Every finding on record at Hillcrest Manor Sanitarium

Based on observation, interview, and record review, the facility failed to (1) check the consistency of the pureed (blended to a smooth and creamy consistency) foods for a resident and (2) ensure the beef patties were cooked according to the manufacturer's guidelines for 48 of 48 residents who received the beef patties. These failures could lead to food that was not palatable and texture that was not safe for a resident to consume. In addition, residents who consume the beef patties could contract food-borne illness.Findings: 1. On 2/11/26 at 11 A.M., an observation during a puree preparation and interview with [NAME] (CK) 1 was conducted. CK 1 poured water into the container of the blender, an amount not measured, and four scoops of thickener into the container of the blender. CK 1 stated they will be serving burgers with baked beans on the side, and she needed to puree the vegetables for one resident. The container was observed with shredded lettuce, diced tomatoes, diced onions, water, and thicker. CK 1 then covered the container and blended the items. CK 1 got a brown cup, poured the blended items into it, and placed it inside the metal container. CK 1 did not check for the consistency and texture of the pureed food. A second puree food observation was conducted. CK 1 got the container of the blender, opened the oven, and took a scooper with a white handle. CK 1 scooped the baked beans, drained the sauce, and put the baked beans into the blender container. CK 1 then scooped two and a half scoops of the baked bean sauce and poured it into the blender. CK 1 put three scoops of the thickener into the container and blended the items. CK 1 then got a brown cup, poured the blended items into the cup, and placed it inside the metal container. CK 1 did not check for the consistency and texture of the pureed food.CK 1 stated she did not follow instructions for pureeing food. CK 1 further said she just knew to put about three to four scoops of thickener without measuring or assessing for the consistency. On 2/11/26 at 11:45 A.M., an interview was conducted with the Dietary Supervisor (DS). The DS stated they did not have instructions on how to puree food, but the cooks were expected to follow the facility's policy on proper food food pureeing. The DS stated the CK blended the food, but could not explain how the CK should check the consistency and texture of the food prior to serving, to ensure that the pureed food was safe and had a proper texture. On 2/12/26 at 11:15 A.M., an interview was conducted with the Registered Dietitians (RD). The RD stated to ensure the pureed food meets the proper consistency and texture, the CK should have performed a fork test (to check if the food will hold shape) and a spoon tilt test (to check for correct consistency) to ensure the pureed food meets the proper consistency and texture. Per the facility's undated policy and procedure, titled Textures, indicated For starches and vegetables: Place cooked items in the food processor or blender and blend until smooth. Add 1/4 - 1/2 slice bread or thickener if necessary . 2. On 2/11/26 at 11:00 A.M., CK 2 was observed grilling the beef patties on the flat grill and transferring the cooked beef patties into the metal container without checking the temperature. CK 2 continued to do the same process until all the beef patties were cooked, covered them, and set them aside. On 2/11/26 at 11:25 A.M., CK 1 was observed tempering the food items and delivered the food in the dining area. A follow-up interview and record review were conducted. CK 1 stated she had tempered the beef patties while in the kitchen area, and the temperature was 155 degrees Fahrenheit. CK 1 stated it was a safe temperature for the residents to eat. Per the manufacturer's guidelines for the Fresh Beef Patties, the recommended cooking was to an internal temperature of 160 Fahrenheit for a well-done product. On 2/11/26 at 11:45 A.M., an interview was conducted with the Dietary Supervisor (DS). The DS stated she agreed with CK 1 and that the beef patties were safe to be served to the residents. On 2/12/26 at 3:30 P.M., an interview was conducted with the Director of Nursing (DON). The DON stated the staff did not follow the manufacturer's guidelines for cooking the beef patties. Per the manufacturer's guidelines for the Fresh Beef Patties, the recommended cooking was to an internal temperature of 160 Fahrenheit for a well-done product.

Based on observation, interview, and record review, the facility failed to staff a Registered Nurse (RN) for at least eight hours a day for 19 days from July 1, 2025, through September 30, 2025. This failure may have prevented residents from receiving advanced care or having their complex medical needs managed effectively. Findings: A review of the PBJ (Payroll-Based Journal) Staffing Date Report and CASPER Report 1705 D, which help Skilled Nursing Facilities identify areas for improvement, showed that in Quarter 4 of 2025 (July 1-September 30), the facility triggered a No RN hours alert. This indicated there were at least four days in the quarter without any RN hours. On 2/11/25 at 10:45 A.M., an observation of the current staffing was posted at the nurse's station.A review of the PBJ report indicated that on 7/3/25, 7/4/25, 7/8/25, 7/9/25, 7/10/25, 7/18/25, 7/28/25, 8/8/25, 8/29/25, 9/1/25, 9/17/25, 9/18/25, 9/21/25, 9/24/25, 9/25/25, 9/26/25, 9/28/25, 9/29/25, and 9/30/25, there was no RN hours. On 2/12/25 at 3:45 P.M., an interview was conducted with the Director of Nursing (DON) and the administrator (ADM). The DON stated that they were hiring registered nurses but had not been able to retain them. The ADM stated they do not have a staffing waiver, and she could not say how many days they do not have an RN. The DON stated that the full-time RN left them and they were hiring. The DON further stated they are trying to staff the floor, but it was challenging. The DON further stated it was important to have an RN to ensure oversight with patient care and safety. The DON also said that the RNs could conduct and assess during a complex change of conditions. Per the facility's undated policy and procedure, titled Nursing Services, indicated, It is the policy of the facility to assure that there is sufficient qualified nursing staff available at all times to provide nursing and related services to meet residents' needs safely and in a manner that promotes each resident's rights, physical. mental, and psychological well being .

Based on observation, interview, and record review, the facility failed to identify and respond to unplanned significant (noticeable) weight loss for one of two sampled residents (Resident 33) who experienced unplanned weight loss. This failure could affect their health and well-being.Findings: Resident 33 was admitted to the facility on [DATE] with diagnoses that included paranoid schizophrenia (a mental health condition that affects the way a person thinks, feels, and behaves) per the admission Face Sheet. Per Resident 's Care Plan Report, dated 8/30/25, indicated Resident 33 had altered nutrition less than body requirements related to meal refusals and had a potential for dehydration. The goal was for Resident 33 to avoid further weight loss, tolerate the prescribed diet without additional loss, and not exhibit any signs or symptoms of dehydration. Resident 33's goal weight range (GWR) was 170 to 185 pounds. The Interventions included honoring food and fluid preferences and referring Resident 33 to the registered dietitian (RD) for dietary recommendations as needed. Per the Vital Signs & Weights Flow Sheet, dated 8/30/25 through 2/2/26, Reident 33's weights were:On 8/30/25 was 181.2 lbsOn 8/31/25 was 180.4 lbsOn 9/1/25 was 179.8 lbsOn 10/2/25 was 180.6 lbsOn 11/1/25 was 183.2 lbsOn 12/2/25, Resident 33 was 189.4 lbs [Resident 33 gained 6.2 lbs] On 1/1/26, Resident 33 was 182.0 lbs [Resident 33 lost 7.2 lbs from 12/2/25 to 1/1/26]On 2/2/26, Resident 33 was 167.8 lbs [Resident 33 lost 14.2 lbs from 1/1/26 to 2/2/26.] There was no documented evidence that an assessment was performed for the unplanned significant weight loss, and there were no further weight recordings to verify that the weight on 2/2/26 was correct. Per the Nutritional Progress Notes, dated 12/12/25, indicated IDT (Interdisciplinary Team) weight variance, indicated that Resident 33's weight gain was not significant. Then on 1/20/26, the Registered Dietitian (RD) documented Resident 33 lost 7.2 lbs. and indicated, it was not significant. On 2/9/26 at 10:03 A.M., Resident 33 was observed in bed wearing a red jacket with an episode of coughing. On 2/11/26 at 10:40 A.M., an interview was conducted with Certified Nursing Assistant (CNA) 1. CNA 1 stated Resident 33 does not like to eat and frequently refuses breakfast and lunch. On 212/26 at 3:36 P.M., an interview was conducted with the Director of Nursing (DON). The DON stated when there was a significant weight loss, the physician should have been notified, and the RD should have been notified to ensure the resident was assessed and proper treatment would be ordered. The DON further stated Resident 33 had a significant weight change and was not assessed in a timely manner. Per the facility's undated policy and procedure, titled Change of Conditions, To assure that appropriate care and documentation occurs when residents experience a change of condition .1. Assess the resident's condition .4. Document what, where, symptoms, assessment, treatment, notification .Weight (+ [greater than] or - [less than] 5 pounds in a month).

Based on interview and record review, the facility failed to ensure one out of one sampled resident (Residents 2) was free of unnecessary medications when Resident 2 received an anticoagulant (blood thinner) medication without staff monitoring for signs and symptoms of side effects.This deficiency had the potential to cause harm due to lack of monitoring for negative side effects of anticoagulant therapy, including excessive bleeding or bruising.Findings:A review of Resident 2's admission Record indicated the resident was admitted to the facility on [DATE] with a diagnosis that included unspecified atrial fibrillation (Afib- irregular, often fast, and chaotic heart rhythm). On 2/12/26 at 11:30 A.M., an interview and record review was conducted with the Infection Preventionist (IP). The IP reviewed Resident 2's physician's order. Physician's order indicated, Eliquis 5 milligrams (mg) one tablet by mouth twice a day for afib. The IP stated there was no documentation for monitoring the negative side effects of the blood thinner for Resident 2 and that there should have been. The IP stated it was important to monitor negative side effects for patient safety. On 2/12/26 at 4:30 P.M., an interview was conducted with the Director of Nursing (DON). The DON stated negative side effects of an anticoagulant were abnormal bleeding and bruising. The DON stated licensed nurses should have monitored and documented negative side effects for residents on a blood thinner. The DON stated there was no policy on an anticoagulant at this time. A review of the facility's policy did not have a policy that addressed monitoring side effects of an anticoagulant. A review of the Prescribing Information (PI, detailed description of a drug's uses, dosage range, side effects, drug-drug interactions, and contraindications that is available to clinicians) for Eliquis (apixaban), dated 4/17/25, retrieved from DailyMed, indicated, .Increased Risk of Hemorrhage [bleeding]. can cause serious, potentially fatal .

Based on observation, interview, and record review, the facility failed to ensure the physician completed the initial visit in a timely manner for one of 19 sampled residents (Resident 40). These failures had the potential to compromise the quality and safety of resident care.Findings: Resident 40 was admitted to the facility on [DATE] with diagnoses that included schizoaffective disorder (a mental health condition characterized by a mix of mood problems and thinking problems), per the facility's admission Face Sheet. On 2/9/26 at 10:21 A.M., Resident 40 was observed walking in the hallway with a walker. Resident 40 stated I've been coughing, and that staff had not done anything about it. A review of Resident 40's clinical record was conducted on 2/11/26. Per the History and Physical, dated 1/9/26, the Physician Assistant (PA) saw Resident 40. On 2/12/26 at 9:05 A.M., a joint interview and record review was conducted with the Director of Nursing (DON). The DON stated the physician (PA) alternates visits with the residents, and the initial visit should happen within 72 hours of admission, no later than one week. The PA saw Resident 40 on 1/9/26, which was late. The DON stated it was important that the physician or the PA do their initial visit to ensure their resident was adjusting well to their new environment, review and confirm the orders were correct, and perform their assessment. Per the facility's undated policy and procedure, titled admission Procedure, .Primary physician's documentation of first visit within 3 days (72 hours) of admission and no later than 7 days .

Based on interview and record review the facility failed to ensure a smoking assessment was completed for one of nine residents (Resident 5).This failure had the potential for Resident 5 to be at risk for burns when smoking.Findings:A record review of Resident 5's admission Record indicated Resident 5 was admitted on [DATE] with a diagnosis which included paranoid schizophrenia (intense, irrational delusions and auditory hallucinations) and syncope (fainting or passing out). On 2/10/26 at 4 P.M. an observation and interview was conducted with the Patio Monitor (PM) in the smoking area. The PM stated resident s who smoke were at risk for burns. The PM stated all residents were required to have a smoking assessment before they could go out to the smoking area to smoke. On 2/12/26 at 11:13 A.M., an interview and record review was conducted with the Infection Preventionist (IP). The IP reviewed Resident 5 medical records which indicated Resident 5 was a smoker. The IP stated there was no smoking assessment documented in Resident 5's medical records. The IP stated a smoking assessment was required to ensure patient safety while smoking. The IP stated there should have been a smoking assessment in Resident 5's medical records. On 2/12/26 at 4:30 P.M., an interview was conducted with the Director of Nursing (DON). The DON stated smoking assessment was important to identify risk related to smoking. The DON stated a smoking assessment should have been in the resident medical records. A review of the facility policy titled Cigarette Smoking and Distribution of Cigarettes, undated, indicated .1. Upon admit, the resident will be assessed for smoking capacity by admitting nurse. 2. Smoking assessment shall be completed annually and as needed.

Based on observation, interview, and record review, the facility failed to assess a resident's respiratory status for one of 19 sampled residents (Resident 40). These failures had the potential to delay care and cause Resident 40's condition to worsen. Findings: Resident 40 was admitted to the facility on [DATE] with diagnoses that included schizoaffective disorder (a mental health condition characterized by a mix of mood problems and thinking problems), per the facility's admission Face Sheet. On 2/9/26 at 10:21 A.M., Resident 40 was observed walking in the hallway with a walker. Resident 40 stated I've been coughing, and that staff had not done anything about it. A review of Resident 40's clinical record was conducted on 2/11/26. Per the Physician's Order, dated 2/10/26, the physician wrote an order to give guaifenesin dextromethorphan (medication for cough) as needed for 10 days. A further review of Resident 40's clinical record was conducted. The Nurse's Notes, dated 2/9/26, contained the first documentation of Resident 40's cough with phlegm; however, the respiratory assessment was not documented. In addition, there was no documented evidence of respiratory assessment was found in subsequent nursing notes on that date, 2/9/26. On 2/11/26 at 10:17 A.M., a joint interview and record review was conducted with Licensed Nurse (LN) 1. LN 1 stated Resident 40 had a cough for 2 days, but Resident 40 thinks he had a respiratory infection. LN 1 stated Resident 40 smokes and has shortness of breath. This could be why Resident 40 was coughing. LN 1 stated she had not listened to Resident 40's lung sounds. On 2/11/26 at 10:30 A.M., an interview was conducted with Certified Nursing Assistant (CNA) 1. CNA 1 stated Resident 40 had been coughing for five days. He told the nurse that, and the nurse handed him a cough drop. CNA 1 further stated he gave the cough drop to Resident 40. On 2/12/26 at 9:05 A.M., a joint interview and record review was conducted with the Director of Nursing (DON). The DON stated per the documentation, Resident 40 had complained of a cough on 2/9/26, and the licensed nurses did not perform a thorough lung assessment. The DON further stated that when a resident complains of a cough, the LNs should conduct a thorough lung assessment to identify normal or abnormal lung sounds to ensure proper treatment for Resident 40. Per the facility's undated policy and procedure, titled Change of Conditions, .1. Assess the resident's condition .2. Document what, where, symptoms, assessment, treatment, notifications .

Based on observation, interview and record review, the facility failed to develop a comprehensive resident-centered care plan were developed and interventions were implemented for three of 19 sampled residents (2, 1, 40) when:1. A care plan for an anticoagulant monitoring of side effect for Resident 2 was not developed.2. A care plan for dementia was not developed for Resident 1.3. A care plan for antipsychotic medications for Resident 40 was not developed. These failures had the potential for the residents not to receive care and services specific to the residents' needs.Findings: 1. A review of Resident 2's admission Record indicated the resident was admitted to the facility on [DATE] with a diagnosis that included unspecified atrial fibrillation (Afib- irregular, often fast, and chaotic heart rhythm). On 2/12/26 at 11:06 A.M., an interview and record review was conducted with the Infection Preventionist (IP). The IP reviewed Resident 2's medical records. The IP reviewed Resident 2's physician's order. The Physician's order indicated Eliquis 5 milligrams (mg) one tablet by mouth twice a day for Afib. The IP stated there was no care plan for the anticoagulant. The IP stated the importance of a care plan was to meet resident care needs. The IP stated there should have been a care plan for Resident 2's anticoagulant. 2. A review of Resident 1's admission Record indicated the resident was admitted to the facility on [DATE] with a diagnosis that included dementia due to traumatic brain injury (a decline in memory, thinking, behavior, and language). On 2/12/26 at 11:26 A.M., an interview and record review was conducted with the IP. The IP stated Resident 1 did not have documentation of a care plan for dementia. The IP stated there should be a care plan for Resident 1's diagnosis of dementia to have a person-centered care plan in place to meet resident needs. On 2/12/26 at 4:30 P.M., an interview was conducted with the Director of Nursing (DON). The DON stated a resident that is on an anticoagulant should have a care plan developed. The DON stated Resident 1 should have had a care plan for a diagnosis of dementia. The DON stated her expectation was for care plans to be in place to meet residents' specific needs. 3. Resident 40 was admitted to the facility on [DATE] with diagnoses that included schizoaffective disorder (a mental health condition characterized by a mix of mood problems and thinking problems), per the facility's admission Face Sheet. On 2/9/26 at 10:21 A.M., Resident 40 was observed walking in the hallway with a walker. A review of Resident 40's clinical record was conducted on 2/11/26. Per the Physician's Order, dated 1/25/26, the physician wrote an order to give haloperidol (a medication used to treat certain mental and mood disorders) five milligrams as needed. On 2/3/26, the physician ordered to discontinue the haloperidol and change it to chlorpromazine (a medication to treat mental and mood disorders). There was no documented evidence that a comprehensive resident-centered care plan was developed for haloperidol and chlorpromazine. On 2/11/26 at 10:17 A.M., a joint interview and record review was conducted with Licensed Nurse (LN) 1. LN 1 stated Resident 40 had an order for haloperidol because Resident 40 had aggressive behavior. LN 1 stated Resident 40 asked the physician to change the haloperidol because he was allergic to it. LN 1 further stated the care plan should have been developed. On 2/12/26 at 9:05 A.M., a joint interview and record review was conducted with the Director of Nursing (DON). The DON stated Resident 40 should have a care plan for the use of the antipsychotic medication and it was not developed. The DON further said it was important to have a care plan to ensure the residents receive consistent care from the staff. Per the facility's undated policy and procedure, titled Care Plans, .The care plan will be complete, current, realistic, time specific and appropriate to the individual needs for each resident .

Based on observation, interview, and record review, the facility failed to ensure one of five sampled residents(Resident 40) reviewed for psychotropic (a drug or substance that affects how the brain works and causes changes in mood, awareness, thoughts, feelings, or behavior) medication had specific behavior monitoring in place for the use of antipsychotic (a class of drugs that treat symptoms of mental disorder by altering brain function). This failure had the potential to result in unnecessary use of psychotropic medication. Findings: Resident 40 was admitted to the facility on [DATE] with diagnoses that included schizoaffective disorder (a mental health condition characterized by a mix of mood problems and thinking problems), per the facility's admission Face Sheet. On 2/9/26 at 10:21 A.M., Resident 40 was observed walking in the hallway with a walker. A review of Resident 40's clinical record was conducted on 2/11/26. Per the Physician's Order, dated 1/25/26, the physician wrote an order to give haloperidol (a medication used to treat certain mental and mood disorders) five milligrams as needed. On 2/3/26, the physician ordered to discontinue the haloperidol and change it to chlopromazine (a medication to treat mental and mood disorders) 25 milligrams every PM (afternoon shift). The order did not indicate the diagnosis, medical symptoms, or behavior monitoring. In addition, there was no documented evidence that the care plan was developed for chlorpromazine, and consent was signed by the responsible party. On 2/11/26 at 10:17 A.M., a joint interview and record review was conducted with Licensed Nurse (LN) 1. LN 1 stated Resident 40 had an order for haloperidol because Resident 40 had aggressive behavior. Resident 40 asked the physician to change the haloperidol because, according to Resident 40, he was allergic to it. LN 1 further stated that there was no behavior monitoring or diagnosis written, and that it should have been. On 2/12/26 at 9:05 A.M., a joint interview and record review was conducted with the Director of Nursing (DON) stated Resident 40 should have a care plan, diagnosis, and behavior monitoring for the use of the antipsychotic medication routinely, and it was not developed. The DON further said it was important to have a care plan to ensure the residents receive consistent care from the staff, and monitoring of the antipsychotic medication to ensure the effectiveness of the drug. Per the facility's undated policy and procedure, titled Psychotropic Medication Use, indicated that Each resident shall receive the necessary care and services to attain and maintain the highest level of physical, mental and psychosocial well-being .If a psychotropic medication is ordered, include in the order the dosage, frequency, route of administration, related diagnosis and medical symptoms .Behavior monitoring shall be initiated .

Based on observation and interview, the facility failed to ensure the medication storage room was free of expired Tuberculin PPD (purified protein derivative) testing solution (used in a skin test to help diagnose tuberculosis infection). This failure had the potential for testing solutions and/or medications to be ineffective and could have had inaccurate results.Findings: On [DATE] at 9:55 A.M., an observation and interview was conducted with Licensed Nurse (LN) 1. LN 1 reviewed Tuberculin PPD, 5 units per 0.1 ml (milliliters) solution had an open date of [DATE]. LN 1 reviewed the manufactures guidelines that indicated, .vials in use more than 30 days should be discarded due to possible oxidation and degradation which may affect potency. LN 1 stated the vial had been open for more than 30 days and should have been discarded. On [DATE] at 11:15 A.M., an interview was conducted with the Infection Preventionist (IP). The IP stated once the Tuberculin PPD solution, it was valid for 30 days and should not be used past the 30 days. The IP stated using the solution after 30 days could decrease its effectiveness, and could have had inaccurate results. The IP stated the Tuberculin PPD solution should have been disposed of. On [DATE] at 4:30 P.M., an interview was conducted with the Director of Nursing (DON). The DON stated a vial of Tuberculin PPD after it was opened was good for only 30 days. The DON stated the vial of Tuberculin PPD should have been removed from the refrigerator and disposed of. The DON stated using the Tuberculin PPD after the expired use by date could have lessened the potency and lead to inaccurate readings. A review of the Prescribing Information (PI, detailed description of a medication that is available to clinicians) for Aplisol (tuberculin PPD, diluted) updated [DATE] retrieved from DailyMed, indicated, .Failure to store and handle Aplisol as recommended may result in a loss of potency and inaccurate test results.Vials in use more than 30 days should be discarded due to possible oxidation and degradation which may affect potency.A review of the facility's policy titled Medication Administration Guidelines undated, indicated .Refrigerator: Expired and DC's meds should be removed.

Based on observation, interview, and record review, the facility failed to ensure five of 25 resident rooms (Rooms SWD 1, SWD 2, SWD 3, SWD 4, and room [ROOM NUMBER]) accommodated no more than four residents. This failure had the potential to limit the freedom of movement for the residents that occupied those rooms, which may place them at risk for injury.Findings:During initial tour on 2/9/26, five of the 25 resident rooms accommodated more than four residents:a. Room SWD 1- 5 Residentsb. Room SWD 2- 5 Residentsc. Room SWD 3- 5 Residentsd. Room SWD 4- 5 Residentse. room [ROOM NUMBER]- 5 ResidentsDuring the course of the survey, those rooms did not impose any safety hazards. There were no complaints about space or room issues from the residents occupying these rooms. There were no quality of care or quality of life concerns identified that negatively affected the residents residing in those rooms.The survey team recommends the approval of the written room waiver continuum request, dated 2/12/26, for the rooms listed in this deficiency.

Based on observation, interview, and record review, the facility failed to provide a minimum of 80 square feet (sq. ft.- unit of measurement) of livable space per resident for four of 25 resident rooms. This failure had the potential to affect the resident's health and safety and prevent the residents from maintaining their highest level of well-being by limiting the movements of those residents in their rooms.Findings: During initial tour, dated 2/9/26, four of the 25 residents' room were observed to be less than 80 sq. ft. per resident. The residents' rooms and their measurements of livable space were noted as follows:a. Room SWD 1 (5 beds) measured: 385.5 sq. ft. (77.1 sq. ft. per resident)b. Room SWD 2 (5 beds) measured: 391.3 sq. ft. (78.2 sq. ft. per resident)c. Room SWD 3 (5 beds) measured: 394.5 sq. ft. (78.9 sq. ft. per resident)d. Room SWD 4 (5 beds) measured: 390.2 sq. ft. (78 sq. ft. per resident) These four rooms were not crowded and did not impose any safety hazards. There were no complaints about space or room issues from the residents occupying these rooms. During an interview with the Administrator, on 2/12/26, the Administrator (ADM) confirmed the measurements for 25 of the 25 residents' rooms and four of those rooms did not meet the required 80 square feet per resident requirement. The survey team recommends the approval of the written room waiver continuum request, dated 2/12/26, for the rooms listed in this deficiency.

Based on observation, interview and record review, the facility failed to ensure the building was secured to prevent the elopement (leaving the facility without permission) of one resident (Resident 1).As a result, Resident 1 eloped from the facility and was at risk for physical injury and psychosocial harm.Findings:A Facility Reported Incident (FRI) was received by the California Department of Public Health on 9/9/25. The FRI reported that Resident 1 was missing from the facility.Resident 1 was admitted to the facility on [DATE] with diagnoses to include schizophrenia (a long-term mental disorder), per the admission Face Sheet.A telephone interview with the Administrator (Admin) was conducted on 9/11/25 at 5:15 P.M. Per the Admin, Resident 1 had eloped from the facility in the early morning of 9/9/25. The Admin stated a window screen was found to be loose in a room leading to an outdoor storage area, and a light outline of a shoe print was observed by staff on 9/9/25 following the incident. The Admin stated the window screen was loose on the right side, allowing space for a person to push open the window, and exit the room. Per the Admin, it was possible Resident 1 had eloped out the loose screen, then was able to climb over the exterior fence. The Admin stated the old, discarded equipment in the outdoor storage area may have been used as a way to climb over the fence and should not be stored in an area visible or accessible to residents.A record review was conducted on 9/15/25.Resident 1's Brief Interview for Mental Status (BIMS, an assessment of cognitive function) score was 0, indicating severely impaired cognition.Resident 1's elopement risk score dated 6/16/25 was 12, indicating he was not at risk for elopement.A concurrent interview with the Director of Maintenance (DM) and observation of the facility was conducted on 9/15/25 at 3 P.M. Window screens located in resident rooms throughout the facility, including the area where Resident 1 had resided, were loosely connected to the window frames, allowing space to reach in and pull screen forward. The DM stated he needed to replace the screens with a more secure option which could be firmly attached to the window frame.The storage area outside of the resident room involved had many large, discarded objects, including bed frames, wheelchairs, desks and office chairs, and large unidentified pieces of laundry or kitchen equipment. The discarded objects were stored against the perimeter chain link fencing. The DM stated the equipment should have been discarded as it was possible for a resident to use the equipment to climb over the six-foot fence. The DM stated he conducted weekly rounds of the facility looking for window screens or other exterior areas that needed repairs or replacement, but he had no documented evidence of the rounds.Per an undated facility policy, titled Interior General Maintenance, It is the policy of this facility to maintain in good repair at all times, all interior surfaces, fixtures.equipment.and furnishings to provide a safe, clean, comfortable environment for our patients.Per an undated facility policy, titled Elopement and Management of Missing Residents, Policy: It is the policy of the facility to promote resident safety.The facility maintains a process to assess all residents for risk of elopement.Elopement is the ability of a cognitively impaired resident, who is not capable of protecting themselves, to successfully leave the facility unsupervised and unnoticed, which may cause a potential harm.

Based on observation, interview, and record review, the facility failed to staff a Registered Nurse (RN) for at least 8 hours a day for twelve days from April 1 - June 30, 2024. This failure had the potential to prevent residents from receiving the care they needed. Findings: Review of PBJ (Payroll-Based Journal) Staffing Data Report, CASPER Report 1705 (a report that can help Skilled Nursing Facilities identify areas for improvement in care and operations) for Quarter 3 2024 (April 1 - June 30) indicated that No RN hours was triggered for twelve days. On 11/20/24 at 9:30 A.M., an observation of current staffing was observed posted at nurse's station. Staffing was within normal limits. On 11/20/24 at 9:57 A.M., a concurrent interview with the Director of Nursing (DON) and record review of PBJ Staffing Data Report, CASPER Report 1705 for Quarter 3 2024 (April 1 - June 30) was conducted during the Sufficient and Competent Staffing Facility Task. The DON indicated from her records the following days did not have a RN scheduled for at 8 least hours: 4/11/24, 4/16/24, 4/18/2, 04/22/25, 5/2/24, 5/8/24 5/16/24, 5/21/24, 5/23/24, 5/27/24, 5/28/24, 5/30/24 & 6/18/24. The DON stated that staffing numbers for Licensed Nurses (LN) and Certified Nursing Assistants (CNAs) were within limit those days, but they were unable to retain the services of an RN. The DON stated the facility had no waivers for staffing. The DON stated that when they do not have a RN on schedule, they have tried to accommodate with more LVNs. The DON stated the expectation was the facility should have a RN at least 8 hours a day. The DON stated the importance of having a RN at least 8 hours a day was to oversee patient care and safety, supervise nursing operations, conducts assessments for residents, and to provide support during change of conditions of residents. A review of undated facility policy titled, Nursing Services indicated, It is the policy of the facility to assure that there is sufficient qualified nursing staff available at all times to provide nursing and related services to meet residents' needs safely and in a manner that promotes each resident's rights, physical, mental, and psychosocial well being .

Based on interview and record review, the facility failed to ensure the staff followed policy and procedure for one of 14 sampled residents (Resident 22) when: 1) the staff did not document the medication administration accurately and 2) the staff did not document the medication administration in a timely manner. As a result, there was a potential the residents did not receive the prescribed amount of medication. Findings: Resident 22 was admitted to the facility on [DATE] with diagnoses which included schizophrenia (a type of mental health illness) per the facility's Admission Face Sheet. 1) A review of records was conducted. The physician order dated, 6/20/24 indicated, Resident 22 was to receive eight units of insulin (a medication to control blood sugar) three times a day. The MAR indicated, LN 2 and LN 3 gave Resident 22 six units of insulin on 11/16/24, 11/17/24 and 11/18/24. On 11/20/24 at 10:09 A.M., an interview with the DON was conducted. The DON stated LN 2 informed her that LN 2 knew the physician order was to give eight units of insulin to Resident 22, but LN 2 did not know why she documented the resident was given six units instead. The DON stated there could have been an effect on the resident if inaccurate medication was given. On 11/20/24 at 12:19 P.M., an interview with LN 2 was conducted. LN 2 stated she did not know why she documented she gave six units of insulin to Resident 22 when the physician order was to give eight units. LN 2 stated it looked like she did not give the prescribed full dose of insulin to Resident 22. LN 2 stated Resident 22's blood sugar could have gone up because of this. LN 3 was not available for interview. 2) On 11/19/24 at 1:45 P.M., an observation and interview was conducted with LN 1. LN 1 was observed documenting on the MAR dated 11/19/24 that she gave eight units of insulin to Resident 22 at 11:45 A.M. LN 1 stated she was supposed to document the medication administration right after she gave it to the resident and not wait two hours later. LN 1 stated if it was not documented right away, the staff may forget and give the resident a double dose. On 11/20/24 at 10:09 A.M., an interview with the DON was conducted. The DON stated the staff may just forget that they already gave the medication to a resident if they did not document it right away. The DON stated the staff was supposed to document on the MAR immediately after giving the medication. Per the facility's policy and procedure titled Medication Administration Guidelines, no date, .POLICY: 3. Each dose administered to a residents' shall be properly recorded in the residents' medical record.

Based on interview the facility failed to ensure that the facility's water system was tested for Legionella (an infectious bacteria that flourishes in air conditioning and water systems that causes a flu like symptoms). This failure had the potential for residents to become infected with Legionella via contaminated water sources. Findings: On 11/21/24 at 10 A.M., during the Infection Control task, an interview with the Director of Nursing (DON) was conducted. The DON stated that she was unaware if the facility was testing the facility's water for Legionella, but that the Administrator (ADM) would know. The DON stated that it was important to test for Legionella to prevent resident infection from Legionella. On 11/21/24 at 10:46 A.M., an interview with the Maintenance Supervisor (MS) was conducted. The MS stated he did not test the water for Legionella or any other bacteria. The MS stated he only tested the water temperature. The MS stated that he was not sure if the ADM was having a company come to test the water. The MS stated that it was important to test the water to prevent infections from Legionella. On 11/21/24 at 10:50 A.M., an interview with the ADM was conducted. The ADM stated that they were not testing for Legionella, and they had plans to contract the service out to a company. The ADM stated the expectation was that the facility should test and monitor the water regularly for possible Legionella contamination of water sources. The ADM stated that the importance of testing for Legionella was to prevent Legionella infections in staff and residents. The ADM stated that they had just developed a Legionella policy and procedure that was not yet approved. Review of QSO (Quality Safety Oversight Group a part of the Centers for Medicare & Medicaid Services that ensures the quality and safety of care for patients receiving Medicare and Medicaid services)-17-30 . DATE: June 02, 2017 REVISED 07.06.2018 indicated .Facilities must develop and adhere to policies and procedures that inhibit microbial growth in building water systems that reduce the risk of growth and spread of Legionella and other opportunistic pathogens in water .This policy memorandum applies to .Long-Term Care .

Based on observation, interview, and record review, the facility failed to ensure five of 25 resident rooms (Rooms SWD 1, SWD 2, SWD 3, SWD 4, and room [ROOM NUMBER]) accommodated no more than four residents. This failure had the potential to limit the freedom of movement for the residents that occupied those rooms, which may place them at risk for injury. Findings: During initial tour on 11/18/24, five of the 25 resident rooms accommodated more than four residents: a. Room SWD 1- 5 Residents b. Room SWD 2- 5 Residents c. Room SWD 3- 5 Residents d. Room SWD 4- 5 Residents e. room [ROOM NUMBER]- 5 Residents During the course of the survey, those rooms did not impose any safety hazards. There were no complaints of space or room issues from the residents occupying these rooms. There were no quality of care or quality of life concerns identified that negatively affected the residents residing in those rooms. The survey team recommends the approval of the written room waiver continuum request, dated 11/18/24, for the rooms listed in this deficiency.

Based on observation, interview, and record review, the facility failed to provide a minimum of 80 square feet (sq. ft.- unit of measurement) of livable space per resident for four of 25 resident rooms. This failure had the potential to affect the resident's health and safety, and prevent the residents from maintaining their highest level of well-being by limiting the movements of those residents in their rooms. Findings: During initial tour, dated 11/18/24, four of the 25 resident rooms were observed to be less than 80 sq. ft. per resident. The residents' rooms and their measurements of livable space were noted as follows: a. Room SWD 1 (5 beds) measured: 385.5 sq. ft. (77.1 sq. ft. per resident) b. Room SWD 2 (5 beds) measured: 391.3 sq. ft. (78.2 sq. ft. per resident) c. Room SWD 3 (5 beds) measured: 394.5 sq. ft. (78.9 sq. ft. per resident) d. Room SWD 4 (5 beds) measured: 390.2 sq. ft. (78 sq. ft. per resident) These four rooms were not crowded and did not impose any safety hazards. There were no complaints of space or room issues from the residents occupying these rooms. During an interview with the Administrator, on 11/21/24, the Administrator (ADM) confirmed the measurements for 25 of the 25 residents' rooms and four of those rooms did not meet the required 80 square feet per resident requirement. The survey team recommends the approval of the written room waiver continuum request, dated 11/18/24, for the rooms listed in this deficiency.

Based on observation, interview and record review, the facility failed to implement an emergency plan for food preparation when the kitchen ceiling had water damage. This failure had the potential for contamination of food for 57 residents. Findings: On 1/23/24, at 6:15 P.M., a concurrent observation was conducted with a Dietary Aide (DA 1) of the dining area. Several residents were in the dining room, some leaving the area. DA 1 stated the residents had just finished eating dinner. DA 1 stated the food preparation was done in the kitchen, but there was no leaking while the food was being prepared. On 1/23/24 at 6:25 P.M., the facility kitchen was toured with the Facility Owner (FO). Several areas of water damage were noted on the kitchen ceiling, including over the stove. Two holes were observed in the ceiling, one over dumbwater area, and one on far left side of the kitchen hood. Some areas noted to have small black circles about the size of a quarter. Pictures were taken. On 1/23/24, at 7:56 P.M., the Dietary Supervisor (DS) was interviewed. DS stated the kitchen had been used to prepare food because when the staff were cooking there was no dripping water. The DS stated if the kitchen was unavailable, the dining room/day room should have been utilized for food preparation. The DS stated the residents would then have meals in their rooms. The facility did not provide a written plan for food preparation in the event of the kitchen being unavailable.

Based on observation, interview and record review, the facility failed to provide a registered nurse (RN) on duty, 8 consecutive hours per day, seven days per week for 33 days out of 91 days from April 2023 thru June 2023. This failure had the potential for more advanced care activities provided by an RN to be unavailable to the residents. Findings: During the initial tour of the facility on 10/09/2023 at 9 A.M., the only RN at the facility was the Director of Nursing (DON). A review of the facility's PBJ (payroll based journal) Staffing Data Report, CASPER report 1705D, FY (fiscal year) Quarter 3, indicated, .triggered: four or more days within the quarter with no RN hours . Further review of the facility's staffing data report indicated: .Infraction dates: 04/01 (SA); 04/02 (SU); 04/08 (SA); 04/09 (SU); 04/13 (TH); 04/15 (SA); 04/16 (SU); 04/22 (SA); 04/23 (SU); 04/25 (TU); 04/28 (FR); 04/29 (SA); 05/02 (TU); 05/06 (SA); 05/07 (SU); 05/12 (FR); 05/13 (SA); 05/20 (SA); 05/21 (SU); 05/22 (MO); 05/27 (SA); 05/28 (SU); 05/29 (MO); 06/03 (SA); 06/04 (SU); 06/08 (TH); 06/10 (SA); 06/11 (SU); 06/17 (SA); 06/18 (SU); 06/25 (SU); 06/29 (TH); 06/30 (FR). An interview was conducted with the Administrator (ADM), 10/09/2023 at 10 A.M. The administrator stated, The only full time RN we have is our DON, Monday through Friday. On weekends we have Licensed Vocational Nurses (LVNs), for years it's been like that here. An interview was conducted with the DON on 10/10/2023 at 7:36 A.M., The DON stated, Staffing is determined by the census. Typically, A.M shift consist of 1 -Restorative Nursing Assistant (RNA), 2 LVNs, 8 -Certified Nursing Assistants (CNAs); P.M. shift consists of 1 RNA and 6 CNAs; Nocturnal/Night (NOC) shift consists of 1 LVN and 5 CNAs. We've never had an RN on the floor, always just the DON. Not sure what the federal requirement is but I can find out. As the DON, I'm in charge of covering all the resident's needs. The Minimum Data Set (MDS) nurse, who is a Licensed Vocational Nurse (LVN) is only here for 3-4 hours per day on weekdays, no weekends. The MDS who is an LVN covers my vacation/time off. My (DON RN) last vacation was in November 2022. A review of the facility's undated policy, undated, titled Nursing Services, indicated, The facility will have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment. A review of the Facility Assessment, dated December 2022, indicated, . 3.2 Staffing Plan- Based on our resident population and their needs for care and support, the following table represents the overall number of facility staff needed to ensure a sufficient number of qualified staff are available to meet each resident's needs . Position: Registered Nurse, Total Number Needed or Average or Range: 1; Position: DON, Total Number Needed or Average or Range: 1.