Every finding on record at Inland Christian Home

Based on observation, interview, and record review the facility failed to maintain a sanitary kitchen when: 1. In the clean dish storage area near the kitchen exit door, the clean dishes had leaves and other debris on them, the floor under the shelves had debris and dirt, and a cart of trash was stored next to the clean dish shelves. The Industrial stand mixer had dry, caked on batter and food residue on the neck and shield. The metal shelves above the cook's preparation area had a sticky residue and were coated with dust. The salad bar refrigerator had old food particles on the shelf surfaces inside the fridge. The drink area with a coffee maker, soda machine, and juice machine, had a coffee spill inside the cabinet that housed the soda bags. The cabinet doors under the steam table had dust, grime, and food particles covering the outer door surface. The shelf under the steam table had dust, grime, and food particles. 2. The Ice machine had a buildup of brown, pink, and black residue on the ceiling of the ice bin, where the ice exits the machine and enters the ice bin. These failures had the potential to contaminate food and cause food-borne illness to the 56 of 57 residents who received food from the kitchen.Findings: 1. During a concurrent observation and interview on August 17, 2026, at 8:54 AM, with the Dietetic Services Specialist (DSS) in the kitchen, there were leaves, dirt, and debris on clean dishes stored in the clean dish storage area. The floor under the clean dish storage shelves had a layer of dirt and debris on it and there was trash stored on a cart next to the clean dish shelf, in front of the kitchen exit door. The DSS stated, the door opens directly outside and was used for deliveries and taking out the trash. During a concurrent observation and interview on August 17, 2026, at 8:56 AM, with the DSS in the kitchen, the large industrial stand mixer was covered in plastic, when observed it had old, dry batter and food residue stuck to the neck and shield of the mixer. The DSS stated, the plastic cover was meant to indicate the mixer was clean and ready for use, she further stated, it needed to be cleaned. During an observation on August 17, 2026, at 9:04 AM, in the kitchen, the metal shelf above the cook's preparation area had a sticky residue and was coated in dust. During an observation on August 17, 2026, at 9:09 AM, in the kitchen, the salad bar refrigerator had old food particles on the shelf surfaces inside the fridge. During a concurrent observation and interview on August 17, 2026, at 9:13 AM, with the DSS in the kitchen, the drink area with a coffee maker, soda machine, and juice machine, had a dried, dark brown spill inside the cabinet that housed the soda bags. The DSS stated, there had been a coffee spill in the drink area the day before. During an observation on August 17, 2026, at 9:15 AM, in the kitchen, the cabinet doors under the steam table had dust, grime, and food particles covering the outer door surface. During an observation on August 17, 2026, at 9:17 AM, in the kitchen, the shelf under the steam table had dust, grime, and food particles. During an interview on August 18, 2026, at 2:38 PM, with the DSS, the findings of the kitchen tour were reviewed. The DSS stated, trash should not be stored in a clean area, dirt and leaves should not be on clean dishes, and the industrial mixer needs to be cleaned after every use. The DSS further stated, the shelves should all be clean, the salad bar should be clean with no food crumbs on the surfaces inside, and all spills should be cleaned up right away. The DSS additionally stated, she expects the area under the steam table to be clean, no food particles or grime. During a review of the facility's policy and procedure (P&P) titled, Sanitation and Infection Prevention/Control: Cleaning of Food and Nonfood contact surfaces, dated January 2025, the P&P indicated, . Nonfood contact surfaces of equipment, such as handles on reach-in units, side of sinks, gaskets on cooler and freezer doors, tracks of sliding doors on equipment, and the exterior of ice machines, shall be cleaned as often as is necessary to keep the equipment free of accumulation of dust, dirt, food particles, and other debris. During a review of the FDA Federal Food Code, dated 2022, 4-601.11 indicated, (C) Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. The objective of cleaning focuses on the need to remove organic matter from food-contact surfaces so that sanitization can occur and to remove soil from nonfood contact surfaces so that pathogenic microorganisms will not be allowed to accumulate, and insects and rodents will not be attracted. 2. During a concurrent observation and interview on August 17, 2026, at 9:21 AM, with the DSS in the kitchen, inside the ice machine, the ice shoot and ceiling of the ice bin had a buildup of brown, pink, and black residue. When wiped with a paper towel, the residue was visibly transferred on to the paper towel but not removed from the surfaces of the ice machine. The DSS stated, she had tried to clean the residue, but the surface is rough and difficult to clean. During a concurrent interview and record review on August 18, 2026, at 2:45PM, with the DSS, the facility document titled, Diversey: Ice Bin/Beverage Station was reviewed. The DSS stated, the document was used as the Ice Machine Cleaning P&P, because the facility does not have an Ice Machine Cleaning P&P. The document reviewed does not indicate cleaning of the areas of concern, nor does it indicate how to address rough, difficult to clean surfaces. During a review of the FDA Federal Food Code 4-602.11, dated 2022, indicated, .(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: (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 specifications, at a frequency necessary to preclude accumulation of soil or mold.In addition, ice makers, and ice bins must be cleaned on a routine basis to prevent the development of slime, mold, or soil residues that may contribute to an accumulation of microorganisms.

Based on observation, interview, and record review, the facility failed to implement their comprehensive care plan (a document that outlines a resident's specific health or personal care needs, the goals for their care, and the steps required to achieve them) for four (4) of 15 sampled residents (Resident 18 10, 6, and 42) when: 1.For Resident 18, the interventions for monitoring seizure (abnormal electrical activity in the brain) medication adverse side effects were not followed. This failure resulted in inadequate monitoring of Resident 18's seizure activity, toxicity, and adverse side effects of the seizure medication, placing Resident 18's health and safety at risk. 2. For Resident 10, the resident did not have a care plan for the depression medication Trazadone (a medication used for the treatment of a common and serious mood disorder that causes lasting sadness and a loss of interest in activities you once enjoyed). 3. For Resident 6, the resident did not have a care plan for the anticoagulant medication Eliquis (a tablet form medication that slow down the time it takes for blood to clot, helping to prevent harmful clots from forming or growing larger). 4. For Resident 42, the resident did not have a care plan for the anticoagulant medication Heparin (an injectable blood thinner medication that slow down the time it takes for blood to clot, helping to prevent harmful clots from forming or growing larger). These failures had the potential for Residents 10, 6 and 42 needs not being identified and addressed, which could lead to a decline in health, safety, and well-being. Findings: 1.During a review of Resident 18's admission record (contains demographic and medical information), the admission record indicated Resident 18 was admitted to the facility on [DATE], with diagnoses which included Alzheimer's Disease (brain disorder that damages memory, thinking, and behavior), seizures, and chronic obstructive pulmonary disease (long-term lung disease that makes it hard to breathe). During an observation on August 17, 2026, at 12:38 PM, in the dining room, Resident 18 was in a wheelchair sleeping while staff attempted to feed her lunch. During a review of Resident 18's Medication Order dated December 16, 2025, the Medication Order indicated Resident 18 received Levetiracetam (medication used to prevent seizures) 100mg/ml (mg- milligram/ ml- milliliter, units of measure) solution, Give 20 ml orally two times a day for seizure disorder. During a review of Resident 18's Care Plan, undated, the care plan indicated, .Give seizure medication as ordered by doctor. Monitor/ document side effects and effectiveness. Monitor labs and report any sub therapeutic or toxic results to MD. During a concurrent interview and record review on August 19, 2026, at 9:34 AM, with Licensed Vocational Nurse 1 (LVN 1), Resident 18's Medication Order for levetiracetam and Resident 18's Care Plan for seizure medication were reviewed. LVN 1 stated, Resident 18 sleeps all the time, has not had any seizure activity, and there is no documentation of monitoring for side effects or labs related to the seizure medication. During a concurrent interview and record review on August 19, 2026, at 1:28 PM, with the Director of Nursing (DON), Resident 18's Medication Order for levetiracetam and Resident 18's Care Plan for seizure medication were reviewed. The DON stated that there was no documented evidence the nursing staff specifically monitored Resident 18 for side effects of the seizure medication or had any labs (laboratory) to monitor for the seizure medication levels done in the past year. The DON stated that he was not aware of Resident 18 having any seizure activity while he had been at the facility. The DON further stated, the Care Plan interventions were not done. 2. During a review of Resident 10's admission record, the admission record indicated Resident 10 was admitted to the facility on [DATE], with diagnoses that included dementia (decline in memory, language, problem- solving and other thinking skills that interferes with daily life), heart failure (when the heart muscle cannot pump blood and oxygen efficiently enough to meet the body's needs), and type 2 diabetes mellitus (a long-term health condition where the body does not use insulin the right way causing high blood sugar in the blood). During an observation on August 17, 2026, at 10:38 AM, in Resident 10's room, Resident 10 was sleeping comfortably in bed with oxygen at 3.5 liters per minute. During a review of Resident 10's physician's orders dated February 8, 2026, the physician's orders indicated, Trazodone (antidepressant medication) HCL (hydrochloride) oral tablet 50 MG (milligram-unit of measurement) (Trazodone HCL). Give 0.5 tablet by mouth at bedtime for depression (a common and serious mood disorder that causes a persistent feeling of sadness, emptiness, and a loss of interest in daily activities) manifested by inability to fall asleep or stay asleep. give 25 mg total. During a concurrent interview and record review on August 20, 2026, at 12:45 PM, with the Director of Nursing (DON), Resident 10's clinical record was reviewed. The DON confirmed that there is no care plan created for Resident 10 receiving Trazadone. 3. During a review of Resident 6's admission record. the admission record indicated Resident 6 was admitted on [DATE], with diagnoses that included hemiplegia (the total or partial paralysis of an entire side of the body including the face arm and leg), hemiparesis (a medical condition that causes weakness or a reduced ability to move on one entire side of the body) following cerebral infarction (the death of brain tissue caused by a block blood vessel). During an observation on August 17, 2026, at 10:05 AM, in Resident 6's room, Resident 6 is lying in her bed resting, denied pain. During a review of Resident 6's physician's orders dated May 27, 2026, the physician's orders indicated, Eliquis (a blood thinner medication that is used to prevent and treat a block blood vessel) oral tablet 5 MG (milligram-a unit of measurement). Give one tablet by mouth every 12 hours for DVT (deep vein thrombosis- a condition where blood clot forms in a deep vein, usually in legs) prophylaxis (any treatment or action taken to prevent a disease from occurring or spreading). During a concurrent interview and record review on August 20, 2026, at 12:49 PM, with the Director of Nursing (DON), Resident 6's clinical record was reviewed. The DON confirmed that there is no care plan created for Resident 6 receiving Eliquis. 4. During review of Resident 42 admission record, the admission record indicated Resident 42 was admitted on [DATE], with diagnoses which included spinal stenosis (narrowing of the spaces within your spine that puts pressure on your spinal cord and nerve), hyperlipidemia (a condition where you have too many fats or lipids) and atherosclerosis of aorta (the buildup of fatty plaque cholesterol and calcium inside the main artery). During observation on August 17, 2026, at 3:05 PM, in Resident 42's room, Resident 42 is lying on her bed resting. Resident 42 denied pain. During review of Resident 42's physician's orders, dated July 18, 2026, the physician's orders indicated, Heparin (a blood thinner medication that stops new blood clots from forming). Inject 5000-unit (a unit of measurement) subcutaneously (giving a medicine or injection into the layer of fat tissue that sits directly under the skin and above the muscle) 2 times a day for DVT (deep vein thrombosis- a serious medical condition where a blood clot forms in a deep vein) prophylaxis. During a concurrent interview and record review on August 20, 2026, at 12:55 PM, with the Director of Nursing (DON), Resident 42's clinical record was reviewed. The DON confirmed there is no care plan created for Resident 42 receiving Heparin. During a concurrent interview and record review on August 20, 2026, at 11:15 AM, with the DON, the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, dated March 2022, was reviewed. The P&P indicated, . Each resident's comprehensive person-centered care plan is consistent with the resident's rights. including the right to. receive the services and/ or items included in the plan of care. The DON stated, the P&P was not followed, and it was important to follow the P&P because the care plan must be implemented and used to direct the resident's care. The DON further stated, if a nurse observes an adverse side effect of a medication it must be reported to the physician.

Based on observation, interview, and record review, the facility failed to ensure their Respiratory Therapy Prevention of Infection Policy was implemented for one (1) of five sampled residents (Resident 49) when an unlabeled open container of prefilled sterile water humidifier was found on Resident 49's bedside table. This failure had the potential to place Resident 49 at risk of infection.Findings: During a review of Patient 49's admission Record (contains demographic and medical information), the admission Record indicated Patient 49 was admitted to the facility on [DATE], with diagnoses that included chronic obstructive pulmonary disease (group of lung diseases that damage the airways and lungs, which can cause difficulty with breathing) and pneumonia (a lung infection that causes the small air sacs in one or both lungs to swell and fill with fluid or pus). During a review of Resident 49's Order Summary Report, dated August 20, 2026, the Order Summary Report indicated, May titrate (adjust) oxygen 2-5 liters (a unit of measurement) via Nasal Cannula (a light plastic tube that clips over your ears and puts two small prongs into your nose to give you extra oxygen) or Mask as needed to maintain oxygen saturation (measures the percentage of hemoglobin in your red blood cells carrying oxygen compared to the total amount available) greater than 94% as needed for oxygen saturation less than 94%. During an observation on August 17, 2026, at 11:54 AM, in Resident 49's room, an unlabeled open container of prefilled sterile water humidifier was found on Resident 49's bedside table and not properly disposed or stored. During a concurrent observation and interview on August 17, 2026, at 11:58 AM, with Director of Staff Development (DSD) in Resident 49's room, an unlabeled open container of prefilled sterile water humidifier was found on Resident 49's bedside table and not properly disposed or stored. DSD acknowledged the finding and stated the staff left it on the table after changing the prefilled sterile water humidifier. This could breed an infection control issue. During a concurrent interview and record review on August 20, 2026, at 12:44 PM, with the Director of Nursing (DON), the facility's policy and procedure (P&P) titled, Departmental (Respiratory Therapy)- Prevention of Infection, dated November 2011 was reviewed. The P&P indicated, General Guidelines: 1. Distilled water used in respiratory therapy must be dated and initialed when opened and discarded after twenty-four (24) hours. The DON stated the policy was not followed. The DON further stated it is important to follow the policy, so the staff can make sure the humidifier will not be reused for another resident and to help prevent infection.

Based on observation, interview, and record review, the facility failed to follow their policy and procedures (P&P) for administration of oxygen for one (1) of 15 sampled Residents (Resident 62) when Resident 62 received oxygen without humidifier. This failure had the potential to result in increased dryness and irritation of Resident 62's nasal passages causing Resident 62 to report respiratory discomfort, dry cough, and dry nose.Findings: During a review of Resident 62's admission record (clinical record with demographic information), the admission record indicated, Resident 62 was admitted to the facility on [DATE], with diagnoses that included pneumonia (an infection that inflames the air sucks in one or both lungs), gastrostomy status (a surgical opening directly into the stomach through the abdominal wall) and heart failure (serious medical condition where the heart muscle cannot pump blood and oxygen). During a concurrent observation and interview on August 17, 2026, at 10:15 AM, with the Infection Prevention Nurse (IP) in Resident 62's room, Resident 62 was observed laying in an upright position with oxygen infusing at 2 liters (a unit of measurement) per minute via nasal cannula (piece of tubing inserted through the resident's nostril). Further observation in Resident 62's room, there was no humidifier (sterile water bottle attached to an oxygen source to add moisture and prevent nasal dryness during oxygen therapy) in used. Resident 62 complained of nasal dryness and dry cough. During interview on August 17, 2026, at 10:30 AM, with the IP nurse, she confirmed that there is no humidifier and there should be one as a standard setup. During a review of Resident 62's physician's orders (a doctor instruction for resident's care, including medications, treatments, tests, or diet to be carried out by other healthcare staff to ensure correct and coordinated treatment), dated August December 20, 2026, the physician's orders indicated, may titrate (adjust) oxygen 2 to 5 liters via NC (nasal cannula) or masks as needed to maintain 02 (oxygen) greater than 94% as needed for 02 saturation (oxygen levels measured in percentage) less than 94%. During a concurrent interview and record review on August 20, 2026, at 12:30 PM with the Director of Nursing (DON), the facility's policy and procedure (P&P), titled, Oxygen Administration, dated 2001, was reviewed. The P&P indicated, Purpose: The purpose of this procedure is to provide guideline for safe oxygen administration. The P&P further stated under Equipment and Supplies: The following equipment will be necessary when performing this procedure.3. Humidifier bottle. The DON acknowledge the P&P was not followed, and a humidifier should have been provided.

Based on interview and record review, the facility failed to ensure a baseline care plan (a personalized, written document that details a resident's health conditions, specific needs, goals, preferences, and the support required to achieve them) for one (1) of 15 sampled Residents (Resident 62) was developed and implemented when Resident 62 did not have a care plan for receiving oxygen. This failure had the potential for Resident 62 needs not being identified and addressed, which could lead to a decline in health, safety, and well-being. Findings: 1. During the review of Resident 62's admission record (clinical record with demographic information), the admission record indicated Resident 62 was admitted on [DATE], with diagnoses that included pneumonia (an infection that inflames the air sucks in one or both lungs, causing them to fill with fluid or puss), gastrostomy status (a surgical opening directly into the stomach through the abdominal wall) and heart failure (serious medical condition where the heart muscle cannot pump blood and oxygen). During an observation on August 17, 2026, at 10:15 AM, in Resident 62's room, Resident 62 was observed lying in a half upright position with oxygen infusing at 2 liters (a unit of measurement) per minute via nasal cannula (piece of tubing inserted through the resident's nostril). During a review of Resident 62's physician's orders (a physician documented instructions for a resident's care, including medications, treatments, tests, or diet to be carried out by other healthcare staff to ensure correct and coordinated treatment), dated August 17, 2026, the physician's orders indicated, may titrate (to adjust the flow rate) oxygen 2 to 5 liters (a unit of measurement) via NC (nasal cannula) or masks as needed to maintain 02 (oxygen) > (greater than) 94% as needed for 02 saturation (the percentage of hemoglobin in your blood that is carrying oxygen compared to the total amount available) less than 94%. During a concurrent interview and record review on August 20, 2026, at 12:40 PM, with the Director of Nursing (DON), Resident 62's clinical record was reviewed. The DON confirmed there is no care plan created for Resident 62 receiving oxygen. During a concurrent interview and record review on August 20, 2026, at 12:55 PM, with DON, the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, undated, was reviewed. The P&P indicated, . a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the residents physical, psychosocial and functional needs is developed and implemented for each resident. 1. The interdisciplinary team (IDT), in conjunction with the resident and his/ her family or legal representative, develop and implement A comprehensive, person-centered care plan for each resident. The DON acknowledged the policy was not followed, and a care plan should have been created.

Based on observation, interview, and record review, the facility failed to ensure accurate records of controlled medications (narcotic medications that are controlled by the government because it may be abused or cause addiction) were maintained in accordance with their Policy and Procedure (P&P) for one of two Medication Carts (Medication Cart 1). This failure had the potential to result in an inaccurate count of narcotic drugs and drug diversion (illegal distribution of controlled drugs for any illicit use) of controlled medications by the staff.Findings: During a concurrent observation, interview, and record review, on August 19, 2026, at 7:15 AM, with Licensed Vocational Nurse 2 (LVN 2) at Station's 1- Medication Cart 1, Medication Cart 1's Narcotic Check Sheet (mandatory, real-time log tracking high-risk medication inventory [Schedules II-V] to prevent theft or misuse. Two licensed nurses verify the log during shift change) dated July 1, 2026, to August 18, 2026, was reviewed. The Narcotic Check Sheet indicated the following: a. On July 25, 2026, missing signature from a licensed nurse on the morning shift count (7:00 AM -3:00 PM) b. On July 25, 2026, missing signature from a licensed nurse on the evening shift count (3:00 PM to 11:00 PM c. On July 30, 2026, missing signature from a licensed nurse on the evening shift count (3:00 PM to 11:00 PM). d. On July 30, 2026, missing signature from a licensed nurse on the night shift count (11:00 PM to 7:00 AM). e. On August 16, 2026, missing signature from a licensed nurse on the night shift count (11:00 PM to 7:00 AM). LVN 2 confirmed the 5 missing signatures on the Narcotic Check Sheet and stated it is important to do a shift narcotic count with another licensed nurse, including a signature acknowledgement so we can make sure the facility has the correct count of narcotics. During a concurrent interview and record review on August 20, 2026, at 12:44 PM, with the Director of Nursing (DON), the facility's Policy and Procedure (P&P) titled, Controlled Substances, dated November 2022 was reviewed. The P&P indicated, .Dispensing and Reconciling Controlled Substances: 3. Nursing staff count controlled medication inventory at the end of each shift, using these records to reconcile the inventory count. 4.The nurse coming on duty and the nurse going off duty make the count together and document and report any discrepancies to the director of nursing services . The DON stated the facility did not follow the policy. The DON further stated it was important to do shift to shift narcotic count so there are no drug diversion and discrepancies in the count.

Based on observation, interview, and record review, the facility failed to honor food preferences for one (1) of 57 residents (Resident 53) when Resident 53 was served French fries for lunch and verbalized his dislike for potatoes and tray ticket indicated Resident 53 dislikes potatoes. This failure had the potential to result in Resident 53 feeling frustrated which may negatively impact Resident 53's feelings of self-worth and creating a mistrust of care providers.Findings: During a review of Resident 53's admission Record (contains demographic and medical information), the admission Record indicated Resident 53 was admitted to the facility on [DATE], with diagnoses which included Peripheral Vascular Disease (a slow, progressive circulation disorder characterized by the narrowing, blockage, or spasms of blood vessels), and hyperlipidemia (build-up of fats in the blood that can increase risk for heart problems), and prediabetes (blood sugar higher than normal). During a concurrent observation, interview, and record review, on August 17, 2026, at 12:23 PM, with Resident 53 in the dining room, Resident 53 was served French fries with his lunch. Resident 53 was visibly upset by the fries. Resident 53 stated the staff knows he does not like potatoes. Resident 53 called the fries 'trash' and pushed the fries away from his other food. Resident 53's tray ticket was reviewed, the tray ticket indicated Resident 53 dislikes potatoes. During a review of Resident 53's Minimum Data Set (MDS- a standardized assessment tool) section C, for Cognitive Patterns (the way the brain understands and responds to information) the Brief Interview for Mental Status (BIMS- tool to assess how the brain processes information) score was 15. The BIMS score indicated no impairment. During a review of Resident 53's Diet Order (doctor's instructions for food a resident can have), dated December 16, 2025, the Diet Order indicated, Resident 53 had an order for a Regular diet, diet texture: regular, and fluid consistency: regular/thin. During a review of Resident 53's Care Plan (a document that outlines an individual's specific health or personal care needs, the goals for their care, and the steps required to achieve them), date-initiated December 19, 2025, and revised on June 19, 2026, the care plan indicated, . honor resident food preferences. During an interview on August 18, 2026, at 2:48 PM, with the Dietetic Services Specialist (DSS), the DSS stated, she expects the kitchen staff to honor resident's food preferences. The DSS further stated, Resident 53 should not receive food he dislikes. During a review of the facility's Policy and Procedure (P&P) titled, Resident Food Services: Resident Meal Service, dated January 2024, the P&P indicated, .Residents will be offered menu choices for all meals, beverages and snacks and are based on their prescribed diet, food preferences, and choices accommodating their allergies, intolerances, preferences, and consistent with their plan of care.

Based on observation, interview, and record review, the facility failed to ensure medication was properly stored when: 1. For one of five sampled residents (Resident 41), barrier cream was found open and not in a sanitary manner on the night table next to the Resident 41's bed. This failure had the potential to cause contamination to the barrier cream and lead to skin infection. 2. One of one treatment cart was found to have 5 expired packets of hydrogel statured gauze (a wound dressing consisting of gauze that has been infused with a hydrogel, a gel-like substance that is primarily composed of water). This failure had the potential to cause worsening of the wound, delayed wound healing and can lead to wound infections. Findings: 1. During a review of Resident 41's face sheet (FS- a document with resident demographics, brief medical history, and emergency contacts), the FS indicated, Resident 41 was admitted on [DATE] with diagnosis of multi-system degeneration of the autonomic nervous system (MSA- a condition that affects the nervous system which control involuntary functions like blood pressure, digestion, and breathing. ), Neuromuscular dysfunction of bladder ( a condition where the nerves and muscles that control the bladders function are impaired leading to problems with storage or emptying if urine), and muscle weakness. During a review of Resident 41's orders, updated on June 18, 2025, it indicates, MASD [Moisture-associated skin damage- skin inflammation cause by prolonged exposure to moisture] to Right Buttock; cleanse with NS [Normal Saline-a solution of water and salt], pat dry, apply xeroform [a type of wound dressing, that is petrolatum -based gauze], add barrier cream to periwound [the area of skin surrounding a wound] and cover with super absorbent dressing every day shift for 14 days. And MASD to left Buttock; cleanse with NS pat dry, apply xeroform, add barrier cream to periwound and cover with super absorbent dressing every day shift for 14 days. During an observation on June 16, 2025, at 10:20 AM on the bedside table, there was a medication cup full of white cream, next to it were opened packets of Zinc Oxide barrier cream (Topical cream that created a protective layer on skin's surface). During an interview with Licensed Vocation Nurse 2 (LVN 2) on June 16, 2025, at 10:27 AM, LVN 2 stated, the medication cup had barrier cream, and it was most likely left like that by the treatment nurse. During an interview with Licensed Vocational Nurse 3 (LVN 3) on June 16, 2025, at 10:50 AM, LVN 3 stated it was not left in there by her and whoever left that medication cup with barrier cream should have tossed it because they are not supposed to leave the medication cups with barrier cream at bedside. During an interview with Infection Preventionist (IP) on June 16, 2025, at 11:20 AM, the IP stated it is not acceptable to leave a medication cup at the resident's bedside regardless of what is in it, and it should have been tossed. During a concurrent interview and record review on June 18, 2025, at 12:37 PM, with the Director of Nursing (DON) of the facility's Policy and Procedure (P&P) titled, Medication Labeling and Storage dated February 2023 was reviewed. The P&P indicated, The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. The DON stated that the barrier cream being left on the bedside table it not considered sanitary, and the P&P was not followed. The DON further stated it is important to get new barrier cream out of the bottle to not have contaminated barrier cream. 2. During an observation with on June 17, 2025, at 12:07 PM, in the treatment cart in front of the nurse's station, five hydrogel saturated gauze were found with expiration date of May 16, 2025. During a concurrent observation and interview with LVN 3 on June 17, 2025, at 12:10 PM, LVN 3 stated, that the hydrogels expired in May 2025, and verified it had been 32 days of it being expired. During a concurrent interview and record review with the DON, on June 18, 2025, at 12:39 PM, of the facility's P&P titled,medication storage in the facility dated June 2016 was reviewed. The P&P indicated, G. All expired medications will be removed from the active supply and destroyed in the facility . The DON stated that the P&P was not followed, and it should have. The DON stated it is important to not have expired medications to get all of the potency of the medications. During an interview on June 19, 2025, at 11:11 AM, with LVN 3, stated that it is her responsibility to check the treatment cart every Friday and make sure all expirations are ok. LVN 3 further stated, there should have not been any expired medications/ supplies in the treatment cart.

Based on observation, interview, and record review, the facility failed to maintain essential equipment in the kitchen free of accumulation of dirt, food residue, and other debris, when on June 16, 2025, at 9 AM during the initial kitchen tour, the 4-burner stove, the flat top griddle, and the grill were found to be in unsanitary conditions. These failures had the potential to lead to the growth of harmful microorganisms, such as bacteria, viruses, and fungi, which could result in foodborne illnesses for all 54 residents who reside in the facility. Findings: During the initial kitchen tour on June 16, 2025, at 9 AM the kitchen was inspected, and the following were found: (1) The 4-burner stove was found to have buildup oil, burnt food particles and grime on, around, and underneath the burners. (2) The flat top griddle was observed with visible layers of grease stains and dark discoloration across the cooking surface. (3) The grill has old burnt food particles sticking to the grill. During an interview with the Director of Kitchen (DOK) on June 16, 2025, at 10:10 AM, the DOK stated that the stove, flat top griddles, and grill had been cleaned four days ago. She highlighted that during cooking, food often spills over onto the stove and should ideally be wiped down immediately to prevent the accumulation of burnt food particles and grease. According to the DOK and the facility's Master Weekly Cleaning log, a thorough deep cleaning of the stove is scheduled for every Friday. During a concurrent interview and record review on June 18, 2025, at 10:52 AM, the facility's Policy and Procedure (P&P) #F013, titled Cleaning of Food and Non-Food Contact Surfaces, revised in January 2025, was reviewed. The P&P indicated, The food contact surfaces of all cooking equipment shall be kept free of encrusted grease deposits and other accumulated soil. Non-food contact surfaces of equipment shall be cleaned as often as necessary to keep the equipment free of accumulation of dust, dirt, food particles, and other debris. The Director of Kitchen (DOK) acknowledged that the P&P #F013 mandates that food contact surfaces of all cooking equipment must be free of encrusted grease deposits and other accumulated soil, while non-food contact surfaces must be cleaned regularly to prevent the build-up of dust, dirt, food particles, and other debris. The DOK admitted that the P&P #F013 was not followed and that the failure to adhere to the policy resulted in the unsanitary conditions observed during the inspection.

Based on observation, interview, and record review, the facility failed to follow proper sanitation and food handling practices when: 1. Two food items (BBQ sauce and Shredded Parmesan Cheese) were found in the refrigerator unlabeled and undated. 2. One food item (A tray of tomatoes) was found in the refrigerator beyond its expiration date on the label. 3. The cooling logs for May and June 2025 indicated improper cooling practices and techniques. These failures had the potential to cause significant health risks for all 54 vulnerable residents who reside in the facility. Findings: 1. During the initial kitchen tour on June 16, 2025, at 8:56 AM all refrigerators and freezers in the kitchen were inspected. The following were found: Two food items were found in the refrigerator unlabeled and undated. Specifically, there was a 1-gallon bottle of [name of brand] Tangy Gold BBQ sauce, which was 1/4 full, and a bag of [name of brand] Shredded Parmesan Cheese, both without labels and dates indicating when they were placed in the refrigerator. 2. One food item, a tray of tomatoes, was found in the refrigerator beyond its expiration date. The tray contained two whole tomatoes and one-half tomato, covered with plastic wrap, labeled must be used by 06/15/2025 at 8 AM. These tomatoes should have been discarded on June 15, 2025, at 8 AM according to the label instructions, but they were still present in the refrigerator the following day. During an interview with the Director of Kitchen (DOK) on June 17, 2025, at 3:35 PM, the DOK stated that the BBQ sauce and the shredded Parmesan cheese should have been labeled and dated when placed in the refrigerator. The DOK also acknowledged that the tomatoes were expired and should have been discarded as per the labeling instructions. The DOK was unsure as of why these items were not properly managed. During a concurrent interview with the DOK and record review on June 17, 2025, at 3:40 PM, the facility's Policy and Procedure (P&P) titled, FOOD AND SUPPLY STORAGE, revised January 2025, was reviewed. The P&P indicated, All food, non-food items and supplies used in food preparation shall be stored in such a manner as to prevent contamination to maintain the safety and wholesomeness of the food for human consumption. Most, but not all, products contain an expiration date. The words sell-by, best-by, enjoy-by or use-by should precede the date. The sell-by date is the last date that food can be sold or consumed . foods past the use-by, sell-by, best-by, or enjoy-by date should be discarded . discard food past the use-by or expiration date. The DOK acknowledged that the facility's P&P was not followed and emphasized the importance of labeling and dating all food items before placing them in storage or refrigeration and discarding expired items immediately. 3. During a review of facility's cooling logs on June 19, 2025, at 1:43 PM, the cooling logs indicated the following: 05/07/2025 - Chicken was placed in the refrigerator at 1:30 PM at 170 F (Fahrenheit-a unit of measurement for cold and heat). Temp rechecked at 3:39 PM was 78.3 F. Temp rechecked at 5:00 PM was 37 F. 05/09/2025 - Chicken was placed in the refrigerator at 8:30 AM at 150 F. Temp rechecked at 10:40 AM was 80 F. Temp rechecked at 12:30 PM was 40 F. 05/11/2025 - Chicken was placed in the refrigerator at 1:30 PM at 170 F. Temp rechecked at 2:30 PM was 120 F. Temp rechecked at 4:30 PM was 39 F. 05/14/2025 - Chicken was placed in the refrigerator at 3:00 PM at 160 F. Temp rechecked at 5:00 PM was 80 F. Temp rechecked at 7:00 PM was 37 F. 05/16/2025 - Chicken was placed in the refrigerator at 12:00 PM at 160 F. Temp rechecked at 1:00 PM was 90 F. Temp rechecked at 4:00 PM was 40 F. 05/22/2025 - Chicken was placed in the refrigerator at 1:00 PM at 170 F. Temp rechecked at 3:00 PM was 90 F. Temp rechecked at 5:00 PM was 38 F. 06/02/2025 - Pork was placed in the refrigerator at 1:27 PM at 141 F. Temp rechecked at 2:15 PM was 110 F. Temp rechecked at 3:00 PM was 40 F. 06/11/2025 - Corn was placed in the refrigerator at 1:22 PM at 141 F. Temp rechecked at 2:15 PM was 112 F. Temp rechecked at 3:00 PM was 36 F. 06/17/2025 - Chicken was placed in the refrigerator at 10:00 AM at 170 F. Temp rechecked at 11:30 AM was 110 F. Temp rechecked at 1:00 PM was 37 F. On June 19, 2025, at 2:05 PM during a concurrent Interview with DOK and record review, the cooling logs and the facility's Policy and Procedure (P&P) #B007 revised January 2025, titled,FOOD AND HANDLING GUIDELINES, were reviewed. During the review of the facility's Cooling Logs dated May 2025 and June 2025 with the DOK, several entries showing temperatures still above 70°F after the two-hour mark, while others show temperature checks performed too early (before the two-hour point) were identified. The P&P indicated, COOLING .Food shall be cooled from 135 F to 70 F as measured at its center within two hours and from 70 'F to 41 'F within an additional four hours for a total cooling time of six hours or less . Foods that have not cooled to 70°F within 2 hours of being placed in the cooling equipment: reheat once to 165 F and re-cool. If food was not below 70°F at 2 hours, and it was reheated, discard if not below 70 F at 2 hours when cooling for the second time. Food that is not below 41 F at 6 hours must be discarded. During the interview, the DOK acknowledges her oversight in monitoring the cooling process properly and explains that she believed cooling food faster was better and acknowledges that she checked the food temperature before the two-hour mark, therefore obtaining inaccurate temperature readings. The DOK stated the documentation must show the temperature reading precisely at the two-hour mark and six-hour mark to demonstrate P&P compliance. The DOK confirmed the facility's P&P was not followed.

Based on observation, interview, and record review, the facility failed to ensure that proper and safe infection control policies were followed for one of 15 sampled resident (Resident 2) when in Resident 2's room, a yankauer (a rigid, hollow medical instrument used for suctioning fluids, secretions, and debris from the mouth and throat) was left uncovered and exposed. Further observation in Resident 2' room, the yankauer and suction canister was found not dated. These failures had the potential to result in cross-contamination (transfer of harmful bacteria) which can lead to infection. FINDINGS: A review of Resident 2's admission Record, ((contains demographic and medical information), indicated Resident 2 was admitted to the facility on [DATE], with diagnoses which included Dementia (decline in mental ability severe enough to interfere with daily life), acute respiratory failure with hypoxia (a severe condition where the lungs cannot provide enough oxygen to the body), and hemiplegia (a condition characterized by paralysis of one side of the body, affecting the face, arm, and leg). During an observation on June 16, 2025, at 10:39 AM, in Resident 2's room, yankauer was found laying on top of suction machine uncovered and exposed to air. Further observation, the yankauer and suction canister was found not dated . During a concurrent observation and interview on June 16, 2025, at 10:44 AM, in Resident 2's room with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated she is not familiar with how often yankauer and suction canister needs to be changed but she believes it should be every four to five days. During an interview on June 17, 2025, at 8:52 AM, with Infection Preventionist Nurse (IP), IP stated that yankauer should be changed every seven days, yankauer should be covered, and should be labeled. The IP further stated that, infection control practices was not followed, and her expectation is that all staff should be able to identify breaches in infection control. During an interview on June 18, 2025, at 12:48 PM with the Director of Nursing (DON), the DON stated the yankauer needs to be changed every time that it is used and should not be left open to air due to infection control. A policy and procedure (P&P) was requested, the facility was unable to provide a P&P regarding infection control practices with yankauer.

Based on interview, and record review, the facility failed to ensure the quarterly Resident Assessment Instrument/Minimum Data Set (RAI/MDS- a facility assessment and care planning process used by nursing home staff as required by the Centers of Medicare and Medicaid Services [CMS] every 3 months or quarterly) was completed in accordance with federal submission timeframes, for two of two sampled residents (Resident 4 and 46) when: 1. Resident 4's Annual Comprehensive Assessment RAI/MDS assessment was completed on June 18, 2025. (146 days late). 2. Resident 46's quarterly RAI/MDS assessment was not completed on June 18, 2025. (122 days late) These failures had the potential to result in a delay in determining the resources necessary to competently care for the Resident 4 and 46 during the day-to-day operations and emergencies. Findings: 1. During a review of Resident 4's History and Physical (H&P -contains resident's medical history, physical examination and reason for admission to the facility), dated June 19, 2025, the H&P indicated, Resident 4 was admitted to the facility on [DATE], with diagnoses which included chronic obstructive pulmonary disease (a group of lung disease that blocks airflow and make it difficult to breathe), heart failure (when the heart does not pump enough blood), mild cognitive impairment (a brain condition that causes noticeable but mild memory and thinking problems), and acute on chronic respiratory failure (a condition where a patient with pre-existing problems experiences a sudden worsening of their respiratory functions). During an interview on June 19, 2025, at 10:57 AM, with the Director of Nursing (DON), the DON stated one of her duties is to make sure the resident's MDS is completed on time. The DON further stated the expectation for the quarterly/ annual comprehensive assessment is that it must be completed within 92 days from the prior quarterly assessment. During a concurrent interview and record review on June 19, 2025, at 11:05 AM, with the DON, Resident 4's quarterly MDS assessment data, dated January 23, 2025, was reviewed. The DON stated the last quarterly assessment was completed on January 23, 2025. The DON further stated the facility did not complete the annual comprehensive assessment that was due on April 26, 2025 (92 days late). The annual comprehensive assessment was completed on June 18, 20025, (146 days late). 2. During a review of Resident 46's H&P dated June 19, 2025, the H&P, indicated, Resident 46 was admitted to the facility on [DATE], with diagnoses which included type 2 diabetes mellitus (high blood sugar), chronic kidney disease (when the kidneys do not work properly), hypertension (a condition where the heart is working harder to pump blood), and anemia (a condition in which the blood doesn't have enough healthy red blood cells and hemoglobin. A protein found in red blood cells, to carry oxygen all through the body). During an interview on June 19, 2025, at 10:57 AM, with the Director of Nursing (DON), the DON stated one of her duties is to make sure the resident's MDS is completed on time. The DON further stated the expectation for the quarterly assessment is that it must be completed within 92 days from the prior quarterly assessment. During a concurrent interview and record review on June 19, 2025, at 11:05 AM, with the DON, Resident 46's quarterly MDS assessment data, dated February 16, 2025, was reviewed. The DON stated the last quarterly assessment was completed on February 16, 2025. The DON further stated the facility did not complete the quarterly assessment that was due on May 19, 2025 (92 days late) and was submitted on June 18, 2025 (122 days late). During a concurrent interview and record review on June 19, 2025, at 11:19 AM, with the DON, the facility's P&P titled, Resident Assessments dated 2001, was reviewed. The P&P indicated, .1. The resident assessment coordinator is responsible for ensuring that the interdisciplinary team conducts timely and appropriate resident assessments and reviews according to the following requirements: a. OBRA required assessments-conducted for all residents in the facility: (1) admission Assessment (Comprehensive); (2) Quarterly Assessment; (3) Annual Assessment (Comprehensive); and P&P titled, Quarterly Assessments, dated 2001, was also reviewed. The P&P indicated, .1. The Quarterly assessment is an OBRA non-comprehensive assessment for a resident that is completed at least every 92 days following the previous OBRA assessment of any type. A. The ARD will not be more than 92 days after the ARD of the most recent OBRA assessment of any type The DON stated the P&P was not followed and should have because it provides accurate reimbursement for the facility and care planning for the residents.

Based on interview, and record review, the facility failed to ensure one of five sampled residents (Resident 37) received the influenza (also known as the flu, which is a contagious respiratory illness caused by influenza viruses) vaccination even though the flu vaccine was requested on November 14, 2024. This failure had the potential for Resident 37 to have an increase the risk of illness, higher risk of complications, and it may contribute to spreading the virus to others. Findings: During a review of Resident 37's face sheet (FS- a document with resident demographics, brief medical history, and emergency contacts), the FS indicated, Resident 37 was admitted on [DATE] with diagnosis of dementia ( a mental ability that interfere with daily life such as memory loss, impaired thinking and changes in behavior), Diabetes Type 2 ( a condition where the body is not producing enough insulin to keep blood glucose in normal level), and dysphagia (difficulty swallowing). During a review of the immunization dashboard, there was no documented evidence resident 37 received the influenza vaccine in 2024. During a concurrent interview and record review with the Infection preventionist (IP) on June 19, 2025, at 9:02 AM, the vaccine consent form dated November 14, 2024, was reviewed. The vaccine consent form indicated, I hereby request that the influenza vaccine be given per facility policy and CDC [Center for Disease Control and Prevention] guidelines. The IP stated that the facility should have followed up with the influenza vaccination since the Resident 37 agreed to it. During a review of the CDC influenza (flu) Vaccine dated January 31, 2025, the influenza Vaccine indicates, everyone 6 months and older should get a flu vaccine every season . During a concurrent interview and record review with the Director of Nursing (DON) on June 19, 2025, at 1:36 PM the facility's Policy and Procedure (P&P) titled Influenza Vaccine dated March 2022 was reviewed. The P&P indicated, Administration of the influenza vaccine will be made in accordance with current Centers for Disease Control and Prevention (CDC recommendations at the time of vaccination. The DON stated the policy was not followed and should have been because the residents are in a high risk environment making them a higher risk for complications.

Based on interview, and record review, the facility failed to ensure the quarterly (every 3 months) Resident Assessment Instrument/Minimum Data Set (RAI/MDS- a facility assessment and care planning process used by nursing home staff as required by the Centers of Medicare and Medicaid Services [CMS]) was transmitted (submitted) to CMS in accordance with federal submission timeframes, for two of two sampled residents (Resident 4 and 46) reviewed for resident assessment when: 1. Resident 4's comprehensive RAI/MDS assessment was completed on June 18, 2025 (146 days late) 2. Resident 46's quarterly MDS assessment was completed on June 18, 2025 (122 days late). These failures resulted in inadequate monitoring of Residents 4 and 46 progress or decline and the lack of Residents 4 and 46 specific information to CMS for payment and quality measure monitoring. Findings: 1. During a review of Resident 4's History and Physical (H&P -contains resident's medical history, physical examination and reason for admission to the facility), dated June 19, 2025, the H&P indicated, Resident 4 was admitted to the facility on [DATE], with diagnoses which included chronic obstructive pulmonary disease (a group of lung disease that blocks airflow and make it difficult to breathe), heart failure (when the heart does not pump enough blood) , mild cognitive impairment (a brain condition that causes noticeable but mild memory and thinking problems), and acute on chronic respiratory failure (a condition where a patient with pre-existing problems experiences a sudden worsening of their respiratory functions). During an interview on June 19, 2025, at 10:57 AM, with the Director of Nursing (DON), the DON stated one of her duties is to make sure the resident's MDS is completed on time. The DON further stated the expectation for the quarterly/ annual comprehensive assessment is that it must be completed within 92 days from the prior quarterly assessment. During a concurrent interview and record review on June 19, 2025, at 11:05 AM, with the DON, Resident 4's quarterly MDS assessment data, dated January 23, 2025, was reviewed. The DON stated the last quarterly assessment was completed on January 23, 2025. The DON further stated the facility did not complete the annual comprehensive assessment that was due on April 26, 2025 (92 days late). The annual comprehensive assessment was completed on June 18, 20025 (146 days late). 2. During a review of Resident 46's H&P dated June 19, 2025, the H&P, indicated, Resident 46 was admitted to the facility on [DATE], with diagnoses which included type 2 diabetes mellitus (high blood sugar), chronic kidney disease, hypertension (a condition where the heart is working harder to pump blood), and anemia (a condition in which the blood doesn't have enough healthy red blood cells and hemoglobin. A protein found in red blood cells, to carry oxygen all through the body). During an interview on June 19, 2025, at 10:57 AM, with the Director of Nursing (DON), the DON stated one of her duties is to make sure the resident's MDS is completed on time. The DON further stated the expectation for the quarterly assessment is that it must be completed within 92 days from the prior quarterly assessment. During a concurrent interview and record review on June 19, 2025, at 11:05 AM, with the DON, Resident 46's quarterly MDS assessment data, dated February 16, 2025, was reviewed. The DON stated the last quarterly assessment was completed on February 16, 2025. The DON further stated the facility did not complete the quarterly assessment that was due on May 19, 2025 (92 days late) and was submitted on June 18, 2025 (122 days late). During a concurrent interview and record review on June 19, 2025, at 11:19 AM, with the DON, the facility's P&P titled, Resident Assessments, dated 2001, was reviewed. The P&P indicated, .1. The resident assessment coordinator is responsible for ensuring that the interdisciplinary team conducts timely and appropriate resident assessments and reviews according to the following requirements: a. OBRA required assessments-conducted for all residents in the facility: (1) admission Assessment (Comprehensive); (2) Quarterly Assessment; (3) Annual Assessment (Comprehensive); and P&P titled, Quarterly Assessments, dated 2001, was also reviewed. The P&P indicated, .1. The Quarterly assessment is an OBRA non-comprehensive assessment for a resident that is completed at least every 92 days following the previous OBRA assessment of any type. A. The ARD will not be more than 92 days after the ARD of the most recent OBRA assessment of any type . The DON stated the P&P was not followed and should have because it provides accurate reimbursement for the facility and care planning for the residents.

Based on interview, and record review, the facility failed to ensure the Physician Orders Life Sustaining Form (POLST-medical orders that communicates to healthcare facilities and providers a patient's wishes for end-of-life interventions) was appropriately completed for one of five sampled residents (Resident 37) reviewed for Advance Directives (legal document that allows you to spell out your decision about end-of-life care) when the facility had Resident 37 with a BIMS (brief interview for mental status indicating decision making capacities in which a score of 13-15 has no significant decisions making impairment, a score of 8-12 has moderate decisions making impairment, a score of 0-7 has severe decisions making impairment) of 00 sign the POLST instead of the legally recognized decisionmaker. This failure had potential to cause emotional distress to Resident 37 and the Resident 37's family for not respecting their wishes to treatment. Findings: During a review of Resident 37's face sheet (FS- a document with resident demographics, brief medical history, and emergency contacts), the FS indicated, Resident 37 was admitted on [DATE] with diagnosis of dementia ( a mental ability that interfere with daily life such as memory loss, impaired thinking and changes in behavior), Diabetes Type 2 ( a condition where the body is not producing enough insulin to keep blood glucose in normal level), and dysphagia (difficulty swallowing). During a review of the Resident 37's POLST dated May 12, 2025, the POLST indicated, that it was discussed with the legally recognized decisionmaker, but it was signed by Resident 37. During a review of the Minimum Data Set (MDS-a standardized, comprehensive assessment that collects information about a resident's functional, medical, psychosocial, and cognitive status.) dated March 9, 2025, section C which include BIMS indicated Resident 37's BIMS score was 00. During a concurrent interview and record review on June 17, 2025, at 8:56 AM with the Director of Nursing (DON) the POLST for Resident 37 was reviewed. The POLST indicated, that it was signed by Resident 37. The DON stated that the POLST should have been signed by the legally recognized decisionmaker and not the resident. During an interview with Social Services Director (SS), on June 17, 2025, at 9:33 AM, the SS stated it is important to have the legally recognized decisionmaker because they want to be sure to follow the family wishes. During a concurrent interview and record review with the DON of the facility's Policy and Procedure (P&P) titled Physician Orders for Life Sustaining Treatment POLST dated November 2017, was reviewed. The P&P indicated, .The form is to be signed by the resident with capacity, or the resident representative when resident lacks capacity . The DON stated that a resident with a BIMS score of 0 does not have the capacity to sign documents and that the POLST should have been signed by the legally recognized decisionmaker. The DON further stated that the policy was not followed and should have been in order to know the family's wishes in case of an emergency.

Based on observation, interview and record review, the facility failed to store food by methods that conserve nutritive value, flavor, and appearance when a tray of pudding and cut melon was stored in the refrigerator uncovered and undated. There was a bag of hot dogs with a mold like substance, tortillas were stored uncovered and leftover pork from May 4 was stored in the refrigerator drawer, ready for use. These failures had the potential for food to not be palatable when served to 52 of 53 vulnerable residents who receive food from the kitchen. Findings: During an observation on May 6, 2024, at 8:50 a.m., inside the reach-in refrigerator, there were tray of pudding and cut melons uncovered and undated ready to use. During an observation on May 6, 2024, at 8:52 a.m., in the lower refrigerator noted, one plastic bag hot dogs with a mold-like substance undated, and one bag of tortillas uncovered, and a small container of leftover pork from May 4 stored in the lower refrigerator drawer ready to use. During an interview with Nutrition Care Manager (NCM) on May 6, 2024, at 9:09 a.m., NCM stated that the hot dogs and tortillas should have been thrown out. During an interview with the Dining Service Director on May 6, 2024, at 9:33 a.m., DSD stated that no food should have been uncovered left in the refrigerator. DSD, further stated, leftovers need to be used within three days. During an interview with the Dining Service Director on May 8, 2024, at 9:20 a.m., DSD stated leftovers should only be kept for three days and all food in the refrigerator should be covered. During a review of the facility policy titled Production, Purchasing, Storage, dated January 2024, indicated, All food, non-food items and supplies used in food preparation shall be stored in such a manner as to prevent contamination to maintain the safety and wholesomeness of the food for human consumption. Under procedures of the policy indicated, Cover, label and date unused portions and open packages.

Based on observation, interview and record review, the facility failed to maintain a sanitary kitchen when: 1. Floor behind the cooking line had a build-up of grease and food crumbs. This had the potential to attract pest and for microorganism growth. 2. Floor under the shelves in the dry storage had build-up of food crumbs. This had the potential to attract pests. 3. In the walk-in refrigerator, thawing meat was not labeled or dated. This had the potential to cause food borne illness (illnesses contracted from eating contaminated food or beverages). 4. Ice machine had a brown slime build-up underside of icemaker, in the top portion of the ice bin. This had the potential to cause food-borne illness. These failures had the potential to cause food borne illness to 52 of 53 medically compromised residents who received food from the kitchen. Findings: 1. During an observation and concurrent interview on May 6, 2024, at 08:58 AM, at the kitchen the cooking line, there was a build-up of grease and food build-up behind stove. Nutrition Care Manager (NCM) stated, it should be kept clean. During interview with Dinning Services Director (DSD) on May 8. 2024 9:12 AM, She stated she had cleaned the area under the cooking line with grease build-up about two weeks ago. DSD stated, it should be cleaned more often under the cooking line on the floor to eliminate the grease build-up. DSD further stated that area is not on the cleaning schedule, the grease build- up. DSD stated, she needed to add those areas that were identified to their cleaning list. During a review of the facility policy titled Sanitation and Infection Prevention/Control, revise date January 2024, indicated Nonfood contact surfaces of equipment .shall be cleaned as often as is necessary. Kitchen floors will be swept and mopped at a minimum daily or as needed. During a review of the FDA Federal Food Code 2022, 4-101.19 indicates, Nonfood-contact surfaces of equipment routinely exposed to splash or food debris are required to be constructed of nonabsorbent materials to facilitate cleaning. Equipment that is easily cleaned minimizes the presence of pathogenic organisms, moisture, and debris and deters the attraction of rodents and insects. 2. During an observation in the kitchen, on May 6. 2024 9:12 a.m., floor under the shelves in dry storage had build-up of food crumbs. During an interview with DSD on May 6, 2024, at 9:32 a.m., DSD stated there should not be any crumbs in hard-to-reach areas of the dry storage. During a review of the facility policy titled Sanitation and Infection Prevention/Control, revised date January 2024, indicated Nonfood contact surfaces of equipment .shall be cleaned as often as is necessary. During a review of the FDA Federal Food Code, dated 2022, 4-601.11indicated Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. In addition, The objective of cleaning focuses on the need to remove organic matter from food-contact surfaces so that sanitization can occur and to remove soil from nonfood contact surfaces so that pathogenic microorganisms will not be allowed to accumulate, and insects and rodents will not be attracted. 3. During an observation in the walk-in refrigerator on May 6, 2024, at 09:05 AM, there were two pieces of steak in 2-gallon bag unlabeled and undated. Four bags of beef not labeled or dated, five tubes ground beef thawing unlabeled and undated and two pans of chicken unlabeled and undated. During interview with the AM Cook, on May 6, 2024, at 9:13 a.m., the cook usually pulls the meat at least three days prior to use. AM Cook further stated the meat should be labeled and dated when put in refrigerator to thaw. During an interview with Dining Food Services Director (DSD), on May 8, 2024, at 9:20 a.m., DSD stated, they defrost the meat 3 days before, but should always be labeled and dated. During a review of the facility policy titled Production, Purchasing, Storage (HACCP) revised date January 2024 indicated Count the day the raw meat is removed from freezer as Day 1; it must be cooked by the end +4 days. Label with the date it was removed from the freezer, and the date by which it must be used. During a review of the FDA Federal Food Code, dated 2022, 3-501.17, indicated refrigerated, ready-to-eat, time/temperature control for safety food prepared and held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded when held at a temperature of 5 C (41 F) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1. In addition, Food which is prepared and held, or prepared, frozen, and thawed must be controlled by date marking to ensure its safety based on the total amount of time it was held at refrigeration temperature, and the opportunity for Listeria monocytogenes to multiply, before freezing and after thawing. 4. During an observation of Ice Machine in the kitchen on May 6, 2024, at 3:14 p.m., noted, in the area where ice was formed there was a black substance and yellow build-up underside the top portion of the ice bin where ice enters the bin. There was a stainless-steel plate that had a slimy substance. During observation and concurrent interview with Dining service Director (DSD), on May 6, 2024, at 3:20 p.m., DSD stated she cleans the ice machine, but did not clean inside where the build-up and slime was found. During observation and concurrent interview with DSD, on May 8, 2024, at 9:20 a.m., DSD stated her expectation is that the ice machine is always clean and has no build-up. During interview with Infection Preventionist Nurse on May 6, 2024, at 3:32 p.m., stated there are no documented cases of norovirus in the last 6 months. During a review of the facility policy titled Instruction Manual, revised date August 7, 2017 under Monthly Maintenance Schedule, it indicated, Underside of Icemaker and Top Kits, Bin Door and Snout. Wipe down with a clean cloth and warm water. During a review of the FDA Federal Food Code, dated 2022, 4-602.11 indicated, Equipment food-contact surfaces and utensils shall be cleaned: (5) At any time during the operation when contamination may have occurred. In addition, Surfaces of utensils and equipment contacting food that is not time/temperature control for safety food such as iced tea dispensers, carbonated beverage dispenser nozzles, beverage dispensing circuits or lines, water vending equipment, coffee bean grinders, ice makers, and ice bins must be cleaned on a routine basis to prevent the development of slime, mold, or soil residues that may contribute to an accumulation of microorganisms.

Based on observation, interview, and record review the facility failed to maintain an effective pest control program when a roll up door in the paper goods storage closet had a gap where light could be seen coming through. This failure is a potentially for pest entry into the kitchen which could contaminate food and cause food borne illness to 52 of 53 residents that received food from the kitchen. Findings: During kitchen observation on May 6, 2024, at 9:32 a.m., in the paper storage room, there was a roll up garage type door with light coming through the floor. Noted small gap between the roll up door and the floor. The floor partially wet. During observation the outside roll up door on May 7, 2024, at 3:00 p.m., the roll up door has a gap between the door and the floor. The ground was wet. During interview with Dining Service Director DSD, on May 6, 2024, at 9:40 a.m., DSD stated that there should be no gap that could allow pest entry. During an interview with Dining Service Director DSD, on May 8, 2024, at 9:20 a.m., DSD stated, the gap needs to be closed. During a review of the facility policy titled Sanitation and Infection Prevention/Control, dated January 2024, indicated, The Food and Nutrition Services Department shall be free of all rodents and insects ., Ensure that all holes and cracks in walls and floors where pests and rodents could gain entry are repaired/sealed ., Ensure that exterior department doors including those leading to outside receiving area and garbage area have less than 1/4-inch gap between door and floor to prevent pest and rodent entry .

Based on observation, interview, and record review the facility did not follow the menu when residents on a Consistent Carbohydrate Order (CCHO) diet (diet involves eating the same number of carbohydrates every day to manage blood sugar levels) received 1/4 cup serving of Yukon whipped potatoes instead of 1/2 cup serving and residents on a regular diet received 2.6 ounces of baked ham instead of 3 ounces that the menu indicated, for lunch on Monday May 6, 2024. This failure caused residents to not get the nutrients that their physician ordered diet included and affected 29 of 52 medically compromised residents who received food from the kitchen. Findings: During lunch meal observation on May 6, 2024, at 11:50 a.m., the cook used a #16 scoop (2 ounces (oz)) to serve the Yukon whipped potatoes for residents 23, 13 and 251 on a CCHO diet . The cook also served resident 204, 2.6 ounces of baked ham. During observation and concurrent interview with Dining Service Director (DSD), on May 6, 2024, at 12:05p.m., the DSD weighed the baked ham and stated it is 2.6 oz. DSD stated, The cook should have followed the menu and served 3 oz or more of the baked ham. During interview with Director of nutrition (DN), Registered Dietitian (RD), Nutrition Care Manager (NCM) and Dining Service Director (DSD), on May 8, 2024, at 9:22 am, RD stated the resident should receive the correct portions according to the menu. During record review of lunch menu titled Diet Extensions: Monday, Week 4, ICH 2024 SS for May 6, 2024, menu includes Baked ham 3 oz, Yukon Whipped potatoes 4 oz for CCHO diet Residents.

Based on observation, interview and record reviews, the facility failed to ensure the correct amount of enteral feeding nutrition (a liquid nutrition formula for tube feeding administered directly into the stomach) was administered as ordered for two of two sample residents (Resident 45 and 13) when the nursing staff did not give the correct amount of feeding formula as prescribed and in accordance with their care plans (the individualized plan for medical care of a resident). These failures resulted in Resident 13 and 45 to not receive the daily calories as ordered and had the potential to cause sub-optimal (less than ideal) nutritional status that may negatively affect Resident's health and well-being. Findings: 1. During a review of Resident 45's Admission Record (contains demographic and medical information), the admission record indicated Resident 45 was admitted to the facility on [DATE], with diagnoses of acute cerebrovascular insufficiency (a reduction in blood flow in the brain), gastrostomy status (having a gastrostomy tube also known as a G-tube, this tube is inserted through the abdomen into stomach to provide nutrition and fluids directly when a person is unable to eat or drink normally) and dysphagia (difficulty of swallowing food or liquids). During a review of Resident 45's MDS (Minimum Data Set - a clinical assessment of all residents in nursing homes) 3.0 Section C -Cognitive dated February 29, 2024, the MDS indicated Resident 45 had a BIMS (brief interview for mental status) score of 8 (A score of 8-12 indicated moderate cognitive impairment). During an observation on May 7, 2024, at 12:15 PM, Resident 45 was observed in bed, a bottle of enteral nutrition was at her bedside. The bottle was connected to a feeding pump (pump which administers enteral nutrition) which was not on and was no longer administering enteral nutrition. The label on the enteral nutrition bottle indicated [Brand Name] 1.2 calories with the total amount of 1000 milliliters (ml-unit of measurement) liquid formula. The label also indicated, the nursing staff administered the enteral nutrition at the infusion rate of 50 ml per hour started on May 6, 2024, at 2:00 PM. The enteral nutrition bottle contained 300 mls of liquid formula. During an interview on May 7, 2024, at 3:10 PM,with License Vocational Nurse, LVN 3, inspected a photograph of Resident 45's bottle of [Brand name] 1.2 calories, taken on May 7, 2024, at 12:15 PM, and acknowledged that there was 300 mL remaining in the bottle. LVN 3, stated Resident 45 did not receive the fluid for six hours based on how much was left in the bottle. LVN 3 further stated, Resident 45 should have received 1000 mls instead of only 700 mls. LVN 3 further stated, Resident 45 may not have received the full amount of enteral feeding, as her feeding may have been placed on hold during personal care activities or when receiving oral gratification. During an interview on May 9, 2024, at 9:30 AM, with the Registered Dietitian (RD), RD stated for Resident 45 the enteral nutrition feeding was her primary source of her diet. RD further stated, mentioned that her expectation was 50 mL to be administered in 20 hours. If this amount was not administered within 20 hours, they should extend the hours until it was completed. The RD stated, it was important for staff to document a rationale if the full amount was not administered. Furthermore, the RD stated, if the full amount of feeding was not received the resident would lose weight. During a review of Resident 45's physician orders, dated May 10, 2024, a physician order indicated Enteral feeding [Brand Name] 1.2 [calories per milliliter Cal/mL of the liquid formula] @ [at] 50 mL/hr. x [for] 20 hours [The resident is receiving 50 milliliters of liquid nutrition per hour through a feeding tube for 20 hours} Flush with Fluid 70 mL Q [every] 4H(hour). Feeding will provide 1000ml [Volume of liquid nutrition] /1200 Kcal, [Liquid nutrition will provide 1200 kilocalories, Kcal is a measure of energy from the food] 60g protein, [the liquid nutrition contains 60 grams of protein], 1155 mL water. ((milliliters of water) Enteral feeding. During a record review of Resident 45's Weight Summary, dated March 1, 2024, through May 2, 2024, the Weight Summary indicated the following: On April 25, 2024, at 11:15 AM: weight 107 lbs (pounds-unit of measurement) On May 2, 2024, at 10:01 AM weight 101 lbs. (6 pound weight loss in 1 week) During a record review of Resident 45's Care Plan dated February 23, 2024, the CarePlan indicated Enteral Feeding -requires enteral feeding for nutrition Gastrostomy tube due to CVA (cardiovascular accident-Stroke occurs when the blood flow for a part of the brain is interrupted), swallowing problem . Interventions .Provide enteral feeding via enteral tube per MD order . During a concurrent interview and record review on May 9, 2024, at 3:30 PM, with the Director of Nurses (DON), the DON reviewed and acknowledged the facility's policy and procedure titled Enteral Nutrition dated November 2018, and stated the policy was not followed, because Resident 45 did not receive the amount of enteral nutrition the physician had ordered. During a review of the facility's policy and procedure (P&P) titled Enteral Nutrition, dated November 2018, the (P&P) indicated Adequate nutritional support through enteral nutrition is provided to resident as ordered .3. The dietitian, with input from the provider and nurse: a. estimates calorie, protein, nutrient and fluid needs; b. determines whether the resident's current intake is adequate to meet his or her nutritional needs; c. recommends special food formulations; and d. calculates fluids to be provided (beyond free fluids in formula) .11. The nurse confirms that orders for enteral nutrition are complete. Complete orders include a. the enteral nutrition product; b. delivery site (tip placement); c. the specific enteral access device . gastric [through the stomach] . d. administration method (continuous, (constant flow) bolus, (a large dose) intermittent [given in separate doses] .; e. Volume and rate of administration; f. the volume / rate goals and recommendations for advancement toward these; and g. instructions for flushing (solution, volume, frequency, timing and 24-hour volume) . 40171 2. A review of Resident 13's Admission Record, (contains demographic and medical information), indicated Resident 13 was initially admitted to the facility on [DATE], with diagnoses which included surgical aftercare following surgery on the digestive system, malignant neoplasm of pancreas (pancreatic cancer), and dysphagia (difficulty swallowing). During an observation on May 6, 2024, at 10:12 AM, in Resident 13's room, Resident 13 had a 1000 milliliters (mls - unit of measure) bag of enteral nutrition (liquid nutrition administered via a feeding tube inserted into the stomach) at his bedside, the bag was connected to a feeding pump (pump which administers enteral nutrition) which was not on and was no longer administering enteral nutrition to Resident 13. The enteral nutrition bag was labeled with the date May 5, 2024, and time 1900 [7:00 PM] (date and time the feeding was started), the residents name, and the rate of administration which was 70 mls an hour (70 ml/hr - rate of enteral nutrition administration via feeding pump). The enteral nutrition bag contained 400 ml of nutrition still in the bag. During a review of Resident 13's physician's orders, dated April 30, 2024, the order indicated, .[brand name of enteral nutrition] 2.0 via [by] GT [Gastrostomy tube - a feeding tube inserted directly into the abdomen and into the stomach to deliver nutrition] at a rate of 70 ml/hr x [times] 12 hours via enteral pump. Infuse until dose completed to yield 840 ml . During a review of Resident 13's care plan (an individualized plan for the medical care of a resident), titled, Requires enteral feeding for nutrition . updated March 18, 2024, the care plan indicated the resident required enteral nutrition due to .Poor PO (by mouth) intake, malnutrition (lack of proper nutrition), history of swallowing problem. During an interview on May 9, 2024, at 3:23 PM, with the Director of Nursing (DON), the DON stated, his expectation was that staff follow the physician's orders when administering enteral nutrition. The DON further stated, enteral nutrition was supposed to be administered until the prescribed dose was complete. The DON stated, it was important that the resident's receive the amount of enteral nutrition as prescribed, so the resident received the correct amount of calories daily. The DON stated, if a resident did not receive a dose of enteral nutrition entirely as prescribed, the staff was supposed to notify the physician that the resident did not get the full dose and document in the resident's medical record. During a concurrent interview and record review on May 9, 2024, at 3:34 PM, with the DON, Resident 13's medical record was reviewed, The DON stated there was no documentation or evidence in Resident 13's medical record to indicate why the full dose of enteral nutrition was not administered on May 5, 2024. The DON further stated, after the prescribed 840 ml dose, the bag should have contained only 160 ml of enteral nutrition. Therefore, there was an excess of 240 ml of enteral nutrition left in the bag which should have been administered to the resident but was not (equivalent to 3.4 hours of administration at the physician's prescribed rate).

Based on observation, interview, and record review, the facility failed to ensure their COVID 19 (CoronaVirus 19, a deadly and highly contagious virus affecting the lungs that can be transmitted through inhalation) infection control policies and procedures were implemented when: 1. A Licensed Vocational Nurse (LVN 1) was wearing a N-95 mask (a mask used by staff to prevent the inhalation of viruses) incorrectly. 2. The facility did not identify a dedicated Licensed Nurse to care for COVID 19 residents exclusively. 3. The facility did not separate residents appropriately according to the resident's COVID test results and suspected COVID 19 signs and symptoms (fever, chills, body aches, diarrhea, etc.) These accumulated failures had the potential to result in the spread of COVID 19 virus to other residents and staff. Findings: 1. During an observation on November 30, 2020 at 11:45 AM, LVN 1 was observed to be wearing the N-95 mask (a protective gear used to cover the nose and mouth) inappropriately. LVN 1 was wearing a surgical mask under the N-95 mask. During an interview with LVN 1 on November 30, 2020 at 12 PM, LVN 1 confirmed she was wearing a surgical mask under the N-95 mask. LVN 1 stated, It is hard for me to breathe while wearing the mask. LVN 1 further stated, I was wearing the mask wrong. During an interview with Infection Preventionist (IP) on November 30, 2020 at 12:15 PM, IP confirmed LVN 1 was wearing the N-95 mask inappropriately. IP stated, She should not be wearing a surgical mask under the N-95 mask. The IP was not able to provide a policy and procedure for N 95 mask wear when requested. The IP stated we follow CDC guidelines on N-95 mask wear. A review of the Centers for Disease Control and Prevention (CDC) titled, Proper N95 Respiratory use for Respiratory Protection Preparedness, indicated, The respirator must fit the user's face snugly (for an example, create a seal) to minimize the number of particles that bypass the filter through gaps between the user's skin and the respirator seal. 2. During an observation on November 30, 2020, at 12:15 PM, Licensed Vocational Nurse (LVN 1) was passing medications in the COVID 19 negative section of the facility (a wing exclusively for residents with no COVID confirmed by negative COVID tests and residents with no signs and symptoms of COVID 19). LVN 1 was later observed passing medications in the COVID positive zone section of the facility (a wing exclusively for COVID positive residents confirmed by positive COVID test with or without symptoms of COVID). During an interview with LVN 1 on November 30, 2020 at 1:15 PM, LVN 1 stated she passes medication to rooms 101-116B (COVID negative and positive rooms). LVN 1 further stated, I pass medications to all residents in my shift. In the morning, I started with the COVID negative residents and then I go to COVID positive residents. In noon time, I start with the COVID negative residents and then I go to COVID positive residents. I go to the nursing station and chart. During an interview with the Infection Preventionist (IP) on November 30, 2020 at 1:25 PM, the IP stated rooms 101, 102, 103, 104, 105, 106, 107, 108, 109, 110, 111, 112, 113, and 114 were COVID negative rooms. The IP further stated room (Room number) and room (Room number) were residents with COVID and residents under investigation for COVID exposure. Resident A was a resident under investigation for exposure for COVID, Resident B was a COVID positive resident. Resident A and B were sharing a room (room number). Resident C was a COVID positive resident, and Resident D was a resident under investigation for exposure for COVID. Residents C and D were sharing a room (room number). The red zone rooms were not identified and were in the middle of a green zone hallway. The yellow zone rooms were also mixed in with the green and red zone rooms. There was no clear delineation of red zone rooms, yellow zone rooms, and green zone rooms. During a review of the facility's nursing assignment dated November 30, 2020, LVN 1's assignment included rooms: 101, 102, 103, 104, 105, 106, 107, 108, 109, 110, 111, 112, 113, 114, 115, and 116. During an interview with IP, on November 30, 2020 at 2 PM, IP confirmed LVN 1 passes medication to COVID negative residents, residents under investigation for possible COVID, and COVID positive residents. The IP stated, It is not right. I will talk to the DON. During an interview with the Director of Nurses (DON) on November 30, 2020 at 2:45 PM, the DON confirmed LVN 1 passes medication to both COVID negative Residents, residents under investigation for possible COVID, and positive COVID residents. The DON stated, There are not enough LVNs available to assign to COVID-19 unit for day, evening, and night shift. During a review of the facility's policy and procedure titled, COVID-19 Preparedness, dated August 10, 2020, indicated, Identify dedicated staff to care for COVID-19 and suspected patients. During a review of the facility's mitigation plan, undated, indicated, All confirmed COVID positive patients will be placed in the Designated Space/ Isolation Area with dedicated staff to manage these patient. During a review of the California Department of Public Health, All Facilities Letter (AFL 20-74), indicated, The COVID-19 positive cohort should be housed in a separate red area (building, unit, or wing) of the facility and have dedicated HCP (Health care personal) who do not provide care for residents in other cohorts and should have separate break rooms and restrooms if possible. 3. During an observation on November 30, 2020, at 3:15 PM, Resident A and Resident B were sharing a room (room number). Further observation, Resident C and Resident D were sharing a room (room number). The facility did not separate the residents into a red zone, (a wing exclusively for COVID positive residents confirmed by positive COVID test with or without symptoms of COVID), and a yellow zone (a wing exclusively for residents under investigation for possible COVID not confirmed by a COVID test). A review of Resident A's clinical records indicated Resident A was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. During a review of Resident A's nursing notes, dated November 27, 2020 at 1:40 PM, indicated, Rapid test done this AM: results negative. A review of Resident A's nursing notes, dated November 27, 2020 at 7:05 PM, indicated, Resident moved from room (room number) to room (room number). A review of Resident A's nursing notes, dated, November 27, 2020 at 10 PM, indicated, 72 hour charting monitor for signs and symptoms of COVID due to exposure. Respirations are even and unlabored, no fever, or respiratory distress noted during shift, vital signs 110/60, 96.4, 74, 20, SPO2 (saturated oxygen level) 98%. Call light within reach. A review of Resident B's clinical records, indicated Resident B was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of Resident B's nursing notes, dated, November 27, 2020 at 6:38 PM, indicated, Resident moved from room (room number) to Room (room number). Notified Dr.(name of the doctor) of patient's positive COVID- 19 test results. During an interview with the Infection Preventionist (IP), on November 30, 2020 at 4 PM, IP confirmed COVID negative Resident A who was COVID negative was sharing a room with COVID positive Resident B. The IP stated, It is not right. I will talk to the DON. A review of Resident C's clinical records indicated Resident C was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. During a review of Resident C's nursing notes, dated November 27, 2020 at 1:27 PM, indicated, Contacted son via phone concerning lab results and COVID-19 positive . A review of Resident C's nursing notes, dated November 27, 2020 at 6:40 PM, indicated, Resident moved from room (room number) to room (room number). A review of Resident C's nursing notes, dated, November 27, 2020 at 10 PM, indicated, 72 hour charting monitor for positive COVID-19, no cough, fever, or respiratory distress observe during shift, Respirations are even and unlabored. No reports of pain or distress during shift. Call light within reach vital signs 120/72, 98.2, 80, 18, 96%. A review of Resident D's clinical records, indicated Resident D was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of Resident D's nursing notes, dated, November 27, 2020 at 1:33 PM, indicated, .rapid test done: resident negative, will relocate to designated area due to exposure. A review of the facility's census, dated November 30, 2020, indicated Resident D was moved to room (room number). A review of Resident D's nursing notes, dated November 27, 2020 at 10:10 PM, indicated, 72 hours charting for exposure to COVID 19. Vital signs 130/64, 96.7, 70, 20, 0/10 pain, resident alert with confusion, able to verbalize needs known, no symptoms of COVID 19 showing at this time, no acute distress, no shortness of breath, encourage fluids intake as tolerated, will continue to monitor. During an interview with the Infection Preventionist (IP), on November 30, 2020 at 4:10 PM, The IP confirmed COVID negative Resident D is sharing a room with COVID positive Resident C. IP stated, It is not right. I will talk to the DON. During an interview with the Director of Nurses (DON) on November 30, 2020 at 2:45 PM, DON confirmed Resident C and D are sharing a room (Room number) and Resident A and B are sharing a room (Room number). The DON stated, We do not have enough rooms. During a review of the facility's policy and procedure titled, COVID-19 Preparedness, dated August 10, 2020, indicated, under the section, Response-driven Testing of Residents, indicated, Place residents into three separate cohorts based on the test results, accordingly : Positive result (Isolation/red cohort) Negative result but exposed within the last 14 days (Quarantine/yellow cohort) Negative results without known exposure within the last 14 days (Non-COVID/Regular Unit/Green cohort). During a review of the facility's mitigation plan, undated, under the section, Testing Residents, indicated, 6. Facility will follow cohorting procedures for disposition of residents. During a review of the California Department of Public Health, All Facilities Letter (AFL 20-74), indicated, Facilities should first ensure confirmed COVID-19 positive residents are placed on the dedicated COVID-19 positive unit (red area) and then evaluate exposure status of other residents in the facility. Facilities should group residents into three separate cohorts, accordingly: COVID-19 positive for the duration of the resident's isolation period: red area. COVID-19 exposed within the last 14 days: yellow exposed status. COVID-19 negative without known exposure within the last 14 days and recovered residents who have completed their isolation period: green status. An immediate Jeopardy (IJ-a situation with the potential to harm the health and safety of the residents) was called under Infection Control. (Refer to F880) on November 30, 2020 at 3:55 PM, in the presence of the Director of Nurses (DON), administrator (ADM), and Infection Preventionist (IP). The DON, ADM, and IP were verbally notified of the IJ situation identified based on the facility's failure to implement their infection control program for COVID 19 when: 1. Licensed Vocational Nurse (LVN 1) was not using the N-95 mask (a mask used by staff to prevent the inhalation of viruses) correctly. 2. The facility did not identify a dedicated Licensed Nurse to care for COVID 19 residents exclusively. 3. The facility did not separate residents appropriately according to the resident's COVID test results and suspected COVID 19 signs and symptoms (fever, chills, body aches, diarrhea, etc) These accumulated failures had the potential to result in the spread of COVID 19 virus to other residents and staff. The facility submitted a corrective action plan which was reviewed and accepted on November 30, 2020 at 6:45 PM, in the presence of the DON, ADM, and IP. The facility's corrective action plan indicated the following: 1. Personal Protective Equipment: INSERVICE TO ALL STAFF ON PROPER USE OF PPE (by staff developer): This has been implemented on 3-11 shift, will inservice 11-7 shift via telephone, and the rest of the staff at 7 am on Tuesday morning. 2. Emergency staffing strategies: HIRE REGISTRY ALL SHIFTS: The staffing agency (name of agency) has been contacted . awaiting response. Current staff members have been called for possibility of working a double and implement 12 hour shifts. 3. Cohorting residents: SEPARATE ROOMS FOR YELLOW-SEPARATE ROOMS FOR RED: We have moved the two PUI (Person under investigation-a resident with suspected COVID) in the designated yellow room on one side of the hallway and the three COVID positive residents in the designated red rooms. A plastic shield at the entrance of the designated areas and tape to separate yellow side from the Red side down the middle of the hall. On December 1, 2020 at 2:45 PM, a review of the facility's corrective action plan was conducted using observation, interview and record review as follows: 1. An observation of staff wearing N-95 mask properly was conducted. 2. Registry staff has been hired to work in the designated red zone. 3. Residents were cohorted according to their testing results. After observation, interview, and record review of the facility's corrective action plan, the IJ was lifted on December 1, 2020 at 3:25 PM in the presence of the DON, ADM, and IP.