff reported to the supervisor a non-functioning ceiling fan equipment in the laundry area, as per facility's policy. 3. Ensure the Director of Nursing (DON), Laundry Staff 2 (LS 2), and Physician 1 (MD 1) used face shield or goggles while in the facility; DON performed hand hygiene before donning (putting on) a face shield; and LS 2 disinfected a reused face shield per facility's Mitigation Plan (MP) policy and CDC (Centers for Disease Control) and CDPH (California Department of Public Health) recommendations. 4. Ensure Housekeeping Staff 1 (HSK 1), Maintenance Assistant (MA), Dietary Aide 1 (DA 1), LS 2, and Certified Nursing Assistants 1 and 4 (CNAs 1 and 4) wore N95 while in the laundry, kitchen and Red Zone areas and the N95 mask was tightly sealed around the nose and mouth; MA avoided touching the outer side of the mask and if touched, perform hand hygiene, per facility's MP policy and CDC recommendation. 5. Ensure CNA 1 washed hands after removing gloves upon finishing Resident 3's bed bath per facility's hand washing policy. 6. Ensure DA 2, Housekeeping Supervisor (HSKS), CNA 1, and LS 1, and were knowledgeable of the contact time (also known as the wet time, is the time that the disinfectant needs to stay wet on a surface in order to ensure efficacy) of the products used for effective disinfection. 7. Ensure a bottle of water and a cellphone were not stored in the laundry with the clean linen. 8. Ensure LS 1, who had an open wound in a finger, wore gloves to handle clean linen. 9. Ensure HSKP 1 and 3, cleaned/disinfected all the high touched areas (handrails and potable cart/chest of drawer storing PPEs) in the Yellow Zone hallway during routine cleaning. Ensure HSK 3 did not use in cleaning a cart with a cleaning cloth that had dropped to the floor. 10. Ensure CNA 2 discarded the isolation gown and gloves before exiting room [ROOM NUMBER] located in the Yellow Zone, as per facility's policy on Infection Control and per CDC's recommendation. 11. Ensure RN 3 used Food and Drug Administration (FDA) - approved disinfectant to disinfect a blood pressure cuff after use 12. Ensure all visitors were screened, prior to entering the facility, for signs and symptoms of COVID-19 (such as, sore throat, fever, cough, loss of taste). These deficient practices had the potential to result in the spread of COVID-19 placing all 54 residents in the facility, staff, and visitors, at risk to be infected with COVID-19 and becoming seriously ill, leading to hospitalization and/or death. On 11/20/2020 at 12:33 p.m., an Immediate Jeopardy (IJ, a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) situation was identified under the Code of Federal Regulations (CFR) 483.80 (F-880) Infection Control, and the facility's administrator (ADM) and DON were informed of the above listed concerns. On 11/21/2020 at 3:02 p.m., the ADM provided an acceptable Plan of Action (POA) during a conference meeting that included the following summarized actions: 1. The facility Maintenance Supervisor (MS) removed all vent covers in the Red Zone and portions of the Yellow Zone area on 11/20/20. 2. The Infection Preventionist (IP) Nurse and Designee provided one-on-one training and skills demonstration to HS 1, MA, and CNAs 1 and 2) on proper donning and doffing of Personal Protective Equipment (PPE - protective clothing, goggles, head/shoe covers, mask, gown, gloves or other garments or equipment designed to protect the wearer's body from infection) on 11/20/20 and 11/21/20. 3. Maintenance Supervisor installed a new motor on the exhaust vent and ensure that the laundry exhaust vent is functioning properly on 11/19/20 and 11/20/20. On 11/24/20 at 2:45 p.m., after verifying satisfactory implementation of the facility's immediate corrective actions within the POA, the IJ situation was lifted in a conference meeting with the ADM and DON. Findings: 1. On 11/19/2020 at 2:53 p.m., during an observation of the exterior of the facility (on an alley alongside the laundry room) with Maintenance Supervisor (MS), there were closed windows except for one window. MS stated the closed windows were residents' room and the open window was for the employee break room. A review of the facility's Floor Plan dated 11/19/2020, indicated Rooms 26, 28, 30, 32, 34, 36, 38, 40 and 42 were located next to the alley (with the observed closed windows) and were in the Red Zone. On 11/19/2020 at 4:20 p.m., during an interview, MS stated both intake and exhaust vents and the windows were all closed off in the Red Zone rooms to prevent the spread of the virus to the rest of the facility as instructed by the ADM. MS stated he did not know how the air was circulating inside the Red Zone rooms. MS acknowledged the air in the Red Zone was stagnant due to poor air circulation., with the vents closed and windows closed, MS answered, yes. MS stated that Resident 2 in room [ROOM NUMBER] in the Yellow Zone used to be a patient isolation room and that they forgot to remove the tape cover. MS added that rooms [ROOM NUMBER], in the Yellow Zone are sharing exhaust and intake through the same air conditioning unit. During an observation on 11/19/2020, at 4:44 p.m , in the presence of MS, the vents in room [ROOM NUMBER] were taped off. During an interview on 11/19/2020, at 4:52 p.m., ADM stated he did not receive recommendation from any agency regarding shutting off both intake and exhaust vents. The residents' rooms had shared vents as they are connected to each other. ADM also stated he was concerned the virus would spread to the rest of the facility. ADM stated they did not have a diagram of the facility's Heating Ventilation and Air Conditioning (HVAC) system. During the facility tour of the Red Zone on 11/19/2020, at 5:40 p.m., in the presence of MS, Rooms 26, 34 and 33 were observed to have both vents covered. During an interview on 11/19/2020, at 6 p.m., ADM stated they would be opening the windows for one hour per shift in the Red Zone but would not remove the covers of the vents until he got more information. During an interview on 11/20/2020, at 11:45 a.m., ADM stated the COVID-19 outbreak started on 11/3/2020 with the first and second COVID-19 positive resident moving into rooms [ROOM NUMBERS] and the HVAC units had been off since. During an interview on 11/20/2020, at 11:45 a.m., the MS stated that four of 10 HVAC units had been turned off. During an interview on 11/20/2020, at 1:18 p.m., IP 1 stated the facility's decision of closing the vents was not discussed with her. IP 1 stated she heard talks about having her office vent covered but the office did not have windows and she decided not to have the vent covered because there would not be air circulation. During an interview on 11/23/2020, at 4:13 p.m., the MS stated they do not have a diagram showing how the air flows in the vents. A review of the United States Environmental Protection Agency's (EPA) document titled, Ventilation and Coronavirus (COVID-19) indicated An important approach to lowering the concentrations of indoor air pollutants or contaminants including any viruses that may be in the air is to increase ventilation - the amount of outdoor air coming indoors. It also indicated that Professionals who operate school, office, and commercial buildings should consult guidance by American Society of Heating, Refrigerating and Air-Conditioning Engineers (ASHRAE), and other professional and government organizations for information on ventilation and air filtration to help reduce risks from the virus that causes COVID-19. A review of ASHRAE's document titled, Coronavirus (COVID-19) Response Resources from ASHRAE and Others an approved statement from ASHRAE leadership regarding transmission of [CONDITION(S)]-CoV-2 and the operation of HVAC systems during the COVID-19 pandemic indicated ventilation and filtration provided by heating, ventilating, and air-conditioning systems can reduce the airborne concentration of [CONDITION(S)]-CoV-2 and thus the risk of transmission through the air. Unconditioned spaces can cause thermal stress to people that may be directly life threatening and that may also lower resistance to infection. In general, disabling of heating, ventilating, and air-conditioning systems is not a recommended measure to reduce the transmission of the virus. 2. During a concurrent observation and interview with MS on 11/19/2020, at 1:05 p.m., MS stated there was only one vent in the laundry area, and that was an exhaust vent. There was a ceiling fan equipment of the soiled linen area that was not turned on. MS stated the ventilation equipment was not working. During an interview on 11/19/2020, at 1:30 p.m., MS stated he was in-charge of checking the vents and the last time the vent in the laundry area was checked was about a month and a half ago and it was working then. Laundry staff did not report to him the ceiling fan was not working. MS explained there was no written policy or log for inspecting the vents. A review of the facility's policy titled, Laundry & Linen Maintenance of the Laundry Room & Laundry Equipment reviewed on 7/9/2020, indicated report any problem with laundry room ventilation or dirt or corrosion on fans or ducts to the supervisor. 3a. During a concurrent observation and interview on 11/19/2020 at 9:42 a.m., LS 2 was not wearing a face shield inside the laundry area. LS 2 demonstrated where he had stored his face shield and stated he takes it off at the end of the day, stores it in an envelope and leaves it in on a shelf next to an office desk at the laundry area to use the next day. LS 2 stated he does not disinfect the Face shield before and after use. LS 2 stated the face shield is dedicated to him and that he uses a separate face shield to wear outside the laundry area. During an interview on 11/19/2020 at 10:07 a.m., the Housekeeping Supervisor stated face shields are to be disinfected every day, before and after use. During an interview on 11/19/2020 at 3:25 p.m., IP 1 stated staff are required to wear an N95 mask and face shield inside the laundry area. During a concurrent observation and interview on 11/20/2020 at 1:05 p.m., LS 2 was in the laundry area folding clean linen without wearing a face shield inside the laundry area. LS 2 stated he only wears a face mask and the face shield or gloves were not needed. 3b. During an observation on 11/23/2020 at 4:33 p.m., DON was not wearing a face shield in the Yellow Zone by Nursing Station 1. Upon interview, DON stated she was not wearing a face shield because she had just stepped out of her office when a staff had suddenly called for her. DON proceeded back to her office to get her face shield and, on the hallway of the Yellow Zone, put the face shield on. DON did not perform hand hygiene before putting on the face shield. 3c. on 11/23/2020 at 3:37 p.m., during an observation in the presence of ADM, MD 1 was in the Yellow Zone Nursing Station and was not wearing any eye protection (face shield or goggles). Upon interview, ADM stated MD needed to wear eye protection when in the Yellow Zone. A review of the facility's COVID-19 Mitigation Plan policy dated 10/ 2020 indicated under Personal Protective Equipment (PPE), use of universal face mask and face shield while in the facility and resident care areas. If a disposable face shield is reprocessed, it should be dedicated to one HCP and reprocessed whenever it is visibly soiled or removed (e.g., when leaving the isolation area) prior to putting it back on. A review of the CDC document titled, Infection Control Guidance indicated under Eye protection, reusable eye protection (e.g., goggles) must be cleaned and disinfected according to manufacturer's reprocessing instructions prior to re-use. A review of the CDPH AFL (All Facilities Letter) 20-39 titled, Coronavirus Disease 2019 (COVID-19) Optimizing the Use of Personal Protective Equipment (PPE) dated 4/13/2020 indicated HCP (Health Care Personnel) should not touch their face shield or eye protection, and immediately perform hand hygiene if they do. Ensure appropriate cleaning and disinfection between users if goggles or reusable face shields are used. 4a. During an observation and concurrent interview on 11/19/2020 at 1:05 p.m., HSK 1 was about to exit the laundry area while her N95 mask was hanging on her neck. HSK 1 stated she was not wearing a mask because she had to drink water. HSK 1 stated she had been fit tested for an N95 mask but was not trained on how to properly wear it. MA, also in the laundry area, had his N95 mask was folded on the side and not tightly sealed around the nose. When this was brought to his attention, MA started adjusting his mask. MA stated he received training on how to conduct seal check when using N95 mask. During an interview on 11/19/2020 at 3:25 p.m., IP 1 stated that staff are required to wear an N95 mask and face shield in the laundry area. 4b. On 11/23/2020 at 12:59 p.m., during an observation and concurrent interviews with DA 1, DA 5 and DS, in the kitchen, DA 1 was not wearing a face mask. DA 1, upon noticing the presence of the Evaluator, immediately put on his N95 mask and did not perform a seal check or hand hygiene. The N95 mask was bent on the side and not sealing around the nose and mouth. DA 1 proceeded to the dishwashing A review of the facility's COVID-19 Mitigation Plan dated 10/2020, indicated under Personal Protective Equipment, use of universal face mask and face shield while in the facility and resident care areas; all staff will wear recommended PPE while in the building per current CDPH PPE guidance; HCP must not to touch their facemask, if they touch or adjust their facemask, they must immediately perform hand hygiene. A review of the CDC document titled, Decontamination & Reuse of N95 Respirators, under N95 FFR [filtering facepiece respirators] contamination and self-contamination risk indicated the outer surface, the surface furthest from the wearer's face, presents the highest risk for pathogen transfer to the wearer. Wearers should practice hand hygiene before and after handling any FFR to avoid potentially contaminating the outside layer of the FFR with their hands. Wearers of new or reused FFRs should be careful to avoid contaminating them when: donning and doffing the FFR, adjusting the fit or placement of the FFR, and when performing a user-seal check when redonning a previously worn FFR. 5. A review of Resident 3's Admission Record indicated the facility admitted the resident on 8/25/2020 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 3's Minimum Data Set (MDS - standardized assessment and care-screening tool) dated 9/1/2020, indicated the resident required total assistance with bathing. On 11/19/2020 at 10:39 a.m. during an observation of CNA 1 providing Resident 3 a bed bath. CNA 1 did not spread Resident 3's legs open to wash the resident's private part. CNA 1 towel dried Resident 3's perineal area (private parts) and hung the used towel on the bed left side upper side rail. After completing the bed bath and without removing the soiled gloves, CNA 1 proceeded to change the bed linen. CNA 1 did not perform hand hygiene after removing the used gloves. CNA 1 used walkie talkie to call for assistance. During an interview on 11/19/20 at 3:20 p.m., CNA 1 stated she does not perform hand hygiene between glove changes. On 11/19/2020 at 3:23 p.m., during an interview, Director of Staff Development (DSD) stated staff should wash their hands before putting on new gloves and after removing their gloves. A review of the facility's policy titled Infection Control-Enhanced Standard Precautions dated 7/9/2020, indicated to wash hands after removing gloves. 6a. On 11/19/2020 at 8:40 a.m., during interviews with DS and DA 2, DS stated the facility used Peroxide Multi-Surface Cleaner and Disinfectant to disinfect soiled dietary food carts. DA 2 stated the cleaner contact time was 25 seconds. On 11/19/2020 at 10:07 a.m., during an interview, HSKS stated the contact time for the Peroxide Multi Surface Cleaner was seven minutes. A review of the Peroxide Multi Surface Cleaner and Disinfectant bottle label indicated the contact time was 30 seconds. 6b. During an interview on 11/19/2020 at 11:13 a.m., CNA 1 stated she wipes the shower area after each resident use with the MicroKill Bleach. CNA 1 stated she did not know the contact time for MicroKill Bleach wipes but she leaves it for three minutes. A review of the MicroKill Bleach container label indicated the contact time was 30 seconds. 6c. On 11/19/2020 at 1:20 p.m., during an interview, LS 1 stated sometimes she eats her food in the office inside the laundry room and uses Avert Sporicidal Disinfectant Cleaner Wipes, stored on the desk, to wipe the area after each use. LS 1 stated she did not know the contact time for the wipes. A review of the Avert Sporicidal Disinfectant Cleaner Wipes label indicated the contact time was one minute. A review of the facility's COVID-19 Mitigation Plan policy dated 10/2020 indicated in-services and competency trainings included environmental cleaning contact time. A review of the CDC document titled, Infection Control Guidance indicated to ensure that environmental cleaning and disinfection procedures are followed consistently and correctly. , 7a. On 11/19/2020 at 9:42 a.m., during an observation of the laundry area in the presence of LS 2, there was a half empty personal water bottle stored on a laundry rack next to clean linens. LS 2 stated he did not know whose water bottle that was. 7b. On 11/19/2020 at 2:58 p.m., during an observation of the laundry area in the presence of LS 1, there was a cellphone sitting on the linen folding table next to clean linen. LS 1 stated she placed her cellphone there to easily reach it. On 11/19/2020 at 4:09 p.m., during an interview, IP 1 stated staff was to store their personal belongings in the locker inside the laundry area. A review of the facility's policy titled Laundry Department - Post in Laundry, P&P Manual & Use for Training reviewed on 7/9/2020 indicated under Personnel Guidelines, no eating, drinking or smoking except in designated areas. 8. On 11/20/2020 at 1:35 p.m. during an observation LS 1 was handling dry linen on the linen folding table. LS 1 had an adhesive bandage on one of her fingers. Upon interview, LS 1 stated she had an open wound and put the bandage over it. LS 1, without the use of gloves, continued to handle clean dry linens. On 11/24/2020 at 3:18 p.m., during an interview, ADM stated LS 2 should wear gloves when handling clean linens to prevent contamination of clean linens. 9a. On 11/19/2020 from 8:49 a.m. to 10:43 p.m., HSK 1 was observed cleaning the banisters and doorknobs in the Yellow Zone hallways with Peroxide Multi-Surface Cleaner. HSK 1 did not clean the isolation cart drawers that were positioned outside each residents' rooms in the Yellow Zone. On 11/19/2020 at 3:10 p.m., during an interview, HSK 1 stated she forgot cleaning the isolation carts. 9b. On 11/23/2020 from 2:01 p.m. to 2:37 p.m., HSK 3 was observed cleaning the banisters, doorknobs, and isolation drawers in the Yellow Zone hallways with Peroxide Multi-Surface Cleaner and Disinfectant. HSK 3 sprayed the tops of the handrails with cleaner in the area from the hallway near room [ROOM NUMBER] extending back to the hallway near room [ROOM NUMBER]. HSK 3 did not return to wipe the entire handrails with a cleaning cloth. HSK 3 was cleaning items in the Yellow Zone hallway across from room [ROOM NUMBER] and dropped a fabric reusable cloth on the floor. HSK 3 picked it up from the floor and placed it on top of an isolation cart, sprayed the cloth with the disinfectant and cleaned the isolation cart with it. Upon interview, at the time of the observation, HSK 3 stated he should was discarded the cleaning cloth. 9c. On 11/24/2020, at 1 p.m., during an observation of HSK3 with REM, HSK 3 was cleaning the Yellow Zone hallway area, spraying the surfaces with Peroxide Multi-Surface Cleaner and Disinfectant and not wiping the disinfectant after. Upon interview, REM stated HSK 3 should have wiped the surfaces afterwards. A review of the product information titled, Peroxide Multi Surface Cleaner and Disinfectant, dated 2/21/2020, indicated to apply with a cloth, mop, sponge, coarse trigger spray, or by immersion. 10. During an observation on 11/19/2020 at 1:50 p.m., CNA 2 exiting room [ROOM NUMBER] located in the Yellow Zone. CNA 2 had on a disposable gown and gloves that were worn while in room [ROOM NUMBER]. CNA 2 had a tray in hand, placed the tray on the tray cart and pushed it 10 feet from room [ROOM NUMBER] to room [ROOM NUMBER]. When CNA 2 was asked why the gown and gloves were worn outside a room in the Yellow Zone, CNA 2 replied she should have removed those items before exiting room [ROOM NUMBER]. A review of the facility's policy titled, Infection Control - Enhanced Standard Precautions, reviewed 7/9/2020, indicated staff are to remove the gown and perform hand hygiene before leaving the resident's room. A review of the CDC document titled, Contact Precautions, indicated, for residents placed on contact precautions, staff are to put on the gown before room entry and discard the gown before exiting the room. 11. On 11/22/2020, at 6:51 a.m., during an observation of RN 3 and a concurrent interview, RN 3 stated she uses cleansing wipes she had in her purse to cleanse a blood pressure cuff after been used. The wipes were labeled Patient Preoperative Skin Preparation. 2% [MEDICATION(S)] Cloth. RN 3 stated those were the wipes she used cleanse and disinfect the blood pressure cuff before and after use. On 11/22/2020 at 10:25 a.m., during an interview, DON stated the wipes use by RN 3 were for skin not for objects. The facility's policy titled, Infection Control-Enhanced Standard Precautions, dated 3/2016, indicated reusable equipment is not used for the care of another resident until it has been appropriately cleaned and reprocessed and single use items are properly discarded. The facility's policy titled, 2019 Novel Coronavirus (COVID-19), dated 3/5/2020, indicated products with EPA-approved for use against COVID-19. These products can be identified by the following claim: Product name has demonstrated effectiveness against viruses like COVID-19 on bard non-porous surfaces. 11. On 11/22/2020 at 6:10 a.m., RN 3 opened the facility's door to allow two Evaluators enter the facility. RN 3 did not perform any type of COVID-19 screening before escorting the Evaluators to the Rehabilitation Room. On 11/22/2020 at 12:45 p.m., during an interview, ADM stated anyone who enters the facility, whether it be visitors or staff, should be screened for signs and symptoms of COVID-19 prior to entering the facility. A review of the facility's policy titled, 2019 Novel Coronavirus (COVID-19), revised 3/5/2020, indicated visitors should be screened for symptoms of acute respiratory illness. A review of the facility's COVID-19 Mitigation Plan policy, revised 10/29/2020, indicated that all permitted visitors will have their temperature taken prior to the entry to the facility. The Mitigation Plan further indicated the recommended PPE for the Red Zone is an N95 respirator.

Based on observation, interview and record review, the facility failed to thoroughly investigate one of one sampled resident (Resident 24), who is totally dependent on staff for activities of daily living and was identified with unknown right hand skin discoloration, to prevent further potential abuse, including: 1. Conduct a thorough investigation to determine the probable cause of an injury when the licensed staff discovered the resident developed right hand discoloration, bluish in color and swelling on January 21, 2019. 2. Conduct a thorough investigation and root cause analysis after Resident 24 was found to have bleeding and a right hand palmar digital crease skin laceration of 3 centimeters on January 22, 2019. 3. Conduct an Investigation after Resident 24 returned from the general acute care hospital (GACH) and the GACH records indicated the resident had a fracture of the fifth finger of the right hand (a broken bone of the right hand), and was treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . 4. Report the results of the investigation related Resident 24's fifth finger fracture to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency within 5 working days of the incident. These deficient practices resulted into Resident 24 delayed identification of right hand fifth finger fracture, diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . In addition, the resident was potentially subjected to untreated pain and further injury of the right hand finger. Cross-reference F609 and F684. Findings: A review of the admission record indicated Resident 24 was initially admitted on [DATE] and readmitted to the facility on [DATE]. Resident 24 diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 24's Minimum Data Set (MDS - an assessment and care screening tool) dated December 27, 2018, indicated Resident 24's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions making were severely impaired. The MDS indicated Resident 24 was completely dependent on staff (two person assist) for moving in bed, transferring from bed to chair, dressing, eating, toilet use, and personal hygiene. A review Resident 24's care plan for [CONDITION(S)] initiated on December 27, 2018 indicated the resident was at risk for injury from tremors and involuntary movement related to [CONDITION(S)]. The care plan indicated the resident will be free from injury daily for 90 days. The interventions in the care plan were to assist the resident with ADLs (activities of daily living) as needed, observe environment for special needs, if involuntary movements noted, at risk for injury, and notify the physician if involuntary movement increase. A review of the incident report dated January 21, 2019 indicated at 6:30 a.m. while checking Resident 24's blood sugar the licensed staff noted the resident had a right hand discoloration, bluish in color with swelling with skin being intact. A review of the SBAR (Situation, background, Assessment and Recommendation- a communication tool) and nursing note dated January 21, 2019, indicated Resident 24's physician was notified regarding the resident's episode of [CONDITION(S)] (low blood sugar), increased involuntary movement and hand tremors, lip smacking and right hand discoloration and swelling. The nursing note indicated the physician called back and gave orders addressing the resident's [CONDITION(S)]. The SBAR note did not mention any interventions or response from the physician regarding the resident's right hand swelling and discoloration, to include further diagnostic tests, or evaluation and or treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no other documented evidence in the License Nurse Record of follow up with the physician regarding Resident 24's right hand swelling and discoloration. A review of Resident 24's care plan for right hand bluish discoloration and swelling initiated on January 21, 2019 indicated goals for the resident's hand to be free from signs of infection, pain and discomfort. The care plan did not specify how to prevent further discolorations and swelling incidents. A review of an SBAR dated January 22, 2019, indicated upon doing rounds at 10:45 p.m., the licensed staff noted Resident 24's right hand was bleeding, with a laceration (cut) between the little finger and the ring finger. The SBAR indicated the physician was notified and he ordered an antibiotic ointment. The SBAR indicated the licensed staff insisted to physician that the laceration may require stitches (repair), but the physician refused to transfer the resident to an acute care hospital in order to further evaluate if the resident required treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no documented evidence in the License Nurse Record dated January 22, 2019, to indicate an investigation was done regarding the laceration, to determine the possible cause of the right hand laceration of January 22, 2019, in order to prevent further lacerations. A review of an SBAR dated January 23, 2019 at 12:59 p.m., indicated the licensed staff noted a right hand palmar crease laceration, right hand bleeding and swelling. The SBAR indicated the physician was notified the physician gave orders to give the resident oral antibiotics for possible [CONDITION(S)]. There was no documented evidence of investigation regarding the right hand palmar crease laceration, to determine the possible cause of the right hand palmar crease laceration of January 23, 2019, in order to prevent further lacerations. A review of Resident 24's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 24's Consultation Note/Progress Note dated January 29, 2019, indicated the resident was seen by the wound care physician for right hand and fifth finger [CONDITION(S)]. The note indicated wound care doctor recommended to perform an x-ray of the resident's 5th finger versus hospital admission for evaluation of possible abscess and intravenous antibiotics (antibiotics administered straight into the vein via a tube). A review of the Licensed Personnel Progress Note dated January 29, 2019, indicated at 10:00 a.m., the licensed staff notified Resident 24's physician and suggested an x-ray of the right hand per recommendation of the wound care doctor. The note indicated at 11: 00 a.m. the physician gave an order to transfer Resident 24 to a general acute care hospital (GACH) for further evaluation of right hand [CONDITION(S)]. A review of the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the radiology report dated January 30, 2019, indicated Resident 24 had a non-healed fracture at the base of the proximal phalanx of the fifth digit (of the fifth finger bones was broken) and there is mild diffuse soft tissue swelling. A review of Resident 24's medical record from the GACH, indicated Resident 24 was admitted for evaluation of right hand [CONDITION(S)] in addition to possible right hand [CONDITION(S)] (infection of the bone). The record indicated Resident 24 remained in the hospital for five days and was treated with two intravenous antibiotics ([MEDICATION(S)] and [MEDICATION(S)]). The discharge summary from the acute care hospital created on February 2, 2019 at 6:27 p.m. indicated discharge diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . It is difficult to treat because it's resistant to some commonly used antibiotics), non-healed fracture of the fifth finger with diffuse (spread out over a large area) soft tissue swelling, acute urinary tract infection (bladder infection), acute [CONDITION(S)] (a general term that means brain disease, damage, or malfunction. The major symptom of [CONDITION(S)] is an altered mental state. The causes of [CONDITION(S)] include infections). On March 5, 2019 at 8:44 a.m., Resident 24 was observed lying in bed. Resident 24 was observed with redness and swelling of the right hand. Resident 24 was nonverbal and was unable to respond to any questions. The resident was physically unable to reach and use a call light or pick up personal items. On March 11, 2019 10:47 a.m., during a concurrent record review and interview Director of Staff Development confirmed there was no documented evidence of an intervention and follow up with the physician regarding the resident's right hand swelling and discoloration on January 21, 2019. The DSD was not sure why there was no follow up but stated, the licensed should have followed up and documented in Resident 24's medical record. On March 11, 2019 at 12:08 p.m. during an interview, the Director of Nursing (DON) stated the facility did not conduct an investigation and did not have an interdisciplinary team (IDT- a group of healthcare professionals) meeting regarding Resident 24 having lacerations on her hand [CONDITION(S)] on her right hand. On March 11, 2019 at 12:08 p.m. during an interview, the DON stated the facility did not conduct an investigation and did not have an interdisciplinary team (IDT- a group of healthcare professionals) meeting regarding Resident 24 having lacerations on her right hand [CONDITION(S)] on The resident's right hand. The DON stated she did not conduct an investigation regarding the fracture when it was identified and when the resident returned to the skilled nursing facility. The DON stated it would be standard practice to do an investigation and try to figure out why the resident had the issues and laceration on right hand, and possible causes of the [CONDITION(S)] and fracture in order to provide appropriate treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] On March 11, 2019 at 12:42 p.m. during a concurrent record review and interview the DSD stated could not find any documented evidence of Resident 24's physician indicating the fracture was pathological in nature (pathological fracture is a bone fracture caused by disease that led to weakness of the bone structure). The DSD stated she could not find a care plan for osteopenia or [CONDITION(S)] (a medical condition in which the bones become brittle and fragile from loss of tissue, typically as a result of hormonal changes, or deficiency of calcium or vitamin D) and risk for pathological fracture in the resident's medical record. The DSD stated could not find a documented evidence of a care plan addressing the fracture. On March 11, 2019 at 1:04 p.m. during a concurrent record review an interview, the DSD confirmed Resident 24's history and physical done prior to the incident did not include a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The DSD reviewed the physician's notes prior to the incident and [CONDITION(S)] was not mentioned as a diagnosis. The DSD also reviewed the face sheet and agreed the face sheet did not mention osteopenia and [CONDITION(S)] was included as the resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On March 11, 2019 at 2:27 p.m., during a concurrent record review and interview the DON stated Resident 24's care plan for [CONDITION(S)] did not indicate specific interventions to address the risk of injury. On March 11, 2019 at 2:43 p.m., the DON stated the facility treated the fracture as happening outside the facility and this was the reason why an investigation was not completed. The DON confirmed she was aware Resident 24 was noted to have right hand swelling, discoloration, bleeding, and laceration prior to being transferred to the hospital where an x-ray revealed a fracture. On March 11, 2019 at 3:20 p.m. during an interview, the Administrator (ADM) stated the fracture was not identified in the facility and was not considered as having happened in the skilled nursing facility therefore he did not conduct an investigation. A review of the facility's Accident and Incidents-Resident Investigation and Reporting policy and procedure revised in January 2017, indicated all accidents or incidents involving residents occurring on facility premises shall be investigated and reported to the administrator. The policy and procedure indicated the nurse supervisor/charge nurse and/or the department director or supervisor shall promptly initiate and document investigation of the accident or incident. The policy and procedure indicated the following data shall be included on the report of the Incident/Accident Form: nature of the injury, circumstances surrounding the accident or incident, date and time the accident or incident occurred, where the accident or incident occurred, the names of witnesses and their account of the accident or incident, any corrective action taken and follow up information. The policy and procedure indicated the nurse supervisor/charge nurse and/or the department director or supervisor shall complete a Report of Incident/Accident form and submit the original to the director of nursing services within 24 hours of the incident or accident and the director of nursing shall ensure the administrator receives a copy of the Report of Incident/Accident for each occurrence. The facility's Accident and Incidents-Resident Investigation and Reporting policy and procedure did not include how to investigate injuries of the resident occurring while the resident It is the policy of the facility to ensure that alleged violations by anyone in the facility involving mistreatment, neglect, or abuse including injuries of unknown sources are reported immediately to the administrator of the facility. The administrator, as the abuse coordinator, will investigate each alleged violation thoroughly and report results to appropriate agencies and personnel. The administrator, or his/her designee, will report each alleged abuse to the Ombudsman's office and the Department of Public Health immediately or within 24 hours per Section 1418.91 of the Health and Safety Code. All others within 24 hours if the events that caused the reasonable suspicion of abuse did not result in serious bodily injury to a resident, the covered individual shall report the suspicion of abuse not later than 24 hours after forming the suspicion. Reporting Procedures include notifying charge nurse as soon as possible. The nurse will initiate a physical and mental assessment of the resident and document objective findings, notify the resident's attending physician or his/her designee regarding alleged incident assessment findings. An incident report will be completed and an investigation will be filed and labeled a confidential document. All interviews, reports, and other pertinent documents shall be maintained in the file. An investigation of alleged abuse form is used to document the investigation. Administrator or designee shall make a reasonable attempt to reach a conclusion as to the cause of the injury and take corrective actions during the investigation to provide a safe environment for the resident (s). A designated person completes the investigation form after the investigation is complete. The completed confidential file and all other material related to the incident are forwarded in its entirety to the administrator. All alleged allegations and all substantiated incidents will be reported to the Department of Public Health and to all other agencies as required by State law. The results of the investigation must be reported within 5 working days of the incident.

Based on observation, interviews and record review, the facility failed to ensure that food was stored in accordance with professional standards for food service safety when the facility failed to eradicate cockroach population and eliminate harborage conditions in the kitchen. The facility's kitchen environment including three (3) of three floor drains directly connected to sewer line, cracks in the walls, broken grouts between the floor tiles, foam sealants under the sinks and plywood pieces that holds the sink in place, provided both food and safe places for harborage of pests and the warm kitchen conditions necessary to encourage the cockroaches to thrive. In addition, lack of an effective reporting and communicating system regarding the presence of cockroaches in the kitchen delayed proper treatment to control harborage. These deficient practices had the potential to cross-contaminate food that could cause food borne illness in 85 of 85 residents who received food from the kitchen. Cockroaches' saliva, droppings, and decomposing roaches' bodies contain proteins known to trigger allergies that can increase the severity of asthma symptoms. Cockroaches are capable of carrying disease causing organisms such as Salmonella typhimurium (is a type of bacteria that cause food poisoning), [MEDICATION NAME] fever (an infectious bacterial fever with an eruption of red spots on the chest and abdomen and severe intestinal irritation), Entamoeba histolytica (a parasite that is transmitted to humans via contaminated water and food), polio[DIAGNOSES REDACTED] virus ([MEDICAL CONDITION] that enters the mouth and spreads from person to person and can invade an infected person's brain and spinal cord, causing paralysis), Staphylococcus spp (a bacteria that cause skin infections), Streptococcus spp (a bacteria that cause diseases such as sore throat), [MEDICAL CONDITION] virus (inflammation of the liver), and coliform bacteria (a bacteria found in water causing diseases). Immediate jeopardy was called on (MONTH) 4, (YEAR) at 5:55 p.m. The facility administrator, Director of nursing and dietary services supervisor was notified of the immediate jeopardy situation. The Facility administrator and other staff present were informed of the cracks on the walls behind the dirty area sink next to the dish machine, holes under the dirty area sink, foam sealants covering under the sinks, and plywood that was holding up the sinks. The facility was also informed of lack of a consistent communication between kitchen and maintenance regarding presence of roaches in the kitchen and lack of aggressive action to control the harborage of cockroaches. An acceptable plan of action was accepted on (MONTH) 4, (YEAR) at 7:20 p.m., the plan of action-included kitchen will remain closed due to infestation, no food will be processed in the kitchen and all open food items will be discarded. Meals for residents will be delivered from sister facility and nearby restaurants and served to residents. Disposable trays, plates and utensils will be used. Deep cleaning of the kitchen floors and other surfaces to remove build-up of grease, grime and other debris. Disinfection of the kitchen floors with bleach, disinfection of equipment would be conducted in the evening. Pest Control Company will begin aggressive management this evening and perform several treatments to exterminate the cockroaches. Plumbers were contacted to clean drains. Maintenance technician to clean and remove plywood and foam sealants under the sinks and outside contractor to cover holes and cracks with cement and metal support for the sinks. Registered Dietitian to conduct in services to dietary staff and nursing staff regarding sanitation, food handling and reporting system for pests. New systems to be established for reporting, monitoring and auditing sanitation including pests in the kitchen. The immediate jeopardy was abated on (MONTH) 6, (YEAR) at 8:15a.m., when the surveyor verified that the facility's plan of action was implemented. Findings: On (MONTH) 4, (YEAR), at 4:20 p.m., an unannounced visit was conducted to the facility to investigate a complaint from Los Angeles County Public Health Environmental Health Department surveyor regarding the notice of facility kitchen closure due to vermin infestation. During an observation of the kitchen on (MONTH) 4, (YEAR), at 4:30 p.m., the kitchen was closed with the notice of closure from Department of Public Health posted on the door. The facility was given 48 hours to eradicate roaches from the kitchen. The kitchen was inspected for the presence of cockroaches. There was one large dead cockroach and two small dead cockroaches observed in the back corner on the floor under the dish machine. Located adjacent to the dish machine was a sink for dirty dishes and underneath the sink, cracks and holes were observed. Cracks under the sink and holes in the wall were partially covered by plywood and foam sealant. There were holes in the grout between floor tiles and the three floor drains has with no cover. During a concurrent interview on (MONTH) 4, (YEAR), at 4:30 p.m., with the Dietary Supervisor (DS), she stated that she has seen roaches off and on but not a lot maybe once a month and always under the dirty dish area sink and the dish machine. DS stated that this morning the facility has notified the maintenance manager about the cracks and holes on the wall behind the sink and under the sink. DS stated that she reports pest issues to maintenance supervisor during morning staff meeting and the maintenance supervisor is the one who calls the pest control. During an interview with Cook 1 on (MONTH) 4, (YEAR), at 4:50 p.m., Cook 1 stated that she sees roaches in the morning when she enters the kitchen. Cook 1 stated that she first kills the roach then alerts her coworkers that there are roaches around and to be careful not to get in food. She also stated that she has told her supervisor about the roaches. During an interview with Dietary Aid (DA 1) on (MONTH) 4, (YEAR), at 5:00 p.m., DA 1 stated that he has seen roaches coming out of the floor drain next to the food preparation sink area. DA 1 stated we know about the roaches. In a telephone interview with the pest control technician (PCT) on (MONTH) 4, (YEAR), at 5:15 p.m., the PCT stated he is on a twice a month schedule with the facility. He stated he used to see a lot more roaches in the kitchen but not as much now compared to last year. He uses a product called Gel Maxforce and stated that this pest control product is used for routine maintenance. He further stated facility has not called him for issues with roaches. He also stated he has seen the foam sealant and plywood that covers the cracks and holes under the sink and that might be a harborage for roaches. (PCT) verified that he received a call from facility this morning and he will come in later to treat the kitchen to exterminate the pests and he will use a liquid product strong for roach infestation. During an interview with the maintenance supervisor (MS) on (MONTH) 4, (YEAR), at 5:45 p.m., the MS stated staff verbally communicates with him regarding repairs or other issues. MS stated that lately the kitchen staff have not told him about roaches. A review of (YEAR) U.S. Food and Drug Administration Food Code, Insects and other pests are capable of transmitting disease to humans by contaminating food and food-contact surfaces. Effective measures must be taken to eliminate their presence in food establishments. In addition routinely inspecting the premises for evidence of pests and if pests are found using methods to control and eliminate harborage conditions. In addition, according to the (YEAR) U.S. Food and Drug Administration Food Code, Fixed equipment is installed in a way that ensures that equipment that is subject to moisture is sealed, prevents the harborage of insects and rodents and provides accessibility for monitoring of pests. A review of website (www.orkin.com) indicated cockroaches are nocturnal insects. They prefer to live and feed in the dark, a cockroach seen during the day is a possible sign of infestation. Cockroaches tend to prefer dark, moist places to hide and breed and can be found behind refrigerators, sinks and stoves, as well as under floor drains and inside of motors and major appliances. In addition, the pest cockroaches can be carriers of various diseases because they are commonly found near waste deposits or in the kitchen, where food is present. Cockroaches often taint food with E. coli and Salmonella bacteria; also, exposure to cockroach waste and dead roaches over time can trigger allergies and asthma.

Based on observation, interview, and record review, the licensed nursing staff failed to effectively manage a residents pain based on an identified level of comfort with pain medication before the intensity of the pain increased, by not continuously assessing and monitoring the need for pain medications before and during the surgical wound dressing change, and by not developing a plan of care based on an identified pain threshold resulting in pain during a dressing change for one out of 19 sample residents (16), and failed to ensure a resident's pacemaker (medical device inserted to regulate the heart beat) was monitored to ensure the device was functioning to effectively regulate the resident's heart rate with the potential for heart failure, for one of two residents with pacemakers out of 19 sample residents ( 11). Findings: a. According to the admission record, Resident 16 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. due to decreased blood flow resulting in sores, wounds, or ulcers that heal slowly or not at all), vascular ulcers to both feet, osteo[DIAGNOSES REDACTED] (bone infection), and hypertension (high blood pressure). The acute care hospital's physician's orders [REDACTED]. On February 23, 2011, the resident was sent to the acute care hospital and had his left hallux (big toe) amputated (removed) because of osteo[DIAGNOSES REDACTED], and a Stage III (loss of fullness of the skin, exposing the under skin layers) vascular non-healing ulcer. The acute care hospital's physician's orders [REDACTED]. The resident returned to the facility from the acute hospital at 11 a.m. A review of the History and Physical physician assessment dated [DATE], indicated the resident did not have the capacity to understand and make decisions because of mental confusion. The Minimum Data Set (MDS) annual assessment dated [DATE], indicated the resident had severely impaired cognitive skills, was totally dependent on staff for locomotion (moving once in the wheelchair) on the unit, toilet use, personal hygiene, and bathing. The MDS section for pain assessment interview, pain presence, pain frequency and intensity using either a numerical rating scale ((0-10) 0 represents no pain and 10 represents the highest level of pain) or a verbal descriptor scale, was not completed. The Pain Management Update dated February 14, 2011, noted the resident had no complaint of pain, with PRN (as needed) pain medication ordered for pain. The Pain assessment dated [DATE], after the left toe amputation indicated the resident had no complaint of pain or discomfort. The pain management plan was to monitor and assess for verbal and nonverbal signs and symptoms of pain or any discomfort. There were existing physician's orders [REDACTED]. A review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The facility's physician's orders [REDACTED]. The order also indicated not to touch the surgical dressing because the Podiatrist did not want the dressing disturbed, and he would be to the facility on [DATE], to change the dressing post (after) surgery. The resident had a physician's orders [REDACTED]. However, there was no documented evidence on the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. In a review of the Licensed Personnel Progress Notes from January 1, 2011, through February 28, 2011, the documentation reflected the resident was assessed as having no pain, despite the [DIAGNOSES REDACTED]. The documentation reflected that the resident had no complaints of pain, and there was no documentation in the referenced notes indicating the resident exhibited the behavior of screaming and/or yelling. According to the Licensed Personnel Progress Notes dated February 23, 2011 at 11 a.m., the resident returned from surgery slightly sleepy, with the surgical dressing intact (in place). The left foot was elevated on two pillows, and circulation was okay on the remaining toes with no bleeding noted. There was no documentation that a nursing assessment was conducted every shift for pain or other post surgery assessments. For example from admission on February 23, 2011, at 11 a.m. to February 24, 2011, on the 11 p.m. to 7 a.m. shift (no specific time was documented), for 12 hours there was no assessment documented. On February 24, 2011, there was no documentation of assessment on the 7 a.m. to 3 p.m. shift or the 3 p.m. to 11 p.m. shift. On February 25, 2011, on the 7 a.m. to 3 p.m. shift or the 3 p.m. to 11 p.m. shift there was no assessment documented. On February 26, 2011 on the 7 a.m. to 3 p.m. shift, and on February 27, 2011, on the 3 p.m. to 11 p.m. shift and the 11p.m. to 7 a.m. shift, there was no assessment documented. According to record review, there was a care plan dated February 23, 2011, for Impaired Skin Integrity related to status [REDACTED]. . During an observation on February 28, 2011, between 8:30 a.m. and 8:50 a.m., the Evaluator heard Resident 16 yelling from his room. The Director of Nurses (DON) and the Evaluator went towards the resident's room, and found the Podiatrist changing the resident's left foot surgical dressing. Before entering the resident's room, the DON was asked if the resident was screaming because he was in pain, and if or when he received pain medication. The DON then entered the room and asked the Podiatrist if the resident was in pain, to which he replied, "No he just reacts." (The Evaluator could hear the conversation between the DON and the Podiatrist). The DON came outside of the room and told the Evaluator the Podiatrist said the resident was not in pain, however what the resident reacts to and why, was not explained. The DON was asked how the Podiatrist would know if the resident was in pain. The DON then went back into the room and asked the Podiatrist again if he wanted the staff to give the resident any pain medication. The Podiatrist again replied, "No" because the resident did not need it. At no time did the DON assess the resident for pain and ask him directly if he was in pain during the first post surgical dressing change. At approximately 8:40 a.m. the Evaluator went to get another Evaluator to interview the resident regarding possible pain. When entering the resident's room, he was still yelling and jerking his foot away from the Podiatrist. The resident appeared confused when the Evaluator asked him if he was in pain. He said no, but continued to yell as the Podiatrist worked on his surgical dressing change. At no time did the Podiatrist stop to ask the resident if he was in pain or request any pain medication to be given to the resident. During the observation a brief interview to determine the resident's mental status was conducted. He did not know the current year, but said it was 1851. When asked why he was always yelling, he said because it made him feel good. A review of literature titled " Behavioral Management in the Demented Elderly" indicated in residents with dementia, all behavior has meaning. When reasoning and language skills are lost, behavior will increasingly become a primary form of communication such as discomfort and pain (of many others). For example, in a young child, crying as a means of communicating hunger, pain, or fear is not considered a "behavior problem," so as with the demented elderly resident. (Sutor, B, Rummans T, and Smith E: Assessment and Management of Behavior disturbances in nursing home patients with dementia: Mayo Clinic Proceedings 2001; 76: 540-550). After the observation prior to leaving the room, at approximately 8:47 a.m., the resident's roommate in Bed A summoned the Evaluator's indicating he wanted to talk. He stated that Resident 16 always yelled at night during care and wakes him up so abruptly it startles him. At approximately 8:49 a.m., at the end of the interview with the roommate, the DON stated she would call the doctor and get an order for [REDACTED]. On February 28, 2011, at 8: 50 a.m., during a private interview with Certified Nursing Assistant 6 (CNA 6) who was in the room at the time the Podiatrist was changing the resident's dressing, she stated she had been Resident 16's nursing assistant for a long time and the resident frequently yells when she provided care to him. She said when the resident yells she informs the Charge Nurses so they can assess him to know what he wants or give him something for pain. A review of the MAR, from January 1, 2011, through February 28, 2011, verified by the DON, revealed there was no documented evidence that the resident had been medicated for pain before or after his amputation surgery. On February 28, 2011, at approximately 3:00 p.m., interviews were conducted with two Licensed Vocational Nurses (LVN 3 and LVN 4), who were the medication administration nurses. When asked about the resident's screaming and if he was assessed and medicated for pain, both stated that the resident frequently screamed when care was provided to him; they didn't think he was in pain. According to the facility policy titled "Pain Assessment and Management" dated February 2010, it is the policy of the facility to assure that resident's pain is identified, monitored, and managed to provide relief in order to attain or maintain the highest practicable physical, mental and psychosocial well-being with every new admission in which the initial pain assessment indicated that pain is identified, with each new order for a pain medication (either routine or PRN) and if there is no plan of care for pain in the clinical record. The resident's pain management control goal and care plan interventions will be reviewed, revised and/or updated, with interventions and measurable goals in managing the resident's pain. The licensed nurse will evaluate and document pain intensity using the pain rating scale of 0-10 every shift. Interventions will be developed according to the root cause analysis of the pain management program to meet the resident's acceptable pain control and intensity goals. The policy noted that behavior observations reflecting pain to be assessed are negative vocalization such as noise or speech with negative or disapproving quality, grunting or groaning, tense body language such as knees pulled up tightly, and fidgeting or guarding of a body part or aggressive behavior. The non-verbal scale for mild pain was guarded movement and grimacing, and for moderate pain was moaning and restlessness, and for severe pain it was increased moaning, restlessness and screaming. b. According to the admission record, Resident 11 was originally admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The resident also had a pacemaker placement. There was no care plan initiated on admission for at risk for pacemaker malfunction. A review of the resident's medical record revealed [REDACTED]. the facility's policy. There was no documentation on the precautions to be taken around the resident's immediate environment such the use of electrical devices, including the use of a cellular phone that may interfere with a pacemaker's efficiency. On February 23, 2011, at 2:45 p.m., during an interview with the Director of Nursing (DON), she was unable to provide documentation that the pacemaker was checked electronically, a care plan was initiated, and education was given to the resident and staff regarding pacemaker malfunction and precautions. According to the facility policy titled "Pacemaker care" dated October 1, 1994, the licensed nurse will document the pacemaker information, such as pacemaker type, insertion date, set rate, resident needs, goals and interventions on the resident care plan.