Every finding on record at La Sierra Care Center

Based on interview and record review the facility failed to ensure a Registered Dietitian (RD) comprehensively and frequently evaluated the effectiveness of food service operations when lapses in the delivery of services associated with meal accuracy and nutritional value of menus, as well as food safety (cross reference F 803, F 806, and F 812) occurred.This failure resulted in lack of sufficient oversight from the RD, which placed 62 out of 65 residents who received food from the kitchen at risk for food borne illness (illness caused by food contaminated with bacteria, viruses, parasites, or toxins) and/or altered nutritional intake, both of which had the potential to result in death and/or nutritional related medical complications.During an interview on 1/22/26 at 5:00 p.m. with the Registered Dietician (RD), the RD stated she had been a remote full-time RD for the facility since 6/2025. The RD stated she visited the facility in 6/2025, 8/2025 and 11/2025. The RD stated she only had a documented onsite kitchen audit for 11/11/25. The RD stated the primary focus of her duties were record reviews which included, the completion of nutritional assessments, diet recommendations, and resident weight reviews. The RD stated she completed her duties through email or phone call. The RD stated, to her knowledge, she was the only RD the facility utilized. The RD stated she communicated primarily with the Certified Dietary Manager (CDM) and the Director of Nursing (DON) for nutritional assessments, diet recommendations, and resident weight reviews. The RD stated the CDM oversaw kitchen operations, such as test trays, tray line, and food safety. The RD stated she did not review the CDM's kitchen audits. The CDM stated she provided no direct physical oversight of kitchen operations. The RD stated the kitchen required direct physical oversight. The RD stated the facility agreed to allow her to work remote and therefore the facility was responsible for ensuring the RD role was fulfilled and met facility policy and procedures, standards of practice and job duty functions.During an interview on 1/23/26 at 12:57 p.m. with the Administrator (ADM), the ADM stated the RD was hired as an employee, rather than a consultant or contractor, in 6/2025. The ADM stated the RD had been remote since hired. The ADM stated the facility did not utilize another RD.During an interview on 1/23/26 at 1:40 p.m. with the DON, the DON stated direct oversight of kitchen operations could not be provided if the RD was remote. The DON stated she communicated by phone call with the RD throughout the week and discussed nutritional and weight needs of residents. The DON stated the RD was hired in 6/2025 and went remote shortly after starting, the DON could not state an exact date. The DON stated she was only aware of one onsite RD visit, 11/11/25, where the RD performed a kitchen audit and inspected kitchen operations. The DON stated the facility allowed the RD to be remote and therefore the facility was responsible for ensuring fulfillment of her required job duty functions that she could not perform remotely. The DON stated the facility RD job duty had not been fulfilled when the RD had been remote since 6/2025 and had only performed one onsite kitchen audit on 11/11/25. The DON stated the RD was returning full-time onsite at the end of 1/2026. The DON stated kitchen operations were at risk for errors with no physical oversight from a RD which could result in food distribution, storing and serving issues which could be detrimental to resident over all health.During a review of the RD's kitchen audit titled, Sanitation Review, dated 11/11/2025, the kitchen audit indicated the RD identified general sanitation and maintenance issues within the kitchen. There was no documented RD follow up of identified issues. The RD could only provide kitchen audit documentation from 11/11/25.During a review of the facility's document titled, Employee Acknowledgment, dated 6/2/25, the document indicated the RD was hired on 6/2/25. The document did not indicate when the RD went remote or exemptions from job duty requirements.During a review of the facility's job duty document titled, Registered Dietician, undated, the job duty document indicated, .the purpose of your job position is to organize, plan, and supervise the overall operation of dietary department.supervise, monitor, [and] train staff to confirm competency adhering to all sanitation, safety and procedural guidelines within the department.performing weekly inspections of dietary measures to assure quality control is being maintained for sanitation, safety and infection control.observe and assesses residents to monitor food acceptance and nutritional status.ensuring food service equipment is clean and operable. checking food storage rooms.concentrates on foundational elements of standards of practice and professional performance, code (s) of ethics accreditation standards, state and federal regulations, national guidelines, and ongoing professional continuing education to maintain currency in practice.During the Re-certification Survey from 1/20/26-1/23/26, multiple issues were identified regarding: not following menu recipes (Cross-reference F803); not serving appealing options of similar nutritive value to residents who choose not to eat food initially served (Cross-reference 806) and food was not stored, prepared, and served in a safe and sanitary manner (Cross-reference F812).

Based on observation, interview and record review the facility failed to ensure five out of five residents on pureed diets (pudding-like consistency food, requiring no chewing and easy to swallow) received the correct serving scoop size for lunch on 1/21/26 when stir fried chicken was served with a #8 scoop (1/2 cup) instead of the required recipe #6 scoop (2/3 cup).This failure resulted in the wrong serving size of a menu item which could result in weight variances, inaccurate nutritional monitoring and lead to serious medical conditions.During a review of the facility's document titled, Diet Type Report, dated 1/22/26, the document indicated five residents at the facility received pureed diet textures.During a review of the facility's menu recipe document titled, Stir Fried Chicken, dated 2026, the recipe indicated, .suggested portion # 6 SCP [scoop].During a review of the facility's menu recipe document titled, Stir Fried Chicken Method, undated, the recipe indicated, .puree.serve with a # 6 scoop .During a concurrent observation and interview on 1/21/26 at 11:47 a.m. with [NAME] (CK) 1, at the start of lunch tray line, CK 1 was observed using a #8 scoop to serve pureed stir fried chicken. CK 1 stated she used a #8 scoop to serve pureed stir fried chicken. CK 1 stated cooks were responsible for ensuring the required menu scoop size was used during tray line. CK 1 stated it was important to use the correct scoop size during tray line to ensure residents received the right amount of food.During a concurrent observation and interview on 1/21/26 at 12:03 p.m. with the Certified Dietary Manager (CDM), during lunch tray line, the CDM stated CK 1 was using a #8 scoop to serve pureed stir fried chicken.During a concurrent observation and interview on 1/21/26 at 12:18 p.m. with [NAME] (CK) 1, at the end of lunch tray line, CK 1 was observed using a #8 scoop to serve pureed stir fried chicken. CK 1 stated she used a #8 scoop to serve pureed stir fried chicken.During a concurrent interview and record review on 1/21/26 at 12:26 p.m. with the CDM, the facility's menu recipe titled, Stir-Fried Chicken, dated 2026, and Stir-Fried Chicken Method, undated, was reviewed. The CDM stated lunch tray line was over and all meals had been plated. The CDM stated, per the menu recipe, CK 1 used the wrong scoop size to plate all pureed stir fried chicken. The CDM stated CK 1 should have used the required #6 scoop size to serve pureed stir fried chicken. The CDM stated pureed diet texture residents did not receive the correct portion of protein for lunch when a #8 scoop was used to serve pureed stir fried chicken. The CDM stated residents on a pureed diet texture received less protein for lunch than the menu recipe called for. The CDM stated residents were at risk of weight loss, weight gain, and inadequate nutrient monitoring when incorrect scoop size were used.During an interview on 1/22/26 at 5:00 p.m. with the Registered Dietician (RD), the RD stated menu recipes were expected to always be followed to ensure nutritional needs and standardized portion sizes were met. The RD stated residents were at risk of altered caloric, mineral, and vitamin intake when scoop sizes were not followed. The RD stated a #8 scoop size was equivalent to 1/2 cup and a #6 scoop size was equivalent to 2/3 cup. The RD stated residents on pureed diets received less of their prescribed meal when a #8 scoop size was used to serve stir fried chicken. The RD stated the facility housed fragile and vulnerable residents who could sustain weight gain, weight loss, and inadequate nutritional monitoring if menu recipes were not followed, which could lead to serious medical conditions.During an interview on 1/23/26 at 1:20 p.m. with the Director of Nursing (DON), the DON stated residents were at risk of not having their nutritional needs met when they were served the incorrect scoop size during lunch tray line. The DON stated it was important to follow menu recipes to ensure standardized portions were served and residents received nutrients and calories as per their prescribed diet orders. The DON stated facility policy and procedure, as well as nutritional standards of practice were not followed when a #8 scoop was used to serve stir fried chicken instead of the menu recipe #6 scoop.During a review of the facility's job description titled, Cook, undated, the job description indicated, .essential duties and responsibilities.reviewing menus prior to food preparation.following menus and recipes.serving food according to established portion control recommended.adhering to all facility policies and procedures of the facility.During a review of the facility's policy and procedure (P&P) titled, Menus, dated 10/2017, the P&P indicated, .menus meet the nutritional needs of residents in accordance with the recommended dietary allowances of the Food and Nutrition Board (National Research Council and National Academy of Science).menus provide a variety of foods from the basic daily food groups and indicate standard portions at each meal.

Based on observation, interview and record review the facility failed to provide appealing and nutritional alternative menu items to 62 out of 65 residents eating at the facility when there was no posted or designated alternative meal menu and the kitchen only designated peanut butter and jelly, grilled cheese and ham and cheese sandwiches as an alternative meal option.This failure resulted in residents having no designated appealing and nutritional alternative meal options, and had the potential to result in decreased satisfaction and resident food intake.During an observation on 1/20/26 at 9:14 a.m. no alternative meal menu was posted outside the kitchen on the menu wall.During an observation on 1/20/26 at 9:16 a.m. no alternative meal menu was posted inside the kitchen.During an observation on 1/20/26 at 11:53 a.m. no alternative meal menu was posted inside the two dining rooms.During a concurrent observation and interview on 1/20/26 at 10:37 a.m. with Resident 20, in Resident 20's room, no alternative meal menu was posted or provided. Resident 20 stated he had a copy of the current weeks menu, but no copy of an alternative menu. Resident 20 stated an alternative menu was not posted anywhere in the facility. Resident 20 stated alternative meal menu items were never the same and he never knew what options he had. Resident 20 stated, if he asked kitchen staff, alternative menu items were peanut butter and jelly, grilled cheese and ham and cheese sandwiches. Resident 20 stated he had to ask or wait for kitchen staff to do rounds to inquire about alternative meal menu options. Resident 20 stated peanut butter and jelly, grilled cheese and ham and cheese sandwiches were not appealing or fulfilling as a meal substitute. Resident 20 stated sandwiches were not an actual meal. Resident 20 stated peanut butter and jelly, grilled cheese and ham and cheese sandwiches were a snack and not a meal replacement if he didn't want what was being served for a meal. Resident 20 stated he would rather skip a meal than choose a sandwich if he did not like what was being served. Resident 20 stated the facility rotated their menus and some months he did not want the same meal again and having alternative menu options would help provide variety.During an interview on 1/22/26 at 10:27 a.m., in the resident council meeting, Resident 9 stated he was not aware there was an alternative menu. Resident 9 stated he was not aware he could choose a meal substitute if he did not like what was being served, instead he would refuse meals and wait for the next meal. Resident 9 stated he knew where the current weeks menu was posted, outside of the kitchen, but there was no posted alternative meal menu. Resident 9 stated facility staff had never informed him of alternative menu options.During an interview on 1/22/26 at 11:17 a.m. with the Certified Dietary Manager (CDM), the CDM stated there was no designated alternative meal menu. The CDM stated there was no alternative meal menu posted or provided to residents. The CDM stated the kitchen typically provided peanut butter and jelly, grilled cheese and ham and cheese sandwiches as alternative meal options. The CDM stated sometimes the kitchen had extra chicken fingers and hamburgers which could be provided as an alternative menu option. The CDM stated she made frequent rounds to resident rooms and discussed daily menus and if residents were not interested in the menu options, she asked what they would like. The CDM stated residents were at risk of being unavailable during rounds to discuss alternative menu options which would result in not knowing their alternative meal menu options. The CDM stated she tried to accommodate resident alternative meal choices if the kitchen had the requested item. The CDM stated residents had a right to know what alternative menu options were offered and available. The CDM stated residents would not know their alternative menu options if it was not posted or provided.During an interview on 1/22/26 at 11:41 a.m. with the Registered Dietician (RD), the RD stated there was no alternative menu when she started in 6/2025. The RD stated she was not aware of a current alternative meal menu option for residents at the facility. The RD stated an RD needed to review and approve all menus. The RD stated kitchen staff made resident rounds to review menus and completed preference diet cards to accommodate resident preferences, when kitchen stock allowed. The RD stated snacks and sandwiches were always available to residents. The RD stated residents had a right to refuse scheduled meal menu items and choose an alternative meal menu option. The RD stated all menus needed to be posted and provided to residents for review to ensure they were informed of their options. The RD stated residents were at risk of forgetting alternative meal menu options if only discussed verbally with kitchen staff. The RD stated if alternative menus were not posted or provided it could not be guaranteed residents knew about meal menu alternative options. The RD stated sandwiches were not an appealing or nutritional substitute to scheduled meal menus. The RD stated an alternative meal menu needed to be available for residents to choose from if they did not want what was being served and their preference diet card could not be accommodated. The RD stated with no alternative meal menu the facility was not providing a homelike environment that encouraged resident right and ability to choose. The RD stated the facility had a vulnerable and fragile population and ensuring nutritional food promoted well-being.During an interview on 1/22/26 at 3:25 p.m. with Certified Nursing Assistant (CNA) 7, CNA 7 stated she was not aware of an alternative meal menu residents could review or choose from. CNA 7 stated only the weekly menu was posted outside the kitchen and in resident rooms. CNA 7 stated if residents refused a meal, she notified the assigned licensed nurse and kitchen. CNA 7 stated if a resident requested a food item, she went to the kitchen to see if the request could be fulfilled. CNA 7 stated if the request could not be fulfilled kitchen staff would provide current available options and she would relay it to the resident.During a interview on 1/23/26 at 1:40 p.m. with the Director of Nursing (DON), the DON stated all menus were required to be posted and provided to residents for review. The DON stated residents had a right to know their meal and alternative options. The DON stated the CDM performed frequent rounds to discuss menus, but it could not be guaranteed residents would recall alternative options or be available to discuss alternative options if not posted or provided a copy. The DON stated sandwiches were not an appealing or nutritional substitute to scheduled meal menus. The DON stated residents had the right to refuse scheduled meal menus and choose an appealing and nutritional substitution. The DON stated facility policy was not followed when the alternative meal menu was not posted or provided to residents and did not provide appealing or nutritional substitutions.During a review of the facility's policy and procedure (P&P) titled, Menus, dated 10/2017, the P&P indicated, .menus are developed and prepared to meet residents choices including religious, cultural and ethic needs while following established national guidelines for nutritional adequacy.the dietician reviews and approves all menus.copies of the menus (as served, including substitutions) are kept on file.copies of menus are posted in at least two (2) resident areas, in positions and in print large enough for residents to ready them.During a review of the facility's P&P titled, Frequency of Meals, dated 7/2017, the P&P indicated, .each resident shall receive at least three (3) meals daily, at times comparable to typical mealtimes in the community, or in accordance with resident needs, preferences, requests and plan of care.alternative meals will be offered to residents who choose to eat at non-traditional or outside of scheduled mealtimes, consistent with the plan of care.During a review of the facility's job duty description titled, Registered Dietician undated, the job duty description indicated, .reviewing menus prior to food preparation .advise on menu changes and evaluates changes to the facility's menus for nutritional adequacy.

Based on observation, interview, and record review, the facility failed to ensure food and beverages were stored, distributed, and served safely in accordance with professional standards of food service safety for 62 out of 65 residents eating at the facility when: Four 48 fluid ounce (fl oz- a unit of measurement) prune juice bottles were not labeled with a received-on date label. The dry food storage room did not have a temperature record log. The food preparation sink did not have an air gap (space between the end of sink pipe and top of sink to prevent backflow). These failures had the potential to result in the serving of expired, spoiled, or contaminated food and beverage items which could result in foodborne illness (illness caused by food contaminated with bacteria, viruses, parasites, or toxins).1.During a concurrent observation and interview on 1/20/26 at 9:26 a.m., in the dry food storage room, with the Certified Dietary Manager (CDM), four 48 fl oz prune juice bottles were observed with no received-on date label. The CDM stated the four prune juice bottles did not have received-on dates. The CDM stated all food and beverage items required a received-on date, opened date, and expiration date label to ensure expired food items were not served. The CDM stated it was important to label all food and beverage items with a received-on date to ensure products were used in a timely manner before expiration. The CDM stated all products in the kitchen were expected to be used in a first in, first out (FIFO) method. The CDM stated the four prune juice bottles were at risk of not being used in a timely manner which could result in the serving of an expired beverage and result in food borne illness, decreased product taste or satisfaction. 2.During a concurrent observation and interview on 1/20/26 at 9:33 a.m., in the dry food storage room, with the CDM, a wall mounted thermometer, which read 60 degrees Fahrenheit (F- a unit of measurement to monitor temperature) was observed. The CDM stated the dry food storage room was required to maintain a temperature between 50F-70F to ensure food safety. No dry food temperature log was observed. A sign posted in the dry food storage room titled, Storeroom Basics, stated, .maintain temperature between 50F-70F.use FIFO, first in, first out.label and date food. The CDM stated the kitchen did not record temperatures in the dry food storage room. The CDM stated she checked the dry food storage room temperature twice a day, Monday through Friday, and cooks checked the temperature on Saturday and Sunday. The CDM could not state how dry food storage temperatures were reviewed or monitored to ensure food safety and compliance with required temperature range if there was no documentation of temperature checks. The CDM stated if something was not documented, it did not happen. The CDM stated the dry food storage room was at risk for temperature fluctuations outside of required temperature ranges which could result in the spoiling of food and lead to foodborne illness. 3.During a concurrent observation and interview on 1/20/26 at 9:41 a.m., in the kitchen, with the CDM, the food preparation sink was observed with no air gap. The CDM stated the food preparation sink was used to wash fruit and vegetables, thaw frozen food items, and prep ingredients residents consumed. The CDM stated without an air gap on the food preparation sink substances could backflow into the sink and contaminate food items residents consumed. The CDM stated air gaps prevented cross contamination and decreased the risk for food borne illness. The CDM stated an air gap on a food preparation sink was a food safety standard of practice. The CDM stated the food preparation sink had never had an air gap. The CDM stated she completed weekly kitchen audits and documented her findings, but no air gap had been placed. During an interview on 1/22/26 at 11:41 a.m. with the Registered Dietician (RD), the RD stated, all food items in the kitchen required a received-on date label to ensure product was used before it expired. The RD stated it was important to label all food and beverage items to ensure product was used in a timely manner before the expiration date to prevent the serving of old or expired food items. The RD stated serving old or expired food items could result in food borne illness. The RD stated the dry food storage room required temperatures to be maintained between 50-70 degrees Fahrenheit to prevent food spoilage. The RD stated if something was not documented, it could not be guaranteed it happened. The RD stated recording dry food storage temperatures ensured temperatures were maintained to uphold food safety, monitor and trend temperature fluctuations. The RD stated it could not be guaranteed dry food storage temperatures were being monitored when there was no dry food storage temperature log. The RD stated all food preparation sinks required an air gap to prevent backflow and cross contamination of food items. The RD stated the food preparation sink did not have an air gap. The RD stated she and the CDM were responsible for identifying issues in the kitchen during audits and reporting findings so they could be corrected. The RD stated she did not review the CDM's kitchen audits. The RD stated she completed a kitchen audit on 11/11/25 and did not identify an air gap. The RD stated unlabeled food items, no dry food storage temperature log and no food preparation sink air gap should have been corrected when identified on kitchen audits. The RD stated the facility housed a fragile and vulnerable population of residents who could be seriously affected by foodborne illness caused by cross contamination. The RD stated she expected the kitchen to adhere to all facility policy and procedures, as well as food safety standards of practice. During an interview on 1/23/26 at 1:40 p.m. with the Director of Nursing (DON), the DON stated she expected the kitchen to adhere to all facility policies and procedures, as well as food safety standards of practice. The DON stated this had not occurred when four prune juice bottles were not labeled with received-on dates, no temperature log was kept for the dry food storage room, and there was no air gap on the food preparation sink. The DON stated she expected the CDM and RD to identify kitchen non-compliance, report their findings, and implement corrections. The DON stated she did not review the CDM or RD's kitchen audits. The DON stated facility residents were at risk for consuming contaminated or spoiled food which could result in food borne illness and lead to serious medical issues. During a review of the RD's kitchen audit, dated 11/11/2025, the document indicated food and beverage items were required to be labeled, dated and rotated on a first in first out method. The document indicated no air gap was identified. During a review of the CDM's kitchen audits, dated 10/21/25, 10/28/25, 11/3/25, 11/11/25, 11/17/25, 11/25/25, 12/3/25, 12/9/25, 12/23/25, 12/29/25, 1/7/26, 1/15/26, and 1/20/26, the documents indicated food and beverage items were required to be labeled, dated and rotated on a first in first out method. The document indicated no air gap was identified.During a review of the facility's policy and procedure (P&P) titled, Food Receiving and Storage, dated 11/2022, the P&P indicated, .food shall be received and stored in a manner that complies with safe food handling practices.food services, or other designated staff, maintain clean and temperature/humidity-appropriate food storage areas at all time.dry foods and goods are handles and stored in a manner that maintains the integrity of the packaging until they are ready to use.During a review of the facility's P&P titled, Food Preparation and Service, dated 11/2022, the P&P indicated, .Food and nutrition service employees prepare, distribute and serve food in a manner that complies with safe food handling practices.identification of potential hazards in the food preparation process and adhering to critical control points can reduce the risk of food contamination and thereby minimize the risk of foodborne illness.cross-contamination can occur when harmful substances, i.e.disease-causing microorganisms transferred to food by hands.food contact surfaces.equipment is arranged to facilitate food preparation, based on input from appropriate individuals including food and nutrition service staff.During a review of the facility's document posted in the dry food storage room titled, Storeroom Basics, undated, the document indicated, .maintain temperature between 50-70F.use FIFO, first in, first out.label and date food. During a review of the professional reference titled, FDA Food Code 2022, section 5-402.11 Backflow Prevention, .(A) A direct connection may not exist between the sewage system and a drain originating from equipment in which food, portable equipment, or utensils are placed. (B) Equipment and fixtures used for food preparation or utensil washing must be installed with an air gap or air brake as required to prevent backflow of sewage into the equipment.

Based on interview, and record review, the facility failed to ensure medical records were complete and accurately documented in accordance with accepted professional standards of practice for three of eight sampled residents (Resident 4, Resident 9, and Resident 31) when Resident 4, Resident 9 and Resident 31's copy of Physician Orders for Life-Sustaining Treatment (POLST - a medical order signed by both the patient and medical provider that specifies the types of medical treatment a patient wishes to receive toward the end of life) were incomplete.This failure had the potential for Resident 4, Resident 9, and Resident 31's decisions regarding treatment options and end of life wishes to not be honored.Findings:During a concurrent observation and interview on [DATE] at 10:20 a.m. in Resident 31's room, Resident 31 was observed dressed, lying in bed. Resident stated he did not remember how long he had been at the facility or why he was at the facility.During a review of Resident 31's admission Record (AR - a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), dated [DATE], the AR indicated Resident 31 was admitted to the facility from an acute care hospital on [DATE] with diagnoses of dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), hydronephrosis (swelling of one or both kidneys when the urine does not drain), chronic kidney disease (a gradual loss of kidney function where the kidneys cannot filter the blood as they should), depression (persistent feelings of sadness, despair, loss of energy, and difficulty dealing with normal daily life), dysphagia (difficulty swallowing), and displacement of nephrostomy catheter (a thin tube that drains urine from the kidney into a bag).During a review of Resident 31's Minimum Data Set (MDS - a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment), dated [DATE], the MDS section C indicated Resident 31 had a Brief Interview for Mental Status (BIMS - a test given by medical professionals to determine cognitive (involving the process of thinking, learning and understanding) understanding on a scale of 1-15 ) score of three (a score of 0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired, 13-15 suggests cognitively intact), which indicated Resident 31 was moderately impaired.During a concurrent interview and record review on [DATE] at 3:08 p.m. with Registered Nurse (RN) 1, Resident 31's POLST, dated [DATE] was reviewed. Resident 31's POLST indicated Section D titled, Information and Signatures was not complete. RN 1 stated all sections of Resident 31's POLST should have been completed. RN 1 stated the POLST indicated what the Resident 31's wishes were for end-of-life care.During a concurrent interview and record review on [DATE] at 2:45 p.m. with the Medical Records Coordinator (MR), Resident 31's POLST, dated [DATE], was reviewed. Resident 31's POLST indicated section D titled Information and Signatures was not complete. The MR stated Section D should have been completed as it indicated who the POLST form was discussed with, the resident or the resident's Responsible Party (RP) and if the resident had an advance directive (a legal document indicating resident preference on end-of-life treatment decisions). The MR stated the POLST form was important because it indicated what the resident or the resident's RP wishes were for end-of-life treatment, to be DNR (do not resuscitate- a medical order written by a doctor to instruct health care providers NOT to do cardiopulmonary resuscitation (CPR) if breathing stops or the heart stops beating) or not. During a concurrent observation and interview on [DATE] at 10:16 a.m. in Resident 4's room, Resident 4 was observed dressed, lying in bed. Resident 4 stated he had been at the facility since [DATE] for rehabilitation after surgery. Resident 4 stated he goes to dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) and the nurses at the dialysis facility changed his catheter dressing.During a review of Resident 4's AR, dated [DATE], the AR indicated Resident 4 was admitted to the facility from an acute care hospital on [DATE] with diagnoses of chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), pleural effusion (a buildup of fluid between the tissues that line the lungs and the chest), respiratory failure (a serious condition that occurs when the lungs cannot get enough oxygen into the blood or remove enough carbon dioxide [a waste gas] from the blood), congestive heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), end stage renal disease (a condition where the kidneys can no longer function on their own and dialysis [a process of removing excess water, and waste products from the blood] or kidney transplant is required to survive), dysphagia (difficulty swallowing), and depression (persistent feelings of sadness, despair, loss of energy, and difficulty dealing with normal daily life).During a review of Resident 4's MDS, dated [DATE], the MDS section C indicated Resident 4 had a BIMS score of 13, which indicated Resident 4 was cognitively intact.During a concurrent interview and record review on [DATE] at 3:08 p.m. with RN 1, Resident 4's POLST, dated [DATE], was reviewed. Resident 4's POLST indicated section D titled, Information and Signatures was not complete. RN 1 stated Resident 4's POLST should have had section D completed. RN 1 stated the POLST indicated what the Resident 4's wishes were for end-of-life care. During a concurrent interview and record review on [DATE] at 2:45 p.m. with the Medical Records Coordinator (MR), Resident 4's POLST, dated [DATE], was reviewed. Resident 4's POLST indicated section D titled, Information and Signatures was not complete. The MR stated Section D should have been completed as it indicated who the POLST form was discussed with, the resident or the resident's Responsible Party (RP) and if the resident had an advance directive (a legal document indicating resident preference on end-of-life treatment decisions). The MR stated the POLST form was important because it indicated what the resident or the resident's RP wishes were for end-of-life treatment, to be DNR (do not resuscitate- a medical order written by a doctor to instruct health care providers NOT to do cardiopulmonary resuscitation (CPR) if breathing stops or the heart stops beating) or not.During a concurrent observation and interview on [DATE] at 11:59 a.m. in Resident 9's room, Resident 9 was observed dressed, lying in bed with a feeding pump (a machine that delivers specific amounts of fluids and nutrition) on pause next to his bed. Resident 9 stated he had been at the facility for two years due to a stroke.During a review of Resident 9's AR, dated [DATE], the AR indicated Resident 9 was admitted to the facility from an acute care hospital on [DATE] with diagnoses of acquired absence of left great toe (surgical removal of toe), type 2 Diabetes Mellitus (when the blood sugar levels in the body are too high), gastrostomy (the surgical formation of an opening through the abdominal wall into the stomach for nutritional support), gastrointestinal hemorrhage (bleeding in the gastrointestinal tract, from the mouth to the rectum), ulcer of the esophagus (open sores or breaks between the throat and the stomach), dysphagia (difficulty swallowing), and acute kidney failure (a condition when the kidneys suddenly are unable to filter waste products from the blood).During a review of Resident 9's MDS, dated [DATE], the MDS section C indicated Resident 9 had a BIMS score of 15, which indicated Resident 9 was cognitively intact.During a concurrent interview and record review on [DATE] at 3:09 p.m. with RN 1, Resident 9's POLST dated [DATE] was reviewed. Resident 9's POLST indicated Section D titled, Information and Signature was not complete. RN 1 stated all sections of Resident 9's POLST should have been completed. RN 1 stated the POLST indicated what Resident 9's wishes were for end-of-life care.During a concurrent interview and record review on [DATE] at 2:45 p.m. with the Medical Records Coordinator (MR), Resident 9's POLST, dated [DATE], was reviewed. Resident 9's POLST indicated section D titled, Information and Signatures was not complete. The MR stated Section D should have been completed as it indicated who the POLST form was discussed with, the resident or the resident's Responsible Party (RP) and if the resident had an advance directive (a legal document indicating resident preference on end-of-life treatment decisions). The MR stated the POLST form was important because it indicated what the resident or the resident's RP wishes were for end-of-life treatment, to be DNR (do not resuscitate- a medical order written by a doctor to instruct health care providers NOT to do cardiopulmonary resuscitation (CPR) if breathing stops or the heart stops beating) or not.During an interview on [DATE] at 2:30 p.m. with the Director of Nursing (DON), the DON stated section D of each resident's POLSTs should have been completed. The DON stated section D of the POLST indicated who the doctor spoke with regarding end-of-life care, and who signed the POLST, the resident or the resident's RP. The DON stated the resident's POLSTs should have had all sections completed. The DON stated the signature section was important to see who the decision maker was for end-of-life care and to see what their wishes were.During a review of the facility's job description document titled, Director of Medical Records, undated, the document indicated, .to maintain resident medical records and health information in accordance with current federal, state and local standards and regulations that govern the facility and as directed by the Administrator.assembling and reviewing resident's medical records as needed.During a review of the facility's job description document titled, Charge Nurse, undated, the document indicated, .perform administrative duties such as completing medical forms, reports, evaluations, studies, charting, etc., as necessary.complete and file required recordkeeping forms/charts upon the resident's admission, transfer, and/or discharge.consult with the resident's physician in providing the resident's care, treatment, rehabilitation, etc., as necessary.ensure that personnel providing direct care to residents are providing such care in accordance with the resident's care plan and wishes.

Based on observation, interview, and record review during the survey period of 1/20/26 through 1/23/26, the facility failed to provide the minimum of at least 80 square feet per resident in 19 of 23 multiple resident rooms (rooms 1, 2, 3, 4, 5, 6, 7, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, and 23).This failure had the potential for residents to not have reasonable accommodations for privacy or adequate space for care to be rendered.Findings:Resident rooms 1, 2, 3, 4, 5, 6, 7, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, and 23 did not meet the required square footage requirements. However, variations were in accordance with the particular needs of the residents. The residents had privacy, there was sufficient room for nursing care and resident ambulation. Wheelchairs and toilet facilities were accessible. The closets and storage space were adequate. Bedside stands were available. The waiver will not adversely affect the health and safety of residents. Room Beds Square Feet1 3 220 2 3 2203 3 2204 3 220 5 3 2106 3 2207 3 22010 3 232 11 3 21612 3 22013 3 22014 3 22815 3 22516 3 23417 3 21718 3 22419 3 22020 3 22523 3 215 Recommend waiver continue in effect. _____________________________________HFES Signature Date Request waiver continue in effect.____________________________________ Facility Administrator Signature Date

Based on observation, interview and record review, the facility failed to provide reasonable accommodation to meet the needs of one of eight sampled residents (Resident 28) when Resident 28, whose vision was severely impaired (no vision or sees only light, colors or shapes column eyes do not appear to follow objects) and dependent on staff for activities of daily living (ADL- a basic skill needed to carry out tasks of everyday life), call light was not within reach.This failure resulted in Resident 28 to be unable to communicate with facility staff for help when needed and be at risk for falls and injury.Findings:During a review of Resident 28's admission Record (AR - a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), dated 1/22/26, the AR indicated, Resident 28, was admitted to the facility on [DATE], acute care hospital and had diagnoses that included . Legal blindness, muscle weakness, cerebral infarction (death of brain tissue due to a lack of blood supply), other seizures (a sudden, temporary disruption in the brain's electrical activity), difficulty in walking, anxiety disorder, unspecified asthma, insomnia (trouble falling asleep or staying asleep), unspecified convulsions (a sudden, uncontrollable, violent shaking or jerking of the body or limbs, caused by abnormal electrical activity in the brain).During a review of Resident 28's Minimum Data Set (MDS- a resident assessment tool used to identify resident cognitive (mental) and physical functional level) assessment, dated 12/4/25, the MDS section C indicated, Resident 28's Brief Interview for Mental Status (BIMS) assessment score was 7 out of 15 (0-6 severe cognitive (pertaining to reasoning memory and judgement) deficit, 7-12 moderate cognitive deficit, 13-15 cognitively intact). The BIMS scores indicated Resident 28 had moderate cognitive deficit.During a review of Resident 28's MDS assessment section Hearing, Speech and Vision, dated 12/4/25, indicated Resident 28's vision score was 4. Resident 28's vision score of 4 is defined as . Severely impaired- no vision or sees only light, colors or shapes column eyes do not appear to follow objects.During a review of Resident 28's MDS assessment section GG Functional Abilities, dated 12/4/25, indicated Resident 28 uses wheelchair, and Resident 28's functional abilities was coded between 01 and 03. Resident 28 was code 01 (dependent: helper does all the effort, resident does none of the effort to complete self-care) for toileting hygiene, putting on/taking off footwear, personal hygiene, sitting to lying, and sit to stand. Resident 28 was code 02 (substantial/ maximal assistance: helper does more than half the effort,) for oral hygiene, shower/bath self, lower body dressing, lying-to-sitting on side of bed, chair/bed to chair transfer, toilet transfer, and tub/shower transfer. Resident 28 was code 03 (partial/moderate assistance: helper does less than half the effort in care) for eating, upper body dressing, and roll left and right. The functional abilities code indicated Resident 28 needed partial/moderate assistance in 3 abilities, needed substantial/ maximal assistance in 7 abilities and was dependent on facility staff in 5 abilities.During a review of Resident 28's MDS assessment dated [DATE], the MDS section H indicated, Resident 28's Bladder and Bowel function included Resident 28 is always incontinent (meaning the inability to control when you urinate or have a bowel movement) (no episodes of continent voiding) for urinary continence. Resident 28 is frequently incontinent (2 or more episodes of continence bowel movement) for bowel continence.During a review of Resident 28's MDS assessment dated [DATE], the MDS section N indicated, Resident 28's Medications included antianxiety (medications used to reduce, prevent, or relieve symptoms of extreme panic, and tension), antidepressants (medications used to treat depression and other conditions like anxiety). Antiplatelets (medications that work by preventing platelets from sticking together and forming clots), hypoglycemics (including Insulin- drugs used to lower high blood sugar levels), anticonvulsant (medications used to prevent, treat, or stop convulsions by calming abnormal electrical activity in the brain).During a concurrent observation and interview on 1/20/26 at 11:28 a.m. with Resident 28 during the initial tour in Resident 28's Room, Resident 28 was lying in bed facing the wall. Resident 28's call light was behind her on the bed. Resident 28 stated I am blind, they don't check on me, I do not have the call light. Resident 28 stated It should not be behind me; it should be in my hand. I do not know where they put the call light. It makes me mad because I cannot see. It can cause safety issues for me.During a record review of Resident 28's Care Plan (CP) on 1/20/26 at 3:36 p.m., the CP interventions on 9/11/25 indicated Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed.During a concurrent observation and interview on 1/20/26 at 1:15 p.m. with Certified Nursing Assistant (CNA) 4, CNA 4 stated she brought Resident 28 into the room from the large dining room. CNA 4 stated Resident 28 could not see and needed to be directed, transferred to bed, and assisted with meals. CNA 4 stated Resident 28 could express her needs, and the call light was clipped to the side of Resident 28's bed. CNA 4 stated the call light should have been placed in Resident 28's hand based on her inability to see. CNA 4 stated it was important that the call light be handed to Resident 28 to enable Resident 28 to call for help when needed.During an interview on 1/21/26 at 2:49 p.m. with CNA 5, CNA 5 stated facility staff should have ensured the call light was within reach and informed Resident 28 of the location and what the call light was for. CNA 5 stated she was aware Resident 28 could not see and needed assistance. CNA 5 stated Resident 28 was incontinent and a feed assist (needed help with feeding). CNA 5 stated the call light should have been in Resident 28's hands because she could not see. CNA 5 stated Resident 28 did not know where the call light was at. CNA 5 stated if the call light is in her hand she will know where it is at all times CNA 5 stated there could be an outcome of injury from Resident 28 trying to get out of bed.During an interview and record review on 1/21/26 at 3:45 p.m. with Registered Nurse/Charge Nurse (RN) 2, RN 2 stated blind residents should be given a bell to call for assistance. RN 2 stated the facility had a bell. RN 2 stated blind residents could also be given the call light, Resident 28 should have been educated to where exactly the call light was. RN 2 stated this could help prevent injury for Resident 28 and ensure Resident 28's needs were met.During an interview and record review on 1/21/26 at 4:36 p.m. with Director of Staff Development (DSD), the DSD started Resident 28's sight was diminished and Resident 28 needed assistance with her meals. The DSD stated the facility staff should be doing rounds often to check on Resident 28. The DSD stated it was important so that Resident 28 can get help and not feel helpless in the room. The DSD stated Resident 28 had the potential to fall because she might attempt to get out of bed without calling for help when she needed assistance.During an interview on 1/22/26 at 4:15 p.m. with Resident 28 in Resident 28's Room, Resident 28 stated I cannot eat by myself. They do not help me with the food, they help only if they have to, if they are not busy, then they help. Resident 28 stated the facility staff do not cue or prompt (an act of assisting) her during meals. Resident 28 stated I have to wait till they are not busy and sometimes the food gets cold. Resident 28 stated I was never given a bell; I don't have a bell. Resident 28 stated they did not discuss my plan of care with me. Resident 28 stated I wear a brief, they change the brief only when I say something, they hardly ever help me. Resident 28 stated sometimes I am sitting in my soiled brief. Resident 28 stated she needed help to be transferred to the wheelchair. Resident 28 stated the only time I get to drink anything is when I am in the dining room.During an interview on 1/23/26 at 1:43 p.m. with RN 1, RN 1 stated facility staff needed to give Resident 28 the call light in her hand so that she could push the button. RN 1 stated it was important to prevent falls and to accommodate Resident 28's needs. RN 1 stated there was a risk of Resident 28 falling and injuring herself because she could not call for assistance when she needed it.During an interview on 1/23/26 at 2:23 p.m. with CNA 6, CNA 6 stated Resident 28 needed more help because it was difficult for Resident 28 to see. CNA 6 stated the call light should have been in Resident 28's hand. CNA 6 stated it was important because Resident 28 would not be able to see the call light if it was by her side. CNA 6 stated that visually impaired residents needed frequent checks. CNA 6 stated if not checked on, there was a potential for fallsDuring a concurrent interview and record review on 1/23/26 at 2:28 p.m. with the MDSC, Resident 28's Care Plan (CP) was reviewed. The CP indicated nonresident-specific interventions for Resident 28. The MDSC stated the admission nurse initiates a baseline CP and Interdisciplinary team (IDT) meets and completes if uncompleted by the admission nurse. The MDSC stated that MDSC develops the comprehensive CP and it is developed based on the resident's diagnosis, medications and needs. The MDSC stated the CP should be resident specific. The MDSC stated a legally blind resident, like Resident 28, is unable to see and unable to physically identify somebody. The MDSC stated a call light should be placed in Resident 28's hand or her chest so that Resident 28 could feel for it, and the facility staff should educate Resident 28 to where the call light each time they left the room. The MDSC stated that when Resident 28 is eating, the facility staff should tell her where certain things are placed on her plate. The MDSC stated Resident 28 should be introduced to her surroundings when in the dining room. The CP indicated .resident to use bell to call for assistance. The MDSC stated Resident 28 did not have a bell. The MDSC stated the facility was not implementing the CP. The MDSC stated Resident 28's care plan could be more detailed for a resident that was legally blind. The MDSC stated the CP was not resident specific to Resident 28's needs. The MDSC stated the facility did not follow the standard of practice for CPs, CPs should be specific to Resident 28's needs. The MDSC stated this was important to ensure the facility was meeting Resident 28's needs adequately. The MDSC stated not having a resident specific CP had the potential for Resident 28 to fall and not have her ADLs met.During a concurrent interview and record review on 1/23/26 at 3:08 p.m. with the Director of Nursing (DON), the DON stated the Resident 28 could not see. The DON stated she once observed that the resident was served without communication of where or what the food was, and she educated staff. The DON stated the call light should be given to the resident because she could not see. The DON stated it was important to enable Resident 28 to call for help anytime she needed help. The DON stated there was the potential outcome of Resident 28's needs not being met.During a review of the facilities policy and procedure (P&P) titled, Accommodation of Needs, dated 3/2021, the P&P indicated, Policy Statement-Our facility's environment and staff behaviors are directed toward assisting the residents maintaining and/or achieving safe independent functioning, dignity and well-being. Policy Interpretation and Implementation 1. The residents' individual needs and preferences are accommodated to the extent possible, except when the health and safety of the individual or other residents would be endangered. 2. The resident's individual needs and preferences, including the need for adaptive devices and modifications to the physical environment, are evaluated upon admission and reviewed on an ongoing basis.4. In order to accommodate individual needs and preferences. staff attitudes and behaviors are directed towards assisting the residents in maintaining ., dignity and well-being to the extent possible and in accordance with the residents' wishes. For example: a. interacting with the residents in ways that accommodate the physical or sensory limitations of the residents, promote communication and maintain dignity.During a review of the facilities policy and procedure (P&P) titled, Care Plans, Comprehensive Person centered, dated 3/2022, the P&P indicated Policy Statement: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.1. The interdisciplinary team (IDT), In conjunction with the resident and his four slash her family or legal representative, develops and implements A comprehensive, person-centered care plan for each resident.3. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. 4. Each resident's comprehensive person centered care plan is consistent with the residents rights to participate in the development and implementation of his or her plan of care, including the right to: a participate in the planning process . d. request revisions to the plan of care: e. participate in establishing the expected goals and outcome of care.g receive the services and/ or items included in the plan of care. 9. Care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making. 10. interventions address the underlying sources of the problem areas.11. Assessments of residents are ongoing, and care plans are revised as information about the residents and the residents' conditions change.During a review of the facility's document titled, Job Description, Certified Nurse Assistant, no date, the document indicated . Position Summary-The purpose . is to provide each resident with routine daily nursing care in accordance with the residents assessment plan along with current federal, state, and local standards that govern the facility and as directed by supervisors. Essential duties and responsibilities- .Answering the call lights.making residents comfortable (putting them in bed, bringing them water.), assisting in feeding residents (by cutting their food and spoon feeding if needed) .abiding with all facility policies and procedures.During a review of the facility's document titled, Job Description, Registered Nurse Supervisor, no date, the document indicated . Position Summary- The purpose.is to provide each resident with routine daily nursing care in accordance with current federal, state, and local standards that govern the facility and as directed by your management. Essential duties and responsibilities- . Assessment and development of resident care plans. monitoring nursing staff to ensure they are complying with the resident's care plan.abiding with all facility policies and procedures .During a review of the facility's document titled, Job Description, Charge Nurse, no date, the document indicated . Position Summary- The purpose.is to provide direct nursing care provide direct nursing care to the residents, and to supervise the day-to-day nursing activities . Essential duties and responsibilities- . Ensure that personnel providing direct care to residents are providing such care in accordance with the resident's care plan and wishes. Ensure that residents who are unable to call for help are checked frequently. Participate in developing, planning, conducting, and scheduling in-service training classes that provide instructions on how to do the job, and ensure a well-educated nursing service department. Monitor nursing care to ensure that all residents are treated fairly, and with kindness, dignity and respect.During a review of the facility's document titled, Job Description, MDS Coordinator, no date, the document indicated . Position Summary- The purpose.is to provide direct care to residents. will conduct and coordinate the development and completion of the Resident Assessment in accordance with current federal, state, and local standards that govern the facility, and as directed by management. Essential duties and responsibilities- .13. Train and educate nursing staff on topics pertinent to provision of direct care including MDS systems and regulatory compliance.During a review of the facility's document titled, Job Description, Director of Staff Development, no date, the document indicated . Position Summary- The purpose. is to manage, develop, and direct the overall operation of the nursing department in accordance with current federal, state, and local standards that govern the facility, and as directed by the administrator and medical director. Essential duties and responsibilities- . Planning, developing, and coordinating orientation programs as well as in service educational and on the job training, . abiding with all facility policies and procedures. Attending meetings and serving on committee's.During a review of the facility's document titled, Job Description, Director of Nursing, no date, the document indicated . Position Summary- Position Summary- The purpose.is to manage, develop, and direct the overall operation of the nursing department in accordance with current federal, state, and local standards that govern the facility and as directed by the Administrator and Medical Director. Essential duties and responsibilities-. Working with DSD in monitoring the in-service trainings, . Making written and verbal recommendations to the Administrator as needed concerning the operations of the nursing department, .Maintaining and updating the policies and procedures that govern the daily functions of the nursing department. Abiding with all facility policies and procedures. Attending meetings and serving on committee's.During a review of Professional Reference titled Fundamentals of Nursing - 9th Edition ([NAME] et al; Elsevier: 2017, p. 391), the reference indicated, .call lights are additional safety features found in health care settings. During a review of National Library of Medicine.org, Professional Reference titled, Use of Notification and Communication Technology (Call Light Systems) in Nursing Homes: Observational Study, dated 3/27/20, (found at https://pmc.ncbi.nlm.nih.gov/articles/PMC7148550/) the reference indicated, .Among the technologies used in nursing homes is the call light system, which plays a key role in communication. The call light system is critical for interactions between the nursing home staff and their residents. Research conducted in other health care settings has reported that nurse call systems significantly influence overall resident satisfaction in the delivery of their health care by creating a communication link between residents and nursing home staff. Nurse call light systems also help to ensure the safety of patients. a lifeline for patients because it is linked with patients' needs and alerts the staff to the situations in which patients may ask for help. Malfunctions of the nurse call light system can cause negative medical outcomes.During a review of National Library of Medicine.org, Professional Reference titled, Best Practices for Treating Blind and Visually Impaired Patients ., dated 5/3/2024, (found at https://doi.org/10.5811/westjem.61686) the reference indicated, .Visually impaired patients are more likely to experience multiple morbidities, . Falls and their sequelae, such as hip fractures, are among the most common reasons for blind patients to be seen in the ED. Ensure the patient knows where the call light is and how to use it. Accommodate the needs of the patient,. Tell the patient what you're going to do before doing it, including before leaving the room, .ensuring that patients are aware of the location and operation of the call light can further empower them and facilitate immediate communication,.

Based on observation, interview and record review, the facility failed to develop and implement a comprehensive care plan for one of eight sampled residents (Resident 28) when Resident 28's whose vision was severely impaired (no vision or sees only light, colors or shapes column eyes do not appear to follow objects) and did not have care plan interventions that were specific to her vision needs.This failure resulted in staff not assisting with meal set up, cue (a gentle hint or signal) and prompting (an act of assisting) of meals, and assistance with activities of daily living (ADLs) care and had the potential for Resident 28 specific needs to be unmet.During a review of Resident 28's admission Record (AR - a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), dated 1/22/26, the AR indicated, Resident 28, was admitted to the facility on [DATE], acute care hospital and had diagnoses that included . Legal blindness, muscle weakness, cerebral infarction (death of brain tissue due to a lack of blood supply), other seizures (a sudden, temporary disruption in the brain's electrical activity), difficulty in walking, anxiety disorder, unspecified asthma, insomnia (trouble falling asleep or staying asleep), unspecified convulsions (a sudden, uncontrollable, violent shaking or jerking of the body or limbs, caused by abnormal electrical activity in the brain).During a review of Resident 28's Minimum Data Set (MDS- a resident assessment tool used to identify resident cognitive (mental) and physical functional level) assessment, dated 12/4/25, the MDS section C indicated, Resident 28's Brief Interview for Mental Status (BIMS) assessment score was 7 out of 15 (0-6 severe cognitive (pertaining to reasoning memory and judgement) deficit, 7-12 moderate cognitive deficit, 13-15 cognitively intact). The BIMS scores indicated Resident 28 had moderate cognitive deficit.During a review of Resident 28's MDS assessment Section B Hearing, Speech and Vision, dated 12/4/25, indicated Resident 28's vision score was 4 .4 Severely impaired- no vision or sees only light, colors or shapes column eyes do not appear to follow objects.During a concurrent observation and interview on 1/20/26 at 11:28 a.m. with Resident 28 during the initial tour in Resident 28's Room, Resident 28 was lying in bed facing the wall. Resident 28's call light was behind her on the bed. Resident 28 stated I am blind, they don't check on me, I do not have the call light. Resident 28 stated It should not be behind me; it should be in my hand. I do not know where they put the call light. It makes me mad because I cannot see. It can cause safety issues for me.During a record review of Resident 28's Care Plan (CP) on 1/20/26 at 3:36 p.m., the CP interventions on 9/11/25 indicated Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed.During an interview and record review on 1/21/26 at 3:45 p.m. with Registered Nurse/Charge Nurse (RN) 2, RN 2 stated blind residents should be given a bell to call for assistance. RN 2 stated the facility had a bell. RN 2 stated blind residents could also be given the call light, the residents should be educated to where exactly the call light is. RN 2 stated this could help prevent injury for Resident 28 and ensure Resident 28's needs are met.During a concurrent observation and interview on 1/22/26 at 4:15 p.m. with Resident 28 in Resident 28's Room, Resident 28 stated I cannot eat by myself. They do not help me with the food, they help only if they have to, if they are not busy, then they help. Resident 28 stated the facility staff do not cue or prompt her during meals. Resident 28 stated I have to wait till they are not busy and sometimes the food gets cold. Resident 28 stated I was never given a bell; I don't have a bell. Resident 28 stated they did not discuss my plan of care with me.During a concurrent interview and record review on 1/23/26 at 1:43 p.m. with RN 1, Resident 28's CP was reviewed. RN 1 stated CPs should be patient-specific to meet their needs. RN 1 was unable to locate specific CPs and interventions related to Resident 28's impaired vision and the need for the call light. RN 1 stated the Minimum Data Set Coordinator (MDSC) creates the care plan.During a concurrent interview and record review on 1/23/26 at 2:28 p.m. with the MDSC, Resident 28's Care Plan (CP) was reviewed. The CP indicated nonresident-specific interventions for Resident 28. The MDSC stated the admission nurse initiates the baseline CPs and Interdisciplinary team (IDT) meets and completes the baseline if uncompleted by the admission nurse. The MDSC stated that the MDSC develops the comprehensive CP and it is developed based on the resident's diagnosis, medications and needs. The MDSC stated the care plan should be resident specific. The MDSC stated a legally blind resident like Resident 28, is unable to see and unable to physically identify somebody. The MDSC stated a call light should be placed in Resident 28's hand or her chest so that Resident 28 could feel for it, and the facility staff should educate Resident 28 to where the call light each time they left the room. The MDSC stated that when Resident 28 is eating, the facility staff should tell her where certain things are placed on her plate. The MDSC stated Resident 28 should be introduced to her surroundings when in the dining room. The CP indicated .resident to use bell to call for assistance. The MDSC stated Resident 28 did not have a bell. The MDSC stated the facility was not implementing the CP. The MDSC stated Resident 28's care plan could be more detailed for a resident that was legally blind. The MDSC stated the CP was not resident specific to Resident 28's needs. The MDSC stated the facility did not follow the standard of practice for CPs, CPs should be specific to Resident 28's needs. The MDSC stated this was important to ensure the facility was meeting Resident 28's needs adequately. The MDSC stated not having a resident specific CP had the potential for Resident 28 to fall and not have her ADLs met.During a concurrent interview and record review on 1/23/26 at 3:08 p.m. with the Director of Nursing (DON), Resident 28's CPs was reviewed. The DON stated the MDSC develops the comprehensive CP and as intervention and needs changes any licensed nurse (LN) can add and update the CP. The DON stated the CP should be collaborative. The CP indicated .resident to use bell to call for assistance. The DON stated Resident 28 did not have a bell. The DON stated the individualized CP is developed based on the residents' specific needs, Resident 28 should have specific care for her impaired vision. The DON stated the facility was not following Resident 28's specific interventions and CP. The DON stated the importance of implementing the interventions was for the facility to meet Resident 28's specific needs. The DON stated failure to develop and implement Resident 28's specific CP had the potential for Resident 28's vision impaired to not be met.During a review of the facilities policy and procedure (P&P) titled, Care Plans, Comprehensive Person centered, dated 3/2022, the P&P indicated, Policy Statement: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.1. The interdisciplinary team (IDT), In conjunction with the resident and his four slash her family or legal representative, develops and implements A comprehensive, person centered care plan for each resident.3. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. 4. Each resident's comprehensive person centered care plan is consistent with the residents rights to participate in the development and implementation of his or her plan of care, including the right to: a participate in the planning process . d. request revisions to the plan of care: e. participate in establishing the expected goals and outcome of care.g receive the services and/ or items included in the plan of care. 9. Care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making. 10. interventions address the underlying sources of the problem areas.11. Assessments of residents are ongoing, and care plans are revised as information about the residents and the residents' conditions change.During a review of the facility's document titled, Job Description, Registered Nurse Supervisor, no date, the document indicated . Position Summary- The purpose.is to provide each resident with routine daily nursing care in accordance with current federal, state, and local standards that govern the facility and as directed by your management. Essential duties and responsibilities- . Assessment and development of resident care plans. monitoring nursing staff to ensure they are complying with the resident's care plan.abiding with all facility policies and procedures .During a review of the facility's document titled, Job Description, Charge Nurse, no date, the document indicated . Position Summary- The purpose.is to provide direct nursing care provide direct nursing care to the residents, and to supervise the day-to-day nursing activities . Essential duties and responsibilities- . Review care plans daily to ensure that appropriate care is being rendered. Inform the nurse supervisor of any changes that need to be made on the care plan. Ensure that your nurses' notes reflect that the care plan is being followed when administering nursing care or treatment. Review resident care plans for appropriate resident goals, problems, approaches, and revisions based on nursing needs. Ensure that your assigned certified nursing assistants (CNAs) are aware of the resident care plans. Ensure that the CNAs refer to the resident's care plan prior to administering daily care to the resident. Assist the Resident Assessment/Care Plan Coordinator in planning, scheduling, and revising the MDS, including the implementation of RAPs and Triggers.During a review of the facility's document titled, Job Description, MDS Coordinator, no date, the document indicated . Position Summary-. is to provide direct care to residents. work to restore or maintain the resident's health and well-being by conducting a thorough evaluation of the resident's health status, which includes gathering medical history, conducting physical assessments, and collaborating with the facility IDT members. the formulation of all patient care plans that guide the direct care that patients receive. These plans are meticulously designed to address the resident's physical, psychological, and social needs providing a holistic approach to their care. will conduct and coordinate the development and completion of the Resident Assessment in accordance with current federal, state, and local standards that govern the facility, and as directed by management. Essential duties and responsibilities- . 2. Conduct comprehensive Resident Assessments upon admission of resident and develop patient care plan.3. Perform healthcare assessments and reassessments and formulate individualized nursing plans of care through documentation review, visual observations, discussions with direct care staff, and interviews with residents and family members.5. Visit residents and evaluate care plans for comprehensiveness and individuality and assess the achievement or lack of achievement of desired outcome. Ensure that the resident's care plan is reassessed and revised according to the evaluation of achievement or lack of achievement of desired outcomes. From evaluation, reassesses resident problems and goals and interventions for appropriateness, realistic value, priority and reassesses overall plan of care. From reassessment, identify new problem or potential problems, establish updated and appropriate goals, revise interventions, and continually evaluate nursing care plan and makes revisions according to change in resident's health status.12. Assess the content of each resident's MDS and medical record to ensure completeness and thoroughness of documentation. 13. Train and educate nursing staff on topics pertinent to provision of direct care including MDS systems and regulatory compliance.During a review of the facility's document titled, Job Description, Director of Nursing, no date, the document indicated . Position Summary- Position Summary- The purpose.is to manage, develop, and direct the overall operation of the nursing department in accordance with current federal, state, and local standards that govern the facility and as directed by the Administrator and Medical Director. Essential duties and responsibilities-.Maintaining and updating the policies and procedures that govern the daily functions of the nursing department. Abiding with all facility policies and procedures. Attending meetings and serving on committee's.During a review of National Library of Medicine.org Professional Reference titled, Nursing Process, dated 4/10/23, (found at https://www.ncbi.nlm.nih.gov/books/NBK499937/) the reference indicated, . Planning: The planning stage is where goals and outcomes are formulated that directly impact patient care based on guidelines. These patient-specific goals and the attainment [the level of knowledge, skills, or qualifications a learner has acquired at a specific point in time] of such assist in ensuring a positive outcome. Nursing care plans are essential in this phase of goal setting. Care plans provide a course of direction for personalized care tailored to an individual's unique needs. Overall condition and comorbid conditions play a role in the construction of a care plan. Care plans enhance communication, documentation, reimbursement, and continuity of care across the healthcare continuum. vital to positive patient outcomes. the nursing process to guide care is clinically significant going forward in this dynamic, complex world of patient care. Aging populations carry with them a multitude of health problems and inherent risks of missed opportunities to spot a life-altering condition.

Based on observation, interview, and record review the facility failed to meet professional standards of practice for three of seventeen sampled residents (Resident 13, Resident 19 and Resident 35) when:Resident 13 was administered hydrocodone-acetaminophen (opioid pain medication used to treat moderate to severe pain) 12 times outside of ordered administration parameters from 1/15/26-1/22/26.Resident 19 was administered tramadol HCL (opioid pain medication used to treat moderate to severe pain) 48 times outside of ordered administration parameters from 11/1/25-1/22/26.These failures had the potential to result in inadequate pain management practices of Resident 13 and Resident 19 which had the potential to lead to adverse consequences such as complications, overdose, misuse or death. 3. Resident 35 did not receive oxygen (O2- a colorless, odorless and tasteless gas essential for life) therapy as ordered by the physician on 1/8/26.This failure placed Resident 35 at risk of excessive oxygenation and respiratory complications.1.During a review of Resident 13's admission Record (AR - a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), dated 1/22/26, the AR indicated Resident 13 was admitted to the facility on [DATE] with diagnoses of gout (inflammation of joints), Peripheral Artery Disease (PAD-reduced blood flow to limbs), and left leg amputation below the knee (Left BKA-removal of leg below knee). During a review of Resident 13's Minimum Data Set (MDS - a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment), dated 12/30/25, the MDS indicated Resident 13 had a Brief Interview for Mental Status (BIMS - a test given by medical professionals to determine cognitive [involving the process of thinking, learning and understanding] understanding on a scale of 1-15 ) score of 14 (a score of 0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired, 13-15 suggests cognitively intact), which suggested Resident 13 was cognitively intact. During a review of Resident 13's Order Summary Report (OSR), dated 1/22/26, the OSR indicated, Resident 13 had an active order for hydrocodone-acetaminophen oral tablet 5-325 MG (milligrams- a unit of measurement for medications) to be given every 6 hours for severe pain of 6-10. The OSR indicated, hydrocodone-acetaminophen was ordered on 1/15/26. The OSR indicated Resident 13 had an active order for acetaminophen 325 MG as needed every 6 hours for mild pain of 1-5. During a review of Resident 13's Medication Administration Record (MAR), dated 1/22/26, the MAR indicated, .hydrocodone-acetaminophen 5-325 MG.give 1 tablet by mouth every 6 hours for severe pain 6-10.order date 1/15/2026. was administered 12 times outside of administered order parameters between 1/15/26-1/22/26, for reported pain scores of 0-5. There were 27 opportunities for administration. The order indicated hydrocodone-acetaminophen was to be administered for resident reports of severe pain of 6-10 and the facility administered the medication for resident reported pain levels of 0-5, outside of order parameters. During a concurrent observation and interview on 1/20/26 at 10:37 a.m. with Resident 13, in Resident 13's room, Resident 13 was observed lying in bed. Resident 13 stated he was recently admitted to the facility and was working on regaining strength following his left BKA. Resident 13 stated he was able to make his needs known and did not have frequent pain. Resident 13 stated he knew he could request medication if he had pain. 2. During a review of Resident 19's AR, dated 1/22/26, the AR indicated Resident 19 was admitted to the facility on [DATE] with diagnoses of parkinsonism (movement problems), osteoarthritis (joint disease), chronic pain syndrome, mononeuropathy (damage to peripheral nerve causing loss of function), right knee effusion (fluid in knee), hemiplegia (paralysis) and hemiparesis (weakness) following cerebrovascular disease (decreased blood flow to brain). During a review of Resident 19's MDS, dated 12/4/25, the MDS indicated, Resident 19 had a BIMS score of 13, which suggested Resident 19 was cognitively intact. During a review of Resident 19's OSR, dated 1/22/26, the OSR indicated, Resident 19 had an order for tramadol HCL oral tablet 50 MG to be given two times a day. The tramadol HCL order indicated it was to be given, .for pain 4-10 hold for [signs and symptoms] of sedation/overdose, if [respirations less than] 12, notify MD if [signs and symptoms] are present. The OSR indicated, tramadol was ordered on 7/4/25. The OSR indicated, Resident 19 had an active order for acetaminophen 325 MG as needed every 6 hours for mild pain, no pain scale was included in the order. During a review of Resident 19's MAR, dated 1/22/26, the MAR indicated, .tramadol HCL oral tablet 50 MG.give 1 tablet by mouth two times a day for pain 4-10 hold for [signs and symptoms] of sedation/overdose, if [respirations less than]12, notify MD if [signs and symptoms] are present.order date 7/4/25. The MAR indicated tramadol HCL was administered 10 times outside of administration order parameters, between 11/1/25-11/30/25, for reported pain scores of 0-3. There were 60 opportunities for administration. The MAR indicated between 12/1/25-12/31/25 tramadol was administered 16 times outside of administration order parameters, for reported pain scores of 0-3. There were 62 opportunities for administration. The MAR indicated between 1/1/26-1/22/26 tramadol was administered 22 times outside of administration order parameters, for reported pain scores of 0-3. There were 43 opportunities for administration. The order indicated tramadol HCL was to be administered for resident pain reports of 4-10 and the facility administered the medication for resident reported pain levels of 0-3, outside of order parameters. During a concurrent observation and interview on 1/20/26 at 10:31 a.m. with Resident 19, in Resident 19's room, Resident 19 was observed lying in bed. Resident 19 stated he frequently received pain medication. During a concurrent interview and record review on 1/22/26 at 9:26 a.m. with Registered Nurse (RN) 3, Resident 13 and Resident 19's Medical Records, dated 1/22/26 were reviewed. RN 3 stated routine pain medication required administration instructions. RN 3 stated routine pain medication administration instructions were expected to be followed as they were written. RN 3 stated Resident 13 had an opioid pain medication order for, .hydrocodone-acetaminophen 5-325 MG.give 1 tablet by mouth every 6 hours for severe pain 6-10. RN 3 stated Resident 13's opioid pain medication order indicated the pain medication was to be administered for a pain score rating of 6-10. RN 3 stated Resident 19 had an opioid pain medication order for, .tramadol HCL oral tablet 50 MG.give 1 tablet by mouth two times a day for pain 4-10 hold for [signs and symptoms] of sedation/overdose, if [respirations less than]12, notify MD if [sign and symptoms] are present. RN 3 stated Resident 19's opioid pain medication order indicated the pain medication was to be administered for a pain score rating of 4-10. RN 3 stated if Resident 13 and Resident 19 reported a pain score outside of their ordered administration instruction range the provider should have been contacted for administration clarification. RN 3 stated Resident 13 and Resident 19's pain medication orders had not been followed as they were written when medication was administered outside of administration instruction guidelines. RN 3 stated Resident 13 and Resident 19 were at risk for adverse effects such as opioid overdose or misuse when their opioid pain medications were administered outside of administration instruction guidelines. RN 3 stated it was important to do complete and accurate pain assessments prior to the administration of pain medication to ensure medication was administered as prescribed. During an interview on 1/22/26 at 12:10 p.m. with the Pharmacy Consultant (PC), the PC stated opioid pain medications required administration instruction guidelines to protect residents from adverse effects and inappropriate pain management. The PC stated licensed nursing staff were expected to administer pain medications as prescribed. The PC stated licensed nursing staff were expected to notify the provider if residents reported pain scores outside of the scheduled pain medication administration instruction guidelines for administration clarification. The PC stated Resident 13 and Resident 19's opioid pain medications were not administered appropriately when given outside of administration instruction guidelines. The PC stated opioid pain medications needed to be managed and monitored to ensure resident pain was effectively being treated and the most appropriate medication was being administered to treat resident reported pain. The PC stated facility policy and procedure needed to be followed when assessing, treating and administering pain medications to residents. During an interview on 1/23/26 at 1:40 p.m. with the Director of Nursing (DON), the DON stated licensed nursing staff were expected, per facility policy and standards of practice, to administer medications as per provider orders. The DON stated order administration instructions were placed within provider orders as guidelines and parameters. The DON stated all guidelines and parameters needed to be followed when administering medications to ensure resident safety and appropriate treatment management. The DON stated Resident 13 and Resident 19's opioid pain medications were not administered as per provider orders when they were given outside of ordered administration instruction. The DON stated residents were at risk of opioid overdose, misuse, and adverse effects if opioids were administered outside of provider orders. During a review of Resident 13's Care Plan Report (CP), dated 1/22/26, the CP indicated, .amputation of (Left BKA).administer medications as ordered. The CP indicated, .has gout.administer analgesics as ordered by the physician . The CP indicated, .has chronic pain [related to] diabetic neuropathy, gout, PAD, Left BKA.administer analgesics as per orders.administer medications as ordered. black box warning [prescription drug warning label designated to highlight safety information]: hydrocodone-acetaminophen addiction, abuse, and misuse.use of hydrocodone/acetaminophen exposes patients and other users to the risk of opioid addiction, abuse, and misuse, which can lead to overdose and death, assess each patient's risk prior to prescribing and reassess all patients regularly for the development of these behaviors and conditions. For additional information see physician order.assess intensity of pain based on a 0-10 scale.evaluate the effectiveness of pain interventions.review for compliance , alleviating of symptoms, dosing schedules. During a review of Resident 19's CP, dated 1/22/26, the CP indicated, .has a history of other substance abuse. The CP indicated, .has Parkinson's disease.give analgesics as ordered by the physician. The CP indicated, .has chronic pain [related to] right knee effusion, osteoarthritis, chronic pain syndrome, neuropathy. administer analgesia as per MD orders.black box warning: Tramadol HCL.assess intensity of pain based on 0-10 scale. During a review of the facility's policy and procedure (P&P) titled, Pain-Clinical Protocol, dated 10/2022, the P&P indicated, .if the physician determines that opioid medication is an appropriate option for managing acute (or in some cases chronic) pain in the resident, the lowest possible effective dose is prescribed for the shortest time possible with ongoing staff monitoring for effectiveness and adverse effects.if pain is stable and the underlying cause is resolved or it is unclear whether a source of pain remains, the physician will consider a trial reduction or elimination of analgesic medication; for example, reduce the standing dose of an analgesic and see if there is any changes in pain -related symptoms or use of PRN analgesics.reductions in opioid analgesics are especially important in light of their limited efficacy in the treatment of chronic non-cancer pain and their many significant side effects. During a review of the facility's P&P titled, Administering Pain Medications, dated 10/2022, the P&P indicated, .the pain management program is based on facility-wide commitment to appropriate assessment and treatment of pain, based on professional standards of practice, the comprehensive care plan, and the resident's choices related to pain management.conduct a pain assessment as indicated.administer pain medications as ordered. During a review of the facility's P&P titled, Pain Assessment and Management, dated 10/2022, the P&P indicated, .the pain management interventions are consistent with the resident's goals for treatment which are defined and documented in the care plan. Pain management interventions reflect the sources, type and severity of pain.the medication regimen is implemented as ordered.ongoing communication between the prescriber and the staff is necessary for the optimal and judicious use of pain medications.if pain symptoms have resolved or there is no longer an indication for pain medication, the multidisciplinary team and physician shall try to discontinue or taper analgesic mediations to the extent possible. During a professional reference review retrieved from https://www.nccmerp.org/recommendations-enhance-accuracy-administration-medications titled, Recommendations to Enhance Accuracy of Administration of Medications, dated 3/30/23, the professional reference review from the National Coordinating Council for Medication Error Reporting and Prevention indicated, . any order that in incomplete, illegible, or poses any concern should be clarified before preparation and administration.the right medication, in the right dose, to the right person, by the right route, using the right dosage form, at the right time, for the right reason. 3. During a concurrent observation and interview on 1/20/2026 at 10:07 a.m. with Resident 35 during the initial tour in Resident 35's Room, Resident 35 was lying in bed with eyes opened, unable to communicate and a nasal cannula (NC- thin plastic tube that delivers oxygen directly into the nose through two small prongs) in her nose, connected to a working oxygen concentrator (device that produces oxygen for breathing) was set to 2.5 LPM (liter per minute- a unit of measurement for the flow rate of oxygen). During a review of Resident 35's admission Record (AR - a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), dated 1/22/26, the AR indicated, Resident 35, was admitted to the facility on [DATE] from acute care hospital and had diagnoses that included . chronic obstructive pulmonary disease (COPD- a progressive lung disease that causes persistent airflow obstruction, making it hard to breathe) , encounter for palliative care (medical support for people with serious illnesses, focusing on relieving symptoms, pain, and stress to improve the patient's and family's quality of life), unspecified dementia (a progressive state of decline in mental abilities), anxiety disorder. During a review of Resident 35's Minimum Data Set (MDS- a resident assessment tool used to identify resident cognitive (mental) and physical functional level) assessment, dated 10/16/25, the MDS section C500 indicated, Resident 35's Brief Interview for Mental Status (BIMS) assessment score was 99 (0-6 severe cognitive (pertaining to reasoning memory and judgement) deficit, 7-12 moderate cognitive deficit, 13-15 cognitively intact, 99 indicates unable to complete the interview). The MDS section C1000 indicated, Resident 35's Staff Assessment for Mental Status- Cognitive skills for daily decision-making score was 3 (0. Independent- decision consistent/ reasonable, 1. modified independence- some difficulty in new situations only, 2. moderately impaired- decisions poor; cues/ supervision required, 3. severely impaired- never/ rarely made decisions). The score indicated Resident 35 was severely impaired. During a review of Resident 35's MDS assessment, dated 10/16/25, the MDS section O indicated, Resident 35's Special Treatment, Procedures, and Programs indicated Resident 35 was on hospice care while as a resident. During a concurrent interview and record review on 01/21/2026 at 3:45 p.m. with Registered Nurse/Charge Nurse (RN) 2, Resident 35's Order Summary Report (OSR), and a picture of Resident 35's O2 concentrator were reviewed. The OSR indicated .Oxygen at 2 L/Min (LPM-liters per minute-unit of measurement) via nasal cannula continuously for shortness of breath every shift with order start date 1/8/26. The picture indicated the flow indicator ball (FIB- ball inside the flow meter tube on an O2 concentrator that measures the flow rate of O2) was at 2.5L. RN 2 stated O2 was to be started based on the physician's order. RN 2 stated the physician's order was for O2 at 2 liters nasal cannula continuous for shortness of breath. RN 2 validated that the concentrator was for Resident 35 and the FIB was on 2.5 liters. RN 2 stated the physician's order was not followed. RN 2 stated it was important to follow the physician's orders for patient safety and patient health. RN 2 stated Resident 35 was at risk for over oxygenation and it could affect her lungs. During a concurrent interview and record review on 01/23/2026 at 1:43 p.m. with RN 1, Resident 35's Order Summary Report (OSR) for O2 with order start date 1/8/26, Resident 35's Care Plan (CP) and a picture of Resident 35's O2 concentrator with the FIB at 2.5L were reviewed. The CP with date initiated 1/8/26 indicated Resident has shortness of breath related to COPD. Started on oxygen 2 L/min via NC continuously . administer oxygen as ordered by MD. 2 L/min via NC continuously and monitor for effectiveness. RN 1 validated the O2 order and picture showing 2.5 liters. RN 1 stated licensed nurse (LN)s needed to follow the policy but did not follow the policy. RN 1stated if O2 is titrated (continuously measure and adjust the balance of medication), the physician should be notified, and it should be documented in Resident 35's progress note. RN 1 stated; when LNs do not follow the physicians orders it is not beneficial for Resident 35. RN 1 stated the potential outcome could be hyperoxia (an excess supply of oxygen to the body's tissues and organs, occurring when oxygen levels exceed the normal range) and Resident 35 could die. During a concurrent interview and record review on 01/23/2026 at 3:08 p.m. with the Director of Nursing (DON), a picture of Resident 35's O2 concentrator with the FIB at 2.5L was reviewed. The DON stated O2 should be administered according to the physician's order. The DON stated LNs had not followed the physician's O2 orders for Resident 35 and were not following the policy for administering medications. The DON stated the importance of following the physician's orders was to meet Resident 35's needs. The DON stated if there were additional needs, LNs needed to communicate with the physician. The DON stated there was the potential outcome of Resident 35 getting too much oxygen in her lungs. During a review of the facility's policy and procedure (P&P) titled, Administering Medications, dated 4/2019, the P&P indicated, Policy Statement: Medications are administered in a safe and timely manner, and as prescribed. 2. The Director of nursing services supervises and directs all personnel who administer medications and /or have related functions.4.medications are administered in accordance with prescriber orders. During a review of the facility's policy and procedure (P&P) titled, Oxygen Administration, dated 10/2010, the P&P indicated, .Purpose.is to provide guidelines for safe oxygen administration.1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration, 2. Review the resident's care plan to assess for ay special needs of the resident. During a review of the facility's document titled, Job Description, Registered Nurse Supervisor, no date, the document indicated . Position Summary- The purpose.is to provide each resident with routine daily nursing care in accordance with current federal, state, and local standards that govern the facility and as directed by your management. Essential duties and responsibilities- . Assessment and development of resident care plans, monitoring nursing staff to ensure they are complying with resident care plan, abiding with all facility policies and procedures. During a review of the facility's document titled, Job Description, Charge Nurse, no date, the document indicated . Position Summary- The purpose.is to provide direct nursing care provide direct nursing care to the residents, and to supervise the day-to-day nursing activities . Essential duties and responsibilities- . Prepare and administer medications as ordered by the physician, .review the resident's chart for specific treatment, medication orders . as necessary, .make periodic checks to ensure that prescribed treatments are being properly administered . ensure that personnel providing direct care to residents are providing such care in accordance with the resident's care plan . Must possess the ability to plan, organize, develop, implement, and interpret the programs, goals, objectives, policies and procedures, etc., that are necessary for providing quality care. During a review of the facility's document titled, Job Description, Director of Nursing, no date, the document indicated . Position Summary- The purpose.is to manage, develop, and direct the overall operation of the nursing department in accordance with current federal, state, and local standards that govern the facility and as directed by the Administrator and Medical Director. Essential duties and responsibilities- . providing assistance to nursing staff when needed., making rounds, abiding with all facility policies and procedures. During a professional reference review retrieved from https://pubmed.ncbi.nlm.nih.gov/19377391/ titled, The use of medical orders in acute care oxygen therapy, dated 2009, the professional reference review indicated, . Oxygen is considered to be a drug requiring a medical prescription and is subject to any law that covers its use and prescription . authorized by a physician following legal written instruction to a qualified nurse . This standard procedure helps prevent incidence of misuse or oxygen deprivation which could worsen the patients hypoxia and ultimate outcome .

Based on observation, interview, and record review, the facility failed to ensure drugs and biologicals (a substance such as vaccines or drugs derived from a living organism used for treatment) were stored and labeled in accordance with currently accepted professional standards and practice when one of eight bottles of prescription eye drops (physician prescribed medication used in the eyes) were not labeled with the resident's name, directions for use, or expiration date.This failure placed residents at risk of receiving the wrong medication which could lead to medication adverse (resulting in negative or harmful effect) reactions.Findings:During a concurrent observation and interview on 1/23/2026 at 11:03 a.m. with Registered Nurse (RN) 2 at Station 2, the medication cart was examined. One of eight prescription eye drop bottles was observed without a label of the resident's name or ordered administration instructions for use. RN 2 stated the bottle should have been labeled in case it came out of its container box so staff would know which resident it was for and so it was not given to the wrong resident.During an interview on 1/23/26 at 2:26 p.m. with the Director of Nursing (DON), the DON stated the eye drop bottle should have been labeled with the resident's name and the administration instructions, and the nurses should be checking for a label before the medication is administered to the resident. The DON stated it was important for the bottle to be labeled in case it came out of the package, so staff would know which patient it belonged to and what the administration directions were. The DON stated there was a risk of giving the medication to the wrong resident which could have caused a negative reaction to the resident.During a review of the facility's job description document titled, Charge Nurse, (undated), the document indicated, . ensure that prescribed medication for one resident is not administered to another .During a review of the facility's policy and procedure (P&P) titled, Medication Labeling and Storage, dated 2/2023, indicated, . Labeling of medications and biologicals dispensed by the pharmacy is consistent with applicable federal and state requirements and currently accepted pharmaceutical practices . the medication label includes, at a minimum . medication name . prescribed dose . strength . expiration date . resident's name . route of administration . appropriate instructions .During a review of the facility's P&P titled, Administering Medications, dated 4/2019, indicated, . medications are administered in a safe and timely manner, and as prescribed . the individual administering the medication checks the label THREE(3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication .

Based on observation, interview, and record review, the facility failed to establish and maintain an effective infection prevention and control program during medication administration for three of 15 sampled residents (Resident 9, Resident 5, and Resident 35) when:1. During a blood glucose check (a process for measuring the concentration of glucose in the blood) and medication administration to a resident on Enhanced Barrier Precautions (EBP - an infection control intervention designed to reduce transmission of resistant organisms [bacteria that have become resistant to certain antibiotics] that requires gown and glove use during high contact resident care activities), Registered Nurse (RN) 2 placed a tray containing supplies for patient care on Resident 9's bedside table who was on EBP, then placed the tray in the medication cart without sanitizing it after providing care and medication administration to Resident 9.2. Personal Protective Equipment (PPE) was not worn during care for Resident 35 and Resident 5. These failures placed residents at risk for cross-contamination (the process when germs are unintentionally transferred from one substance or object to another, which causes a harmful effect) and infection (an invasion of the body by germs that cause disease).Findings: 1. During a concurrent observation and interview on 1/22/26 at 11:55 a.m. with Licensed Vocational Nurse (LVN) 1, in the hallway outside Resident 9's room and in Resident 9's room, LVN 1 was observed preparing a tray with paper towels, a cup of water, a glucometer (an instrument for measuring the concentration of glucose in the blood), alcohol wipes, lancets (a device with a needle used to poke the skin for blood sample), glucose test strips (a strip that collects blood for the glucometer to measure blood glucose) and tissue prior to entering Resident 9's room. LVN 1 donned a gown and gloves prior to entering Resident 9's room and placed the tray on Resident 9's bedside table and proceeded to start Resident 9's artificial feeding through his g-tube (a surgical opening made through the abdominal wall into the stomach to insert a feeding tube for long-term nutritional support) and checked Resident 9's blood glucose. After administering Resident 9's medication, LVN 1 placed the tray back into the medication cart without sanitizing it. LVN 1 stated the tray should have been cleaned prior to placing back in the medication cart for infection control. LVN 1 stated since the tray was placed on Resident 9's bedside table and would be used for another resident's medication, it needed to be cleaned to prevent cross-contamination and possible infection of another resident. During an interview on 1/22/26 at 5:22 p.m. with the Infection Preventionist (IP), the IP stated EBP were initiated for wounds, urinary catheters, dialysis ports (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed), g-tubes, any multi-drug resistant organisms (MDRO - bacteria that have become resistant to multiple types of antibiotics making them more difficult to treat, can spread rapidly, and threaten patient safety) with a sign posted outside the resident's room and a blue dot next to the resident's name to indicate which resident was on EBP. The IP stated the tray used for patient care and administration of medication should have been cleaned and sanitized prior to putting it back in the medication cart to prevent the spread of infections. During an interview on 1/23/26 at 2:33 p.m. with the Director of Nursing (DON), the DON stated trays should have been cleaned and disinfected prior to placing them back in the medication cart, after using the tray in a resident's room and placing the tray on a resident's table who was under EBP precautions. The DON stated the tray should have been disinfected prior to putting it back into the medication cart since it came from an infected room. The DON stated the nurse should have used a barrier on any resident's table prior to placing the tray down and should have disinfected the tray after using it. The DON stated there was a risk of contaminating other items in the cart and other residents. During a review of the facility's policy and procedures (P&P) titled, Policies and Practices – Infection Control, dated 10/2018, indicated, . this facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and manage transmission of diseases and infections.the objectives of our infection control policies and practices are to .prevent, detect, investigate, and control infections in the facility.maintain a safe, sanitary, and comfortable environment.provide guidelines for the safe cleaning and reprocessing of reusable resident-care equipment. During a review of the facility's P&P titled, Standard Precautions, dated 9/2022, indicated, .Standard precautions are used in the care of all residents regardless of their diagnoses, or suspected or confirmed infection status .reusable equipment is not used for the care of more than one resident until it has been appropriately cleaned and reprocessed. During a review of the facility's P&P, titled, Cleaning and Disinfection of Resident-Care Items and Equipment, dated 9/2022, indicated, .resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current CDC recommendation for disinfection.non-critical items are those that come in contact with intact skin but not mucous membranes.non-critical environmental surfaces include bed rails, bedside tables, etc.reusable resident care equipment is decontaminated and/or sterilized between residents. 2. During a concurrent observation and interview on 1/20/2026 at 10:07 a.m. with Resident 35 during the initial tour in Resident 35's room, there was enhanced barrier precaution (EBP) signage outside the room door and a blue dot on Resident 35's name. Resident 35 was lying in bed with eyes opened, unable to communicate. Resident 35 had a gastrostomy tube (G-tube or PEG tube- a surgical opening made through the abdominal wall into the stomach to insert a feeding tube for long-term nutritional support) with no feeding pump. During an interview on 1/20/2026 at 10:32 a.m. with Certified Nursing Assistant (CNA) 3, CNA 3 stated the blue dot is for the residents on EBP. During an observation on 1/20/2026 at 11:11 a.m. the call light was observed to be unattended to outside Resident 35's room. Upon entry into Resident 35's room, CNA 3 was observed in Resident 35's room with gloves on and no gown worn, performing resident care on Resident 35; soiled brief was observed on Resident 35's bed. During a review of Resident 35's admission Record (AR - a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), dated 1/22/26, the AR indicated, Resident 35, was admitted to the facility on [DATE] from acute care hospital and had diagnoses that included . encounter for surgical aftercare following surgery on the digestive system, gastrostomy status, unspecified dementia (a progressive state of decline in mental abilities). During a review of Resident 35's Minimum Data Set (MDS- a resident assessment tool used to identify resident cognitive (mental) and physical functional level) assessment, dated 10/16/25, the MDS section C500 indicated, Resident 35's Brief Interview for Mental Status (BIMS) assessment score was 99 (0-6 severe cognitive (pertaining to reasoning memory and judgement) deficit, 7-12 moderate cognitive deficit, 13-15 cognitively intact, 99 indicates unable to complete the interview). The MDS section C1000 indicated, Resident 35's Staff Assessment for Mental Status- Cognitive skills for daily decision-making score was 3 (0. Independent- decision consistent/ reasonable, 1. modified independence- some difficulty in new situations only, 2. moderately impaired- decisions poor; cues/ supervision required, 3. severely impaired- never/ rarely made decisions). The score indicated Resident 35 was severely impaired. During a review of Resident 35's Order Summary Report (OSR), the OSR indicated .NPO diet (nothing by mouth) NPO texture, NPO consistency- order start date 10/11/25, enteral feed order every night shift - order start date 10/10/25, . enhanced barrier precaution due to peg-tube every shift-order start date 10/10/25. During a concurrent observation and interview on 1/20/2026 at 10:47 a.m. with Resident 5 during the initial tour in Resident 5's room, there was EBP signage outside the room door and a blue dot on Resident 5's name. Resident 5 was observed to be sitting in her wheelchair. Resident 5 stated she had a pressure ulcer and the pressure ulcer was healing well. Resident 5 stated the facility staff do not put on PPE when performing wound care. Resident 5 stated they are changing the bandage everyday like they are supposed to. they have gloves on; nobody puts on the gown. During a review of Resident 5's AR dated 1/22/26, the AR indicated, Resident 5, was admitted to the facility on [DATE] from acute care hospital and had diagnoses that included . Severe sepsis without septic shock, pressure ulcer of sacral region unspecified stage, cellulitis (serious bacterial skin infection affecting the deep dermis and subcutaneous tissues) of unspecified parts of limb. During a review of Resident 5's MDS assessment, dated 10/128/25, the MDS section C indicated, Resident 5's BIMS assessment score was 15 out of 15. The score indicated Resident 5 was cognitively intact. During a review of Resident 5's MDS assessment, dated 10/28/25, the MDS section M indicated, Resident 5's Skin Conditions included Resident 5 had Stage 3 pressure ulcer. During a review of Resident 5's Order Summary Report (OSR), the OSR indicated . Cleanse pressure ulcer stage 3 to the sacral area with NS .- order date 12/30/25, . enhanced barrier precautions every shift for unhealed wounds-order date 8/4/25. During an interview on 01/20/2026 at 12:59 p.m. with CNA 3, CNA 3 stated EBP meant facility staff needed to put on PPE which included a gown and glove when a resident had a feeding tube or wound. CNA 3 validated performing resident care on Resident 35. CNA 3 stated her actions were a quick reaction without donning PPE. CNA 3 stated it was important to put on the gown to protect both Resident 35 and staff. CNA 3 stated there was a possibility of transmitting infection without proper precautions. CNA 3 stated the expectation was to follow the Infection Control policy. CNA 3 stated the policy was not followed during resident care with Resident 35. CNA 3 stated it was important that appropriate PPE was used for Resident 35's protection and facility staff's protection. CNA 3 stated there was the possibility of passing on infection. During an interview on 01/21/2026 at 2:49 p.m. with CNA 5, CNA 5 Stated EBP was required when residents had a G-tube, any type of wound, or any contagious bacteria. CNA 5 stated staff were required to put on gowns and gloves and depending on the specific precaution level some situations required masks or full PPE. CNA 5 stated this was important because it prevented liquid from splattering onto staff and protected them from contact with open wounds. CNA 5 stated; when a resident had a pressure ulcer, staff were required to wear gowns, gloves and masks. CNA 5 stated this protected against any type of spread including gushing or pus that leaked from the wound. CNA 5 stated failure to use proper PPE could be life threatening if staff contracted an infection through bodily exposure or bloodstream contact. CNA 5 stated this could also result in transmission of the infection from resident to resident. During an interview on 01/21/2026 at 3:45 p.m. with Registered Nurse/Charge Nurse (RN) 2, RN 2 stated staff were required to use enhanced precautions for residents who had wounds, G-tubes, intravenous lines (IVs- a thin, flexible tube inserted into a vein to deliver fluids, medications, blood, or nutrients directly into the bloodstream), or wound vacs (treatment that uses a suction pump to create a negative pressure (vacuum) over a wound). RN 2 stated for residents with pressure ulcers, staff were required to put on gowns and gloves, and for residents with G-tubes staff were required to put on gowns, gloves and mask. RN 2 stated this prevented infection transmission to the residents, ensured patient safety, and prevented the spread of infection outside the room to other residents. RN 2 stated residents were at increased risk for infection and if infected, they could develop symptoms such as fever and the wound or G-tube site would deteriorate. During an interview on 01/23/2026 at 1:43 p.m. with RN 1, RN 1 stated when a patient had a wound, foley catheter (a flexible, thin tube inserted into the bladder to drain urine into a collection bag), ostomy (an artificial opening in an organ of the body, created during an operation), or G-tube; staff were required to put on full PPE including gown, mask and gloves. RN 1 stated the importance was to prevent infection transmission from residents to residents and protect staff members. RN 1 stated if staff did not use proper PPE they could transmit infection to other residents. During an interview on 01/23/2026 at 2:15 p.m. with the Infection Preventionist (IP), the IP stated residents with foley catheter, surgical wounds, pressure ulcers, IVs, Peripherally Inserted Central Catheter (PICC lines- a long, thin, flexible tube inserted into a peripheral vein in the arm and threaded up to a large central vein near the heart, providing long-term IV access for medications, nutrition, fluids, or blood draws, avoiding repeated needle sticks for treatments), G- tubes, dialysis ports (surgically created entry points that allow blood to be removed) or any device inserted through the skin were placed on EBP. The IP stated the facility implemented EBP to prevent multi-drug-resistant Organism (MDRO- germs, mostly bacteria, that have evolved to resist multiple antibiotics, making common treatments ineffective and infections harder to cure) infections and to protect both residents and staff. The IP stated gowns and gloves were required and staff were required to put on PPE before entering the residents on EBP's room. The IP stated the policy was not being followed. The IP stated this was necessary to prevent infection and the spread of MDRO infections. The IP stated potential outcome could be residents would contract infection and the facility would experience an outbreak. During an interview on 01/23/2026 at 2:54 p.m. with the Director of Staff Development (DSD), the DSD stated regarding EBP, CNAs were required to put on gowns before providing care to residents in designated rooms. The DSD stated this protected both the residents and the staff members from infection. The DSD stated failure to follow protocol could result in someone becoming ill. During an interview on 01/23/2026 at 3:08 p.m. with the Director of Nursing (DON), the DON stated staff were expected to know the protocol, identify which residents were on the EBP program, and they were required to put on gowns and gloves especially when providing direct resident care including tube feeding. The DON stated this was necessary for Resident 35's safety and the safety of others. The DON stated staff could spread infection and jeopardize the health of the residents. During a review of the facility's document titled, Job Description, Certified Nurse Assistant, no date, the document indicated . Position Summary-The purpose . is to provide each resident with routine daily nursing care in accordance with the residents assessment plan along with current federal, state, and local standards that govern the facility and as directed by supervisors. Essential duties and responsibilities- .abiding with all facility policies and procedures. follow infection and control policies. During a review of the facility's document titled, Job Description, Registered Nurse Supervisor, no date, the document indicated . Position Summary- The purpose.is to provide each resident with routine daily nursing care in accordance with current federal, state, and local standards that govern the facility and as directed by your management. Essential duties and responsibilities- . Checking that staff wear and/ or use safety equipment and supplies when providing resident care .abiding with all facility policies and procedures. follow infection and control policies. During a review of the facility's document titled, Job Description, Charge Nurse, no date, the document indicated . Position Summary- The purpose.is to provide direct nursing care provide direct nursing care to the residents, and to supervise the day-to-day nursing activities . Essential duties and responsibilities- . Assist the Director and/or Infection Control Coordinator in identifying, evaluating, and classifying routine and job-related functions to ensure that tasks in which there is potential exposure to blood/body fluids are properly identified and recorded, ensure that all personnel performing tasks that involve potential exposure to blood/body fluids participate in appropriate in-service training programs prior to performing such tasks.ensure that personnel providing direct care to residents are providing such care in accordance with the resident's care plan . Must possess the ability to plan, organize, develop, implement, and interpret the programs, goals, objectives, policies and procedures, etc., that are necessary for providing quality care. During a review of the facility's document titled, Job Description, Director of Staff Development, no date, the document indicated . Position Summary- The purpose. is to manage, develop, and direct the overall operation of the nursing department in accordance with current federal, state, and local standards that govern the facility, and as directed by the administrator and medical director. Essential duties and responsibilities- . Planning, developing, and coordinating orientation programs as well as in service educational and on the job training, . following infection and control policies, DSD will assist and may be required to fill in for infection preventionist absence on temporary basis of facility infection prevention program ., abiding with all facility policies and procedures. During a review of the facility's document titled, Job Description, Infection Preventionist, no date, the document indicated . Position Summary-. is accountable for decreasing the incidence and transmission of infectious diseases between patients, staff, visitors and the community. Essential duties and responsibilities- . Oversees the operation of the infection prevention, epidemiology and relevant safety programs, . Authority and responsibility for ensuring appropriate intervention and education occurs with staff, volunteers and medical staff when health care infection trends, outbreaks or noncompliance to infection control/ OSHA are identified, Ensures that education and counseling on infection prevention is available for staff, volunteers, medical staff, patients . During a review of the facility's document titled, Job Description, Director of Nursing, no date, the document indicated . Position Summary- The purpose.is to manage, develop, and direct the overall operation of the nursing department in accordance with current federal, state, and local standards that govern the facility and as directed by the Administrator and Medical Director. Essential duties and responsibilities- . working with the DSD in monitoring the in-service trainings, ., making rounds, . abiding with all facility policies and procedures. During a review of the facility's policy and procedure (P&P) titled, Infection Control dated 10/2018, the P&P indicated, Policy Statement: This facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and manage transmission of diseases and infections. Policy Interpretation and Implementation 1. This facility's infection control policies and practices apply equally to all personnel, consultants, contractors, residents, visitors, volunteer workers, and the general public.2. The objectives of our infection control policies and practices are to: a. prevent, detect, investigate, and control infections in the facility; b. maintain a safe, sanitary, and comfortable environment for personnel, residents, visitors, and the general public; c. establish guidelines for implementing isolation precautions, including standard and transmission-based precautions; .4. All personnel will be trained on our infection control policies and practices upon hire and periodically thereafter, including where and how to find and use pertinent procedures and equipment related to infection control. The depth of employee training shall be appropriate to the degree of direct resident contact and job responsibilities. During a review of the facility's policy and procedure (P&P) titled, Enhanced Barrier Precaution dated 04/2024, the P&P indicated, Purpose: Enhanced barrier precautions (EBP) are utilized to prevent the spread of multidrug resistant organisms (MDROs) to residents. Policy interpretation and implementation 1. Enhanced barrier precautions (EBPs) are used as an infection prevention and control intervention to reduce the spread of multidrug resistant organisms (MDROs) to residents. 2. EBPs employ targeted gowns and gloves used during high contact resident care activities when contact precautions do not otherwise apply. A gloves and gowns are applied prior to performing the high contact resident care activity. 3. Examples of high contact resident care activities requiring the use of gown and gloves. c. transferring d. providing hygiene . f. changing briefs or assisting with toileting. h. wound care (any skin opening requiring a dressing) .5. EBPs are indicated for residents with wounds and/ or indwelling medical devices regardless of MDRO colonization. 9. Staff are trained to care for residents on EBPs. During a review of Centers for Disease Control and Prevention (CDC)'s website, Professional Reference titled, Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs), dated 7/12/22, (found at https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/PPE.html) the reference indicated, .Multidrug-resistant organism (MDRO) transmission is common in skilled nursing facilities, contributing to substantial resident morbidity and mortality and increased healthcare costs. Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of resistant organisms that employ targeted gown and glove use during high contact resident care activities. EBP may be indicated (when Contact Precautions do not otherwise apply) for residents with any of the following: Wounds or indwelling medical devices, regardless of MDRO colonization status, Infection or colonization with an MDRO. Effective implementation of EBP requires staff training on the proper use of personal protective equipment (PPE) and the availability of PPE and hand hygiene supplies at the point of care.

Based on interview and record review, the facility failed to develop and implement a baseline care plan (a personalized, written document that outlines a resident's health needs, goals, and the specific actions and services to be provided) for one of three sampled residents (Resident 1) when Resident 1 was a known elopement (a resident who leaves a nursing facility without authorization or staff knowledge) risk and did not have a care plan in place for elopement.This failure resulted in Resident 1 not having a care plan with interventions in place to prevent elopement and led to Resident 1 eloping from the facility on the evening of 11/16/25.During a review of Resident 1's admission Record (AR - a summary of important information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), the AR indicated, Resident 1 was admitted to the facility on [DATE] with diagnoses which included dementia (a decline in mental abilities that makes daily life difficult, affecting memory, thinking, and behavior) and severe intellectual disabilities (a person that has a serious difficulty with learning, communication, and daily living skills that requires ongoing, hands-on support from caregivers).During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool used to identify resident cognitive and physical function) assessment dated [DATE], Resident 1's MDS assessment indicated Resident 1's Brief Interview for Mental Status (BIMS -assessment of cognitive status for memory and judgment) assessment score was 9 out of 15 (0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, 13-15 no cognitive impairment) indicating moderate cognitive impairment.During a review of Resident 1's Admission/ readmission Data Tool, dated 10/21/25, the Admission/ readmission Data Tool indicated, XV. Elopement Risk Assessment . T. Evaluation of Resident Elopement Risk . 1. Is resident independently mobile? . b. Yes . If the 'yes' option is selected for one or more of the questions above, a resident may be considered as 'AT RISK' for elopement . 5. Based on the above criteria, is the resident at risk for elopement? . b. Yes . 5a. Has a care plan been initiated for elopement risk? . 1. Yes . Signed by [Licensed Vocational Nurse 2] . Signed Date 10/21/25.During an interview on 11/19/25 at 12:03 p.m. with the Director of Nursing (DON), the DON stated Resident 1 had dementia and episodes of sundowning (a state of increased confusion, anxiety, agitation, and mood changes that occurs in the late afternoon and evening in people with cognitive impairment) and tended to wander around the facility, especially in the evenings. During an interview on 11/19/25 at 12:26 p.m. with Resident 1, Resident 1 stated nursing staff would get busy and would not always have time to take her outside. Resident 1 stated staff did not notice her when she eloped from the facility on 11/16/25.During an interview on 11/19/25 at 1:01 p.m. Licensed Vocational Nurse (LVN) 1, LVN 1 stated Resident 1 had a habit of wandering the facility since she was admitted on [DATE]. LVN 1 stated it was known to nursing staff that Resident 1 tended to wander the facility, especially in the evenings. LVN 1 stated Resident 1 frequently needed to be kept near the nurse's station (a central workspace in a healthcare facility where nurses and other staff coordinate patient care activities) for monitoring. LVN 1 stated that nursing staff were not following a care plan for Resident 1 for elopement. LVN 1 stated she did not think Resident 1 had a care plan for elopement in place prior to her elopement on 11/16/25. LVN 1 stated it was important for Resident 1 to have a care plan for elopement in place since she was known to wander the facility. LVN 1 stated a care plan for elopement for Resident 1 was important because it would guide her care and would provide nursing staff with interventions to prevent elopement from happening. During an interview on 11/19/25 at 1:10 p.m. with Registered Nurse (RN) 1, RN 1 stated Resident 1 had a habit of wandering the facility since she was admitted on [DATE]. RN 1 stated Resident 1's wandering behavior was worse in the evenings. RN 1 stated that prior to Resident 1 eloping, staff were just keeping an eye on her and redirecting her. RN 1 stated that nursing staff were not following a care plan for Resident 1 for elopement. RN 1 stated that care plans were important to ensure residents were getting individualized care. RN 1 stated that if Resident 1 did not have a care plan for elopement in place, nursing staff would not know which interventions to implement to prevent elopement. RN 1 stated Resident 1's elopement could have been prevented if there had been a care plan in place for elopement. During a concurrent interview and record review on 11/19/25 at 2:03 p.m. with the MDS/Licensed Vocational Nurse (MDS) nurse, Resident 1's Admission/ readmission Data Tool, dated 10/21/25, was reviewed. The Admission/ readmission Data Tool indicated Resident 1 was identified as an elopement risk and that a care plan for elopement had been initiated by LVN 2. The MDS nurse stated the Admission/ readmission Data Tool indicated Resident 1 was an elopement risk and a care plan for elopement had been initiated by LVN 2 on 10/21/25. During a concurrent interview and record review on 11/19/25 at 2:08 p.m. with the MDS nurse, Resident 1's Care Plan Report dated 10/21/25, was reviewed. The Care Plan Report indicated Resident 1's care plan for elopement was initiated on 11/16/25, after her elopement had occurred. The MDS nurse stated Resident 1's care plan for elopement was not initiated by LVN 2 on 10/21/25 when Resident 1 was admitted and identified as an elopement risk. The MDS nurse stated that LVN 2 should have initiated a care plan for elopement for Resident 1 once she identified that she was an elopement risk. The MDS nurse stated that it was important for Resident 1 to have a care plan in place for elopement so nursing staff could identify issues that might trigger the resident to elope. The MDS nurse stated that if a care plan for elopement had been initiated on admission for Resident 1, her elopement could have been prevented. During an interview on 11/19/25 at 2:51 p.m. with the DON, the DON stated LVN 2 should have initiated a care plan for elopement for Resident 1 on 10/21/25 when she was admitted and identified as an elopement risk. The DON stated it was important for Resident 1 to have a care plan for elopement in place to provide nursing staff with specific interventions . to help prevent the resident from eloping. The DON stated she expected nursing staff to implement care plans for elopement when they identify a resident as an elopement risk. The DON stated having a care plan for elopement in place for Resident 1 on admission could have potentially prevented her elopement. During an interview on 11/19/25 at 2:51 p.m. with the Administrator (ADM), the ADM stated that if Resident 1 was identified as an elopement risk on admission, a care plan for elopement should have been initiated. The ADM stated he expected nursing staff to follow facility policies and procedures in creating care plans and implementing interventions to prevent elopement. During a review of the facility's policy and procedure (P&P) titled, Wandering and Elopements, dated 2001, the P&P indicated, The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents . 1. If identified as at risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety.During a review of the facility's P&P titled, Care Plans, Comprehensive Person-Centered, dated 2001, the P&P indicated, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident . 3. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment . 9. Care plan interventions are chosen after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes .

Based on interview and record review the facility failed to follow facility's policies and procedures that meet professional standards of quality when: 1.) One of three sampled Residents (Resident 1) did not have nursing documentation in the progress notes for 346 times that he was found on the floor and head-to-toe assessments were not complete. This failure result in no head-to-toe assessments completed and had the potential for delay in care of for Resident 1 and missed opportunity for updating his care plan. 2.) Two of five Certified Nursing Assistant ' s (CNA) working during the afternoon shift were not wearing any identification badges identifying themselves as staff. This failure had the potential for facility residents to not know who was providing care to them, and if they worked in the facility. Findings: 1. During a review of Resident 1's Admission Record (AR) (document containing resident demographic information and medical diagnosis), dated 3/24/2025, the AR indicated Resident 1 was originally admitted to the facility on [DATE]. Resident 1's diagnosis included but are not limited to .PARKINSONISM (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements) .PERSISTENT MOOD [AFFECTIVE] DISORDER ( disorder that causes them to lose interest in everyday activities, lack productivity, experience low self-esteem, feel hopeless, and feel inadequate) .OTHER MUSCLE SPASM (occur when your muscle involuntarily and forcibly contracts uncontrollably and can't relax) . DIFFICULTY IN WALKING (inability to walk properly due to abnormal and uncontrollable walking patterns) . LACK OF COORDINATION (a problem with movement, balance, or coordination) . During a review of Resident 1's Admission MDS assessment, dated 3/6/2025, the Admission MDS assessment indicated, Resident 1's Brief Interview for Mental Status (BIMS -an evaluation of attention, orientation, and memory recall) score of 13 (0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, 13-15 no cognitive impairment), indicating Resident 1 had no cognitive impairment. During a record review of Resident 1's Medication Administration Record, dated 3/1/2025 -3/31/2025, the Medication Administration Record indicated, Resident 1 had 354 episodes of Resident 1 placing himself on the floor. During a record review of Resident 1 ' s Progress Notes, dated 3/1/2025 - 3/31/2025, the Progress Notes indicated, licensed nursing staff documented eight of 354 episodes of Resident 1 placing himself on the floor. During an interview on 3/24/2025 at 5:50 p.m., with Resident 1, Residents 1 stated he falls and places himself on the floor multiple times a day. Resident 1 stated when he falls or places himself on the floor, he will remain on the floor until staff assist back into bed or a chair. Resident 1 stated there are times when staff will not come check on him immediately, so he remains on the floor until they come into the room. During an interview on 3/24/2025 at 6:37 p.m., with the Director of Nurses (DON), the DON stated the facility did not consider that when Resident 1 was found on the floor as a fall. The DON stated Resident 1 ' s placed himself on the floor, so they were not considered unwitnessed falls by her, but she considered them resident behaviors. During a concurrent interview and record review on 4/3/2025 at 1:45 p.m., with the Administrator (ADM), the facilities policy and procedure (P&P) Assessing Falls and Their Causes dated December 2021 was reviewed. The ADM stated per P&P, falls should be documented, and residents assessed, whether witnessed or unwitnessed by licensed nursing staff. Nursing staff is expected to follow proper fall protocols to ensure resident safety and to assess potential injuries. ADM stated his expectations would have been for Resident 1 to be assessed, placed under observation, care plans should have been updated, neuro checks should be completed, and proper communication should be provided to primary physician if a fall were to occur. ADM stated nursing staff did not document assessment of incidents for falls indicated on behavior monitoring. During a concurrent interview and record review on4/3/2025 at 2:10 p.m., with Licensed Vocational Nurse (LVN) 1, Resident 1 ' s electronic medical records (EMR) dated 3/1/2025-3/30/2025 was reviewed. LVN 1 stated Resident 1 had multiple instances of being found on the floor from 3/1/2025 to 3/31/2025. LVN 1 stated documentation of the resident being found on the floor are charted in the medication administration monitoring, the nurses failed to document these same incidents in the nursing progress notes. LVN 1 stated, when Resident 1 was found on the floor should be considered falls. LVN 1 stated when Resident 1 is found on the floor, a resident assessment should have been conducted. LVN 1 stated full head to toe assessment were not conducted during 3/1/2025 to 3/31/2025 when Resident 1 was found on the floor. LVN 1 stated he did not follow fall policy and procedure, head to toe assessments and physician notification were not completed. LVN 1 stated there is a potential risk for injury to Resident 1 because a head-to-toe assessment is not completed after Resident 1 is found on the floor. During a concurrent interview and record review on 4/3/2025 at 2:18 p.m., with LVN 1, facility P&P Assessing Falls and Their Cause, dated December 2021 was reviewed. LVN 1 stated P&P indicated P&P indicates when a resident falls, documentation in the resident medical record should indicated information that includes head to toe assessment, condition of the resident, notification of responsible parties including physician and appropriate interventions. LVN 1 stated facility staff are not following fall policies for Resident 1. During a concurrent interview and record review on 4/3/2025 at 2:24 p.m., with LVN 2, facility P&P Assessing Falls and Their Cause, dated December 2021 was reviewed. LVN 2 stated on the P&P for falls, facility nursing staff were not following protocols for his witnessed or unwitnessed falls as no assessment or communication were conducted to primary physician for each occurrence as indicated in P&P. LVN 2 stated, resident falls a lot, approximately five to six times a day so he would constantly be under charting. LVN 2 stated on normal occasions those falls would be documented each time with full head to toe assessment, neuro (an evaluation of a person's nervous system) checks, interventions updated, and resident placed under observation for 72 hours with communication to responsible personnel. LVN 2 stated resident is falling multiple times a day and they are unwitnessed most the times so proper documentation should be conducted by nursing staff. During an interview on 4/10/2025 at 12:00 p.m., with Certified Nursing Assistant (CNA 1), CNA 1 stated Resident 1 has difficulties with his Parkinson ' s which contributes to Resident 1 falling a lot. CNA 1 stated he could not tell if Resident 1 is placing himself on the floor purposefully or it ' s related to his diagnosis because there are times when he will be on the floor when he enters the room and Resident 1 will does not explain why he is on the floor. CNA 1 stated when he finds Resident 1 on the floor, he notifies licensed nursing staff when resident is on the floor. CNA 1 stated he does not document his notification to licensed staff anywhere. A review of the facility policy and procedure, titled, Accidents and Incidents- Investigation and Reporting, dated July 2017, indicated .The Nursing Supervisor/Charge Nurse and /or the department director or supervisor shall promptly initiate and document investigation of the accident or incident .date and time incident took place .nature of injury .e.g. bruise, fall .circumstances surrounding incident .time attending physician was notified . A review of the facility policy and procedure, titled, Assessing Falls and Their Causes, dated December 2021, indicated .Procedure guidelines for assessing a resident after a fall and to assist staff in identifying causes of the fall .falling may be related to underlying clinical or medical conditions .if a resident had just fallen, or is found on the floor without a witness to the event, evaluate injuries to the head, neck, spine and extremities . obtain and record vital signs . provide appropriate first aid and/or obtain medical treatment . notify the residents attending physician . in an appropriate time frame .observe for delayed complications of a fall .document any observed signs or symptoms of pain, swelling, bruising, deformity and/or decreased mobility .complete incident report for resident falls no later than 24 hours after the fall occurs .evaluate chain of events . time of fall .what was resident doing .whether the resident was among other persons or alone .environmental risk factors . pattern of falls .resident falls should be recorded in the medical record .condition in which the resident was found .assessment data .interventions .notification of the physician . completion of post fall assessment . A review of the facility policy and procedure, titled, Behavior Assessment, Intervention and Monitoring, dated March 2019, indicated .As part of the comprehensive assessment, staff will evaluate, based on input from the resident, family and caregivers, review of medical record and general observations . the resident usually patterns of cognition, mood and behavior . the resident ' s usually method of communicating . The nursing staff will identify, document and inform the physician about specific details regarding changes in an individual mental status, behavior and cognition . onset, duration, intensity, and frequently of behavioral symptoms . the interdisciplinary team will thoroughly evaluate .underlying causes and address any modifiable factors that may have contributed to the resident change in condition .the IDT will seek and document any improvements or worsening in the individuals behavior, mood and function . the IDT will monitor the progress of the individuals . interventions will be adjusted based on the impact on behavior and other symptoms . 2. During a review of facility policy and procedures, titled, Identification Name Badges, dated January 2008, indicated .In order to promote safety and security measures established by our facility, each employee must wear his/her identification name badge at all times while on duty . an identification name tag or badge must be clearly visible and contain the employees first name initial, last name and job title . employees will be responsible for maintaining their identification tags or badge and wearing them to work . employees must report lost identification tags or badges to their supervisors so that replacement tags/badges can be issued . During an observation and interview on 3/24/2025 at 5:37 p.m., with Certified Nursing Assistant (cna) 2, CNA 2 stated she knows she is supposed to be wearing her identification (ID) badge, but she forgot it at home. CNA 2 stated she does have an ID badge she just doesn ' t have it with her today. CNA 2 stated residents already know she works at the facility but understands staff are supposed to be wearing proper identification in order for others to identify staff when needed. During an observation and interview on 3/24/2025 at 5:44 p.m., with CNA 3, CNA 3 was observed not wearing her identification badge while in the facility. CNA 3 stated her ID badge was left at home, and she understands it is important to wear their badge daily in order for families and residents to identify staff when assistance is required. CNA 3 stated it is part of facility policies to wear a badge at all times and currently she is not abiding by that policy if she is missing her ID badge. She stated all staff receive ID badge on the first day of employment and if they lose or are missing their ID badge, they are to notify leadership to obtain replacement. CNA 3 stated in the meantime, temporary ID badge can be made indicating name and title in order for proper identification. During an interview on 3/24/25 at 7:20 p.m., with the DON, the DON stated proper identification of staff is necessary and important in order to be properly identified in the facility in order to provide the appropriate care needs of the resident. Identification is important in order for family to identify staff during a resident ' s time in need. DON confirmed the two missing ID badges on staff is an issue and it could potentially cause a delay in resident care if a family member or resident is unable to identify staff who are not wearing the appropriate name tags. All staff members should be wearing name tags at all times while working in the facility according to facility protocols.

Based on observation, interview, and record review, the facility failed to assess dietary preferences for seven of ten (Resident 1, 3, 6, 7, 8, 9, 10) sampled residents when they were not assessed for food preferences within 48 hours of admission. This failure resulted in Resident 1, 3, 6, 7, 8, 9 and 10's food preferences to not be considered when the facility provided meals. Findings: During an interview on 10/23/24 at 9:57 a.m. with Resident 1, Resident 1 stated she told staff multiple times she doesn't drink milk. Resident 1 stated even though she told multiple staff members, they keep bringing her milk. Resident 1 stated no one has asked her preference regarding any dietary foods. During a concurrent interview and record review on 10/23/24 at 11:30 a.m. with the Registered Dietitian (RD), Resident 1's, 3's, 6's, 7's, 8's, 9's, 10's Electronic Medical Record (EMR-digital version of the paper charts which contains the medical and treatment history of the patient/resident), dated 10/23/24 were reviewed. The EMR's indicated, Resident 1, 9, and 10 Dietary Profile/Preference was not completed. The EMR's indicated Resident 1, 9 , and 10 had been admitted to the facility more than 48 hours ago. The EMR's indicated, Resident 3, 6, 7, 8 Dietary Profile/Preference was completed on 10/23/24, over 48 hours past admission. The RD stated the expectation was for the dietary preference to be completed within 48 hours of admission. The RD stated the delay in completing the dietary preferences could have negative side effects including delay in would healing, slower recovery, increased stay at facility, and losing weight. During a concurrent interview and record review on 10/23/24 at 12:00 p.m. with the Dietary Manager (DM), Resident 1's, 9's, 10's EMR's, dated 10/23/24 was reviewed. The EMR's indicated, Resident 1, 9, 10 had no Dietary Preference completed. The DM stated he was off for a few days and when he got back, he was very busy and had not gotten to doing it yet. The DM stated the expectation was for the dietary preference to be completed within 48 hours of admission. The DM stated he should have completed the dietary preference within 48 hours of admission. The DM stated the delay in completed the dietary preference could result in delayed wound healing, weight loss, and other negative side effects. The DM stated since Resident 1 had a recent surgery, eating the proper food is important for her healing process. During an interview on 10/23/2024 at 2:25 p.m. the Director of Nursing (DON), the DON stated the expectation is for all residents to have dietary preferences to be completed by 48 hours of admission. The DON stated the delay in completing the dietary preference could slow down the healing process for wounds, could increase stay at facility, could lose weight, and other negative side effects. During a review of Registered Dietitian Job Description (RDJD), undated, the RDJD indicated, . ESSENTIAL DUTIES AND RESPONSABILITIES . Observes and assesses residents to monitor food acceptance and nutritional status . Adhering to all dietary policies and procedures of the facility . Assess the nutritional needs, nutritional diagnosis, intervention and evaluation of patient and document in the medical record . Concentrates on foundational elements of standards of practice and professional performance, code(s) of ethics accreditation standards, state and federal regulations, national guidelines . During a review of Dietary Manager Job Description (DMJD), undated, the DMJD indicated, . ESSENTIAL DUTIES AND RESPONSIBILITIES . Ensuring charted dietary progress notes are informative and descriptive of meals provided . Adhering to all dietary policies and procedures of the facility . During a review of the facility's policy and procedure (P&P) titled, Food and Nutrition Services, dated October 2017, the P&P indicated, Policy Statement: Each resident is provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident. Policy Interpretation and Implementation: 1. The multidisciplinary staff, including nursing staff, the attending physician and the dietitian will assess each resident's nutritional needs, food likes, dislikes and eating habits, as well as physical, functional, and psychosocial factors that affect eating and nutritional intake and utilization. 2. A resident-centered diet and nutritional plan will be based on this assessment .

Based on observation, interview, and facility document and policy review, the facility failed to provide palatable meals. This failure had the potential to affect all residents who received meals from the facility's kitchen. Findings included: A facility policy titled, Food and Nutrition Services, revised in 10/2017, revealed, Each resident is provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident. The policy also revealed, 7. Food and nutrition services staff will inspect food trays to ensure that the correct meal is provided to each resident, the food appears palatable and attractive, and it is served at a safe and appetizing temperature. During an interview on 08/19/2024 at 11:52 AM, Resident #29 complained that the facility's food was cold. According to a significant change in status Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/26/2024, Resident #29 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. A menu titled, Week 4 Regular [facility name] CYCLE 2 2024 indicated that on 08/20/2024 the planned lunch meal included rosemary roast pork, noodles, and zucchini/tomatoes. During observations of the lunch meal service on 08/20/2024 from 12:22 PM to 12:44 PM, the cook was observed removing four to five plates from a plate warmer at one time to plate the food, then passing them to a dietary aide to cover them and place them on the tray cart. At 12:45 PM, the last tray cart left the kitchen, with a test tray also included. Prior to leaving the kitchen, the Dietary Manager (DM) checked the temperatures of the items on the test tray with the following results: rosemary roast pork -120 degrees, mashed potatoes -118 degrees (substituted for noodles), and zucchini/tomatoes - 138 degrees. The DM and surveyor followed the tray cart and observed as staff passed the trays out to the residents. The last resident tray was served at 1:05 PM, and the temperatures of the items on the test tray were checked with the following results: rosemary roast pork - 90 degrees, mashed potatoes -100 degrees, and zucchini/tomatoes -100 degrees. On 08/20/2024 at 1:08 PM, all surveyors tasted the food items on the test tray, and the food was found to be cold. The rosemary roast pork had no taste and was dry, the mashed potatoes had no taste, and the zucchini/tomatoes were overcooked, soggy, and had no flavor. 45555 During an interview on 08/20/2024 at 12:55 PM, Resident #29 stated they took one look at the lunch meal and could not eat it, so they asked for chicken noodle soup instead. During an interview on 08/20/2024 at 2:02 PM, Resident #58 stated the lunch was cold and the meat was dry but at least they got protein. According to an admission MDS, with an ARD of 06/27/2024, Resident #58 had a BIMS score of 13, which indicated the resident was cognitively intact. 49044 During a Resident Council Meeting held on 08/20/2024 at 2:22 PM, with eight residents in attendance, the residents reported the facility needed to add more seasoning to the food and reduce the amount spice used. The residents reported that the noodles served for the lunch meal on 08/20/2024 had no seasoning, and they could not tell what the vegetables were. The residents also reported the roast served for lunch was too peppery, and in general, the food was not warm enough. During an interview on 08/21/2024 at 12:20 PM, Resident #15 stated the food served for lunch on 08/20/2024 was awful. The resident said they thought they could get better food at a fast-food restaurant. Resident #15 said they could not tell what the vegetables served for lunch on 08/20/2024 were and said they tasted awful. According to a quarterly MDS, with an ARD of 05/29/2024, Resident #15 had a BIMS score of 15, which indicated the resident was cognitively intact. During an interview on 08/20/2024 at 12:19 PM, the DM stated he was aware of some complaints about food temperatures, but he thought the food left the kitchen at a reasonable temperature. He stated the staff were slow to pass out the meal trays, so the food could get could. During an interview on 08/23/2024 at 1:17 PM, the Director of Nursing (DON) said she expected the food to be at the right temperature when it left the kitchen and indicated she had spoken to the nursing staff regarding prompt distribution of the food. She also said she expected the food to look and taste good. During an interview on 08/23/2024 at 2:14 PM, the Administrator said he expected the kitchen to ensure cold foods were served cold and hot foods were served hot.

Based on observation, interview, and facility document and policy review, the facility failed to ensure dietary staff did not document lunch meal service temperatures prior to placing the food items on the steam table for meal service and failed to ensure dietary staff utilized proper hand hygiene during meal service. These failures had the potential to affect all residents who received meals from the facility's kitchen. Findings included: A facility policy titled, Food Preparation and Service, revised 10/2017, revealed, Food and nutrition services employees shall prepare and serve food in a manner that complies with safe food handling practices. The policy also indicated, 5. Food preparation staff will adhere to proper hygiene and sanitary practices to prevent the spread of foodborne illness. The policy also indicated, 6. Bare hand contact with food is prohibited. Gloves must be worn when handling food directly. However, gloves can also become contaminated and/or soiled and must be changed between tasks. 1. During an initial tour of the facility's kitchen, on 08/19/2024 at 9:40 AM, the meal service temperature logs were requested from the Dietary Manager (DM). On 08/19/2024 at 9:45 AM, the Food Temperature Logs were provided. The Food Temperature Log, dated 08/19/2024, contained both breakfast and lunch food item temperatures, despite the lunch meal having not yet been placed onto the steam table for meal service. During an interview on 08/19/2024 at 10:03 AM, the DM stated staff documenting meal service temperatures in advance was unacceptable. He indicated meal service temperatures should only be taken when the food was placed on the steam table. During an interview on 08/20/2024 at 1:50 PM, Dietary Staff #14 said meal service temperatures should be taken when food is placed on the steam table, not prior. During a phone interview on 08/22/2024 at 5:38 PM, Dietary Staff #15 stated she had worked at the facility for many years, and she knew what the temperatures of items on the steam table would be, which is why she filled out the lunch meal temperatures early on 08/19/2024. Dietary Staff #15 said she knew that meal service temperatures were to be documented on the temperature logs as the food was placed on the steam table, not prior; she stated she also knew not to guess on what the temperatures would be. Dietary Staff #15 said she knew it was very important to have accurate temperatures documented on the logs so that the residents would get food at the correct temperatures and to make sure the steam table was keeping the food at an acceptable temperature. During an interview on 08/23/2024 at 2:14 PM, the Administrator stated the meal service temperatures should not be taken in advance and should be done accurately. 2. During an observation on 08/20/2024 at 12:25 PM, Dietary Staff #14 was observed wearing gloves in the kitchen while opening boxes and touching surfaces. Dietary Staff #14 then prepared a grilled cheese sandwich without changing her gloves. At 12:30 PM, while preparing the grilled cheese sandwich, Dietary Staff #14 pulled at the waist of her pants and pulled her shirt down with one of her gloved hands, then proceeded to prepare another grilled cheese sandwich without changing gloves or washing her hands. During an interview on 08/20/2024 at 1:50 PM, Dietary Staff #14 said she should have changed her gloves after she touched her clothing while preparing the grilled cheese sandwiches. During an interview on 08/20/2024 at 2:14 PM, the Dietary Manager (DM) said he expected dietary staff to change gloves as needed, especially if they touched their clothes or touched a garbage can lid. During an interview on 08/23/2024 at 1:17 PM, the Director of Nursing (DON) stated she expected the staff not to touch their clothing and then touch food. During an interview on 08/23/2024 at 2:14 PM, the Administrator stated he expected staff to change their gloves when they touched other items, such as their clothes or if they changed tasks.

Based on observation, interview, document review, and facility policy review, the facility failed to ensure residents' rooms measured at least 80 square (sq) feet (ft) per resident in 19 (Rooms 1 through 7, Rooms 10 through 20, and room [ROOM NUMBER]) of 23 resident rooms in the facility. Findings included: A facility policy titled Bedrooms revised 05/2017, revealed, All residents are provided with clean, comfortable and safe bedrooms that meet federal and state requirements. The policy revealed, 2. Bedrooms measure at least 80 square feet of space per resident in double rooms, and at least 100 square feet of space in single rooms. The Client Accommodations Analysis, signed by the Maintenance Supervisor (MS) and dated 08/20/2024, revealed the following: - In room [ROOM NUMBER], there was 73.3 sq ft for each resident - In room [ROOM NUMBER], there was 73.3 sq ft for each resident - In room [ROOM NUMBER], there was 73.3 sq ft for each resident - In room [ROOM NUMBER], there was 73.3 sq ft for each resident - In room [ROOM NUMBER], there was 70 sq ft for each resident - In room [ROOM NUMBER], there was 73.3 sq ft for each resident - In room [ROOM NUMBER], there was 73.3 sq ft for each resident - In room [ROOM NUMBER], there was 77.3 sq ft for each resident - In room [ROOM NUMBER], there was 72 sq ft for each resident - In room [ROOM NUMBER], there was 73.3 sq ft for each resident - In room [ROOM NUMBER], there was 73.3 sq ft for each resident - In room [ROOM NUMBER], there was 76 sq ft for each resident - In room [ROOM NUMBER], there was 75 sq ft for each resident - In room [ROOM NUMBER], there was 78 sq ft for each resident - In room [ROOM NUMBER], there was 72.3 sq ft for each resident - In room [ROOM NUMBER], there was 74.6 sq ft for each resident - In room [ROOM NUMBER], there was 73.3 sq ft for each resident - In room [ROOM NUMBER], there was 75 sq ft for each resident - In room [ROOM NUMBER], there was 71.6 sq ft for each resident During an interview on 08/23/2024 at 10:52 AM, the MS stated he had been MS since April 2023. The MS stated the facility had waivers for some of the rooms because the rooms did not meet the allotted square footage per resident The MS stated he did not have any concerns brought to him about the sizes of the rooms, neither from staff nor from residents. During an interview on 08/23/2024 at 12:48 PM, the Director of Nursing stated she had not heard of any complaints about the sizes of the rooms. During an interview on 08/23/2024 at 2:21 PM, the Administrator stated the size of the resident rooms did not impede on other residents. The Administrator stated as long as the residents were comfortable and could move and staff could treat and provide care to the residents, he did not have any issues with it. Per the Administrator, no one voiced any complaints to him about the size of resident rooms.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure the medication error rate was less than 5 percent (%). Observation of medication administration revealed the facility had 3 medication errors out of 28 total opportunities, resulting in a medication error rate of 10.71%, affecting 2 (Residents #9 and Resident #32) of 9 residents observed during medication administration. Findings included: A facility policy titled, Administering Medications, revised in 04/2019, specified, 4. Medications are administered in accordance with prescriber orders, including any required time frame. The policy further specified, 10. The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. 11. The following information is checked/verified for each resident prior to administering medications: a. Allergies to medications; and b. Vital signs, if necessary. 1. An Admission Record indicated the facility admitted Resident #9 on 10/13/2017. According to the Admission Record, the resident had a medical history that included a diagnosis of primary hypertension. Resident #9's Order Summary Report, listing active orders as of 08/22/2024, contained an order, dated 07/08/2024, for atenolol (an antihypertensive) 25 milligrams (mg) by mouth one time a day for hypertension with instructions to hold the medication if the resident's pulse was less than 60 beats per minute (BPM) or if their systolic blood pressure (SBP, the top number of a blood pressure value) was less than 110 millimeters of mercury (mmHg). On 08/20/2024 at 8:32 AM, Licensed Vocational Nurse (LVN) #12 entered Resident #9's room and obtained the resident's pulse, with a result of 84 BPM. LVN #12 then prepared and administered atenolol 25 mg to the resident without checking the resident's blood pressure. During an interview on 08/20/2024 at 8:56 AM, LVN #12 stated that when viewing atenolol on the resident's medication administration record, there was only a place to document the pulse, so she thought that was what the medication was primarily for; however, after reading the entire order, LVN #12 realized she should have also obtained the resident's blood pressure to know whether to hold the medication for a low SBP. During an interview on 08/23/2024 at 1:17 PM, the Director of Nursing (DON) stated the nurses should obtain all needed vital signs prior to administering medications. The DON stated if the vital signs were outside of the physician-ordered parameters, the nurses should hold the medication and notify the physician. She stated the nurses should read the full physician's order and follow any instructions for the medications. During an interview on 08/23/2024 at 2:21 PM, the Administrator stated the nurses should be following physician's orders and giving medications accordingly. He stated the nurses should read the medication orders in their entirety and all recommendation/special instructions should be followed, including obtaining a blood pressure and pulse if needed. 2. An Admission Record indicated the facility admitted Resident #32 on 02/10/2020. According to the Admission Record, the resident had a medical history that included diagnoses of chronic ischemic heart disease and primary hypertension. Resident #32's Order Summary Report, listing active orders as of 08/22/2024, contained an order, dated 05/04/2024, for lisinopril (an antihypertensive) 10 milligrams (mg) one time a day for hypertension. The order included instructions to hold the medication if the resident's pulse was less than 60 beats per minute (BPM), systolic blood pressure (SBP, the top number of a blood pressure value) was less than 110 millimeters of mercury (mmHg), or diastolic blood pressure (DBP, the bottom number of a blood pressure value) was less than 60 mmHg. Resident #32's Medication Administration Record [MAR] for August 2024 revealed transcription of an order, dated 05/04/2024, for lisinopril 10 mg with instructions to give 10 mg by mouth one time a day for hypertension and to hold if the resident's pulse was less than 60 BPM, SBP was less than 110 mmHg, or DBP was less than 60 mmHg. The MAR also revealed transcription of an order, dated 05/04/2024, for amlodipine besylate (an antihypertensive) 5 mg with instructions to give 5 mg by mouth one time a day for hypertension and to hold if the resident's pulse was less than 60 BPM, SBP was less than 110 mmHg, or DBP was less than 60 mmHg; the transcribed order had a discontinue date of 08/21/2024 at 10:02 AM. On 08/21/2024 at 7:58 AM, Licensed Vocational Nurse (LVN) #13 entered Resident #32's room and obtained the resident's blood pressure, with a result of 122/78 mmHg. LVN #13 then administered Resident #32's lisinopril and amlodipine without obtaining the resident's pulse. During an interview on 08/21/2024 at 8:44 AM, LVN #13 stated she only obtained Resident #32's blood pressure. After reviewing the orders for Resident #32, she stated she should have obtained the resident's pulse to determine whether the medications needed to be held. According to LVN #13, the resident's MAR only prompted staff to record a blood pressure. During an interview on 08/23/2024 at 1:17 PM, the Director of Nursing (DON) stated the nurses should obtain all needed vital signs prior to administering medications. The DON stated if the vital signs were outside of the physician-ordered parameters, the nurses should hold the medication and notify the physician. She stated the nurse should read the full physician's order and follow any instructions for the medications. During an interview on 08/23/2024 at 2:21 PM, the Administrator stated the nurses should be following physician's orders and giving medications accordingly. He stated the nurses should read the medication orders in their entirety and all recommendation/special instructions should be followed, including obtaining a blood pressure and pulse if needed.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure 3 (Residents #9, #32, and #19) of 12 residents reviewed during medication administration and for unnecessary medication were free from significant medication errors. Specifically, the facility failed to ensure physician ordered vital signs were obtained prior to administering medications for Resident #9 and Resident #32 and failed to hold Resident #19's medications when their blood pressure and/or pulse were outside of physician-ordered parameters for administration. Findings included: A facility policy titled, Administering Medications, revised in 04/2019, specified, 4. Medications are administered in accordance with prescriber orders, including any required time frame. The policy further specified, 10. The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. 11. The following information is checked/verified for each resident prior to administering medications: a. Allergies to medications; and b. Vital signs, if necessary. 1. An Admission Record indicated the facility admitted Resident #9 on 10/13/2017. According to the Admission Record, the resident had a medical history that included diagnosis of primary hypertension. Resident #9's Order Summary Report, listing active orders as of 08/22/2024, contained an order, dated 07/08/2024, for atenolol (an antihypertensive) 25 milligrams (mg) by mouth one time a day for hypertension with instructions to hold the medication if the resident's pulse was less than 60 beats per minute (BPM) or if their systolic blood pressure (SBP, the top number of a blood pressure value) was less than 110 millimeters of mercury (mmHg). During an observation of medication administration 08/20/2024 at 8:32 AM, Licensed Vocational Nurse (LVN) #12 administered atenolol 25 mg to Resident #9 without checking the resident's blood pressure. Resident #9's Medication Administration Record [MAR] for August 2024 revealed staff documented atenolol was administered daily at 8:00 AM from 08/01/2024 through 08/10/2024, on 08/12/2024, 08/13/2024, and 08/15/2024 through 08/20/2024. The MAR revealed that prior to 08/21/2024, there was no documented evidence staff were monitoring the resident's blood pressure prior to the administration of the atenolol. During an interview on 08/20/2024 at 8:56 AM, Licensed Vocational Nurse (LVN) #12 stated that when she pulled up the order for atenolol for Resident #9 on the electronic MAR, there was only an option to document the resident's pulse. LVN #12 stated that she thought the atenolol was being administered to primarily treat the resident's pulse. LVN #12 stated that after reading the entire order she had realized that she should have taken the resident's blood pressure to know whether to hold the medication. During an interview on 08/23/2024 at 1:17 PM, the Director of Nursing (DON) stated the nurses should obtain all needed vital signs prior to administering medications. The DON stated if the vital signs were outside of the physician-ordered parameters, the nurses should hold the medication and notify the physician. She stated the nurses should read the full physician's order and follow any instructions for the medications. During an interview on 08/23/2024 at 2:21 PM, the Administrator stated the nurses should be following physician's orders and giving medications accordingly. He stated the nurses should read the medication orders in their entirety and all recommendation/special instructions should be followed, including obtaining a blood pressure and pulse if needed. 2. An Admission Record indicated the facility admitted Resident #32 on 02/10/2020. According to the Admission Record, the resident had a medical history that included diagnoses of primary hypertension and chronic ischemic heart disease. Resident #32's Order Summary Report, listing active orders as of 08/22/2024, contained an order, dated 05/04/2024, for lisinopril (an antihypertensive) 10 milligrams (mg) one time a day for hypertension. The order included instructions to hold the medication if the resident's pulse was less than 60 beats per minute (BPM), systolic blood pressure (SBP, the top number of a blood pressure value) was less than 110 millimeters of mercury (mmHg), or diastolic blood pressure (DBP, the bottom number of a blood pressure value) was less than 60 mmHg. Resident #32's Medication Administration Record [MAR] for August 2024 revealed a transcription of an order dated 05/04/2024 for lisinopril 10 mg with instructions to give 10 mg by mouth one time a day for hypertension and to hold if the resident's pulse was less than 60 BPM, SBP was less than 110 mmHg, or DBP was less than 60 mmHg. The MAR revealed a transcription of an order dated 05/04/2024 for amlodipine besylate (an antihypertensive) 5 mg with instructions to give 5 mg by mouth one time a day for hypertension and to hold if the resident's pulse was less than 60 BPM, SBP was less than 110 mmHg, or DBP was less than 60 mmHg; the transcribed order had a discontinue date of 08/21/2024 at 10:02 AM. The MAR revealed that prior to 08/22/2024 there was no documented evidence staff obtained the resident's pulse prior to administering the medications. During an observation of medication administration on 08/21/2024 at 7:58 AM, Licensed Vocational Nurse (LVN) #13 entered Resident #32's room and obtained the resident's blood pressure. LVN #13 then administered Resident #32's lisinopril and amlodipine without obtaining the resident's pulse. During an interview on 08/21/2024 at 8:44 AM, LVN #13 stated she only obtained Resident #32's blood pressure. After reviewing the orders for Resident #32, she stated she should have obtained the resident's pulse to determine whether the medications needed to be held. According to LVN #13, the resident's MAR only prompted staff to record a blood pressure. During an interview on 08/23/2024 at 1:17 PM, the Director of Nursing (DON) stated the nurses should obtain all needed vital signs prior to administering medications. The DON stated if the vital signs were outside of the physician-ordered parameters, the nurses should hold the medication and notify the physician. She stated the nurse should read the full physician's order and follow any instructions for the medications. During an interview on 08/23/2024 at 2:21 PM, the Administrator stated the nurses should be following physician's orders and giving medications accordingly. He stated the nurses should read the medication orders in their entirety and all recommendation/special instructions should be followed, including obtaining a blood pressure and pulse if needed. 46659 3. An Admission Record revealed the facility admitted Resident #19 on 11/10/2022. According to the Admission Record, the resident had a medical history that included diagnoses of hypertension and chronic ischemic heart disease. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/07/2024, revealed Resident #19 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident had intact cognition. The MDS indicated Resident #19 had active diagnoses of hypertension and chronic ischemic heart disease. Resident #19's care plan, included a focus area initiated on 05/25/2018 and revised on 05/15/2024 that indicated the resident had hypertension and chronic ischemic heart disease. Interventions directed staff to administer anti-hypertensive medications as ordered, monitor for side effects such as orthostatic hypotension and increased heart rate (Tachycardia), and monitor for effectiveness (initiated 05/25/2018). Resident #19's Medication Administration Record [MAR] for June 2024, July 2024, and August 2024 revealed the resident's physician orders were transcribed as follows: - diltiazem hydrochloride (HCL) 120 milligrams (mg), one tablet by mouth one time a day related to chronic ischemic heart disease. The MAR indicated the medication should be held if the resident's systolic blood pressure (SBP, the top number of a blood pressure value) was less than 110 millimeters of mercury (mmHg), diastolic blood pressure (DBP, the bottom number of a blood pressure value) was less than 65 mmHg, or the pulse was less than 60 beats per minute (BPM). The MARs indicated diltiazem was ordered on 05/04/2024, and according to the June 2024 and July 2024 MAR, the order was discontinued on 08/21/2024 at 10:13 AM. - metoprolol tartrate 25 mg tablet, one tablet by mouth two times a day for hypertension and to hold the medication for a SBP less than 110 mmHg, DBP less than 60 mmHg, or a pulse less than 60 BPM. The MAR revealed the medication was ordered on 05/04/2024 and according to the June 2024 and July 2024 MAR, the order was discontinued on 08/21/2024 at 10:13 AM. - hydrochlorothiazide 25 mg, one tablet by mouth two times a day for hypertension started on 05/04/2024. The MAR revealed hydrochlorothiazide should be held for a SBP less than 110 mmHg, DBP less than 60 mmHg, or pulse less than 60 BPM. Resident #19's MAR for June 2024 revealed staff documented that diltiazem was administered on 06/03/2024 at 8:00 AM, when the resident's DBP was 64 mmHg (less than the physician ordered parameter of 65 mmHg). The MAR also revealed staff documented that metoprolol tartrate and hydrochlorothiazide medications were administered on 06/26/2024 at 8:00 AM, when the resident's SBP was 108 mmHg (less than the physician ordered parameter of 110 mmHg). Resident #19's MAR for July 2024 revealed staff documented that diltiazem was administered on 07/09/2024 at 8:00 AM when the resident's DBP was 64 mmHg and on 07/14/2024 at 8:00 AM when the resident's DBP was 62 mmHg (less than the physician ordered parameter of 65 mmHg). The MAR revealed on 07/23/2024 at 5:00 PM staff documented that hydrochlorothiazide and metoprolol tartrate were administered even though the resident's pulse was 57 BPM (less than the physician ordered parameter of 60 BPM). Resident #19's MAR for August 2024 revealed staff documented diltiazem was administered on 08/08/2024 at 8:00 AM when the resident's SBP was 108 mmHg. Per the MAR, staff also documented that hydrochlorothiazide was administered on 08/08/2024 at 8:00 AM when the resident's SBP was 108 mmHg and metoprolol tartrate were administered on 08/02/2024 at 5:00 PM when the resident's SBP was 100 mmHg, and the pulse was 58; on 08/08/2024 at 8:00 AM when the resident's SBP was 108 mmHg; and on 08/08/2023 at 5:00 PM when the resident's SBP was 106 mmHg. Resident #19's Progress Notes for the timeframe from 06/01/2024 through 08/20/2024 revealed no documented evidence that the medications were held. During a phone interview on 08/23/2024 at 10:24 AM, Licensed Vocational Nurse (LVN) #4 stated that she was familiar with Resident #19's medication orders and was aware the resident's blood pressure and diuretic medications had parameters for administration. LVN #4 stated based on the documented vital signs, she should have held the resident's medications on 07/23/2024. During a phone interview on 08/23/2024 at 9:36 AM, LVN #16 stated she was aware of Resident #19's medication orders and she should have held the resident's medications on 08/02/2024 and on 08/08/2024. During an interview on 08/23/2024 at 9:01 AM, LVN #2 stated she had completed orientation in early 08/2024 and administered Resident #19's medications on 08/08/2024. She stated on 08/08/2024, she should have held Resident #19's diltiazem medication because the documented vital signs did not meet the physician ordered parameters. During an interview on 08/21/2024 at 3:04 PM, the Director of Nursing (DON) stated that if a medication had parameters, the staff should hold the medication if the vitals did not meet the ordered parameters. During a follow-up interview on 08/23/2024 at 1:17 PM, the DON stated she expected nurses to triple check and verify physician orders before administering medications. She said if a vital sign was outside the parameters the medication should be held. She stated it was very important to follow physician orders because the parameters were there to keep the resident safe. During an interview on 08/23/2024 at 2:14 PM, the Administrator stated he expected the nursing staff to follow the physician orders.

Based on interview, record review, and facility policy review, the facility failed to ensure Minimum Data Set (MDS) assessments were accurate for 2 (Resident #46 and Resident #69) of 17 sampled residents. Findings included: A facility policy titled, Resident Assessments, revised October 2023, revealed, 12. Information in the MDS assessments will consistently reflect information in the progress notes, plans of care and resident observations/interviews. 1. An Admission Record revealed the facility Resident #46 on 08/12/2022. According to the Admission Record, the resident had a medical history that included diagnoses of hypertensive heart disease and heart failure. An annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/08/2024, revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident had intact cognition. The MDS revealed the resident used a hearing aid. A quarterly MDS assessment, with an ARD of 08/08/2024, revealed that the resident had a BIMS score of 14, which indicated the resident had intact cognition. The MDS revealed the resident used a hearing aid. During an interview on 08/19/2024 at 11:12 AM, Resident #46 stated the facility was supposed to get them hearing aids but had not done it. During an interview on 08/22/2024 at 3:32 PM, the MDS Coordinator stated she was not aware the resident did not have hearing aids. During an interview on 08/23/2024 at 10:56 AM, Licensed Vocational Nurse #1 stated Resident #46 was hard of hearing and did not have hearing aids, but she knew the resident was in the process of getting hearing aids. During an interview on 08/23/2024 at 11:18 AM, Certified Nursing Assistant #11 stated Resident #46 did not have hearing aids. During an interview on 08/23/2024 at 2:21 PM, the Administrator stated he expected the MDS to be completed timely and accurately. During an interview on 08/23/2024 at 5:43 PM, the Director of Nursing (DON) stated she was responsible for ensuring the accuracy of the MDS. The DON stated the MDS should have indicated Resident #46 did not have hearing aids. 2. An Admission Record revealed the facility admitted Resident #69 on 05/27/2024. According to the Admission Record, the resident had a medical history that included diagnoses of chronic obstructive pulmonary disease, hypertension, and polyneuropathy. A Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 05/31/2024, revealed Resident #69 discharged to a short-term general hospital on 05/31/2024. Resident #69's Progress Notes dated 05/31/2024 at 7:00 AM, revealed the resident left the faciity on [DATE] against medical advice (AMA). The Statement Releasing Facility from Liability when Resident Leaves AMA, dated 05/31/2024, revealed the form was signed by the resident on 05/31/2024 at 7:05 AM, which indicated the resident left the facility AMA. The Physician Discharge Summary, signed by a physician and dated 07/08/2024, revealed the resident discharged /Transferred to: AMA. During an interview on 08/23/2024 at 9:15 AM, the MDS Coordinator stated she did not know she selected the wrong discharge disposition for Resident #69. During an interview on 08/23/2024 at 2:21 PM, the Administrator stated he expected the MDS to be completed timely and accurately. The Administrator stated accuracy was important and the disposition upon discharge for Resident #69 was an error. During an interview on 08/23/2024 at 5:43 PM, the Director of Nursing (DON) stated she was responsible for ensuring the accuracy of the MDS. The DON stated the MDS should be accurate for a resident's disposition at the time of discharge.

Based on observation, interview, and record review, the facility failed to maintain a safe and comfortable environment for 58 of 58 residents (Residents 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, and 58), when on 9/6/22 at 4:20 p.m., the ambient (surrounding area) temperature levels inside 23 resident rooms, including the two nursing stations, exceeded 81 degrees Fahrenheit (F- a scale for measuring temperature in which water freezes at 32 degrees and boils at 212 degrees). The measured ambient room temperatures reached up to 97.8 degrees in residents whose beds were in the middle (bed B) or next to the glass sliding doors (bed C). The facility staff were fully aware of the extreme hot weather and heatwave forecasts and warnings during the week of (9/5/22 to 9/9/22), and the facility failed to monitor, prepare, plan, implement interventions, and provide sufficient cooling equipment that would ensure each residents ' comfort and safety at all times. These failures placed Residents 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54 55, 56, 57, and 58), at risk for dehydration (a condition that occurs when the body loses too much water and other fluids caused by illness, not drinking enough water or other fluids, sweating too much during hot weather conditions, or taking certain medicines), heat related illnesses such as heat exhaustion (manifested by weakness, headache, vomiting, cramps, loss of consciousness) or heat-stroke (a serious heat-related illness manifested by high body temperature of 104 degrees F or higher, rapid breathing, increased heart rate); and reduced ability to participate in normal activities of daily living. Because of the potential serious harm to Residents 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, and 58 related to the facility ' s failure to maintain safe and comfortable ambient temperatures in the facility, an Immediate Jeopardy (IJ) (a situation in which entity or facility non-compliance has placed the health and safety of residents or patients in its care at risk for serious injury, harm, impairment, or death; and involves immediate action to remove the threat of harm or potential harm) was called onsite, with a scope and severity of L under 42 CFR S483.10(i)(6) - F584, on 9/6/22 at 7:34 p.m., with the Regional Director of Operation (RDO), Administrator (ADM), and Director of Nursing (DON). The facility was provided the IJ template which listed the identified regulatory non-compliance, the potential or actual outcomes of the non-compliance, and the requirement for the facility to develop, implement, and submit a Plan of Removal (POR, a plan consisting of interventions or action items that must be immediately implemented by the facility to correct and remove the IJ situation). The facility submitted an acceptable IJ POR (Version 2) on 9/7/22, which addressed the actions needed to remove the IJ situation. The IJ POR included but was not limited to the following: 1) Immediate assessment of all residents, including their hydration status, vital signs (heart rate, temperature, respiration rate, blood pressure), and implementation of cooling measures, provision of lightweight clothing, additional fans, hydration stations (a designated area strategically placed to promote and provide fluids for hydration) and extra fluids if not contraindicated, 2) Development of a monitoring tool to assess and document room temperatures to ensure the ambient temperatures were safe, comfortable, and within the acceptable ranges of 71 degrees F to 81 degrees F, 3) Immediate training and in-service of all staff for awareness of safe and comfortable ambient temperature levels and signs and symptoms of heat stroke, heat exhaustion, and dehydration, 4) Immediate implementation of scheduled rounds (act of visiting the residents and other living spaces or areas) to monitor residents and medications in the affected areas with corresponding documentation, and 5) Inspection and maintenance of the facility's chiller/cooling systems by a reputable vendor to ensure the systems were properly functioning and able to maintain safe and comfortable ambient temperatures at all times. On 9/8/22, the components of the IJ POR were validated onsite through observations, interviews, and record review. The IJ was removed on 9/8/22 at 2:55 p.m. with the RDO, ADM, DON, and Director of Staff Development (DSD). Findings: During an observation on 9/6/22, at 4 p.m., on the facility ' s designated entrance, there was a mister above the entrance door that sprayed a fine mist of water towards the Smoking Area, where three individuals were smoking. Upon entering the facility, the screening area by the door and the hallway leading to the DON ' s office and nursing station near the timecard machine was hot and humid. A blower fan was observed blowing air towards the DON ' s office. During a concurrent observation and tour of the facility and interview, on 9/6/22, at 4:20 p.m., with the Administrator (ADM), resident rooms were measured for ambient temperatures using the surveyor ' s infrared temperature gun (ITG, a tool that can measure temperatures from a distance). The rooms whose temperatures were not measured (TNM) had the doors closed during provision of care or were out of their room. All temperature measurement were shown to, viewed and confirmed by the ADM. The ADM asked five of the six residents (Residents 18, 27, 30, 38, and 50) who complained it was hot in their room. The ambient room temperatures were as follows: Room 1 1A: TNM 1B: Vacant (V) 1C: V 1D: V Room 2 2A: 83.8 degrees F 2B: TNM 2C: TNM Room 3 3A: within range - 80.8 degrees F 3B: within range - 81 degrees F 3C: 84.2 degrees F Room 4 4A: 81.4 degrees F 4B: 82.2 degrees F 4C: 82.6 degrees F Room 5 (Red Zone Room - RZR, room dedicated to quarantine residents who are positive for COVID - 19, an infectious disease caused by the corona virus), door closed. 5A: 89.8 degrees F 5B: 86 degrees F 5C: 89 degrees F Room 6 (RZR), door closed 6A: 85 degrees F, Resident 14 stated, It is hot here! 6B: 86 degrees F 6C: 86 degrees F Room 7 (RZR), door closed 7A: 85 degrees F 7B: 86 degrees F Room 8 8A: 86.8 degrees F 8B: 86 degrees F 8C: 92 degrees F Room 9 9A: V 9B: 83.4 degrees F, Resident 22 stated, It is hot. 9C: 87 degrees F Room 10 10A: 86 degrees F 10B: 87.4 degrees F Room 11 11A: TNM 11B: TNM 11C: TNM Room 12 12A: 87 degrees F 12B: 87 degrees F 12C: 87.8 degrees F, Resident 31 stated, It is hot. Room 13 13 A: 91 degrees F 13B: 92.6 degrees F 13C: 95.8 degrees F, Resident 34 stated, it is hot! Room 14 14 A: 84.6 degrees F 14B: 85.2 degrees F 14C: 87 degrees F Room 15 15A: 88 degrees F Room 16 16A: V 16B: 85 degrees F 16C: 89.2 degrees F Room 17 17A: 90 degrees F 17B: 92 degrees F, Resident 42 was observed with sweat on the forehead, did not have his shirt on, his face flushed and Resident 42 stated, It feels like 100 degrees here! 17C: 95.2 degrees F, Resident 43 was observed to not have his shirt on. Room 18 18A: 86 degrees F 18B: 86 degrees F Room 19 19A: 86.2 degrees F 19B: TNM Room 21 21A: 91 degrees F 21B: 92 degrees F 21C: 97.8 degrees F Room 22 22A: 84.2 degrees F, Resident 54 stated, It is hot here! 22B: 87.6 degrees F Room 23 23A: 83.67 degrees F 23B: 85 degrees F 23C: 85.8 degrees F During a concurrent observation and interview, on 9/6/22 at 4:36 p.m., with Licensed Vocational Nurse (LVN) 1, at the nurses ' station, LVN 1 stated it had been very hot and humid inside the facility for about a week or so and the administration/leadership were aware that it had been hot. LVN 1 stated the facility had only 2 blowers. LVN 1 stated, It is hard to breathe especially with the PPEs (personal protective equipment such as gowns, face shield, and masks) . During an interview, on 9/6/22 at 4:45 p.m., with the ADM, the ADM stated, We have heatwave , . we have provided the residents with popsicle this morning . the residents have electric fans in their rooms . I am just now aware of the ambient room temperatures and had been texting facility staff and corporate regarding the room temperatures which are out of comfortable range . The ADM stated she had just instructed staff to provide ice water and cooling washcloths to the residents. When asked if she was aware or had been made aware of problems with the air-conditioning (AC) units and of the high ambient temperatures inside the facility, the ADM stated maintenance supervisor (MS) 1 had informed her all the AC units were working well. The ADM then requested to measure the AC vent in the nursing station, and the temperature of the air blowing in measured at 84 degrees Fahrenheit. The ADM stated there were no other interventions (such as assisting or encouraging residents to dress in lightweight, loose-fitting clothing, keeping the residents well hydrated with particular attention to dependent residents, temporarily suspending smoking schedules during the hottest parts of the day, encouraging showers and baths, keeping a hydration station readily available, instructing staff to be alert to adverse changes in resident conditions, and conduct an environmental assessment to determine the root cause of the elevated ambient room temperatures) that were implemented by the facility during the heatwave to maintain the ambient temperature between 71 to 81 degrees F. During observation on 9/6/22 at 5:00 p.m., there were 2 large blowers in the opposite hallways of the facility. There were no hydration stations in the two nursing stations. Some residents in the hallways were observed fanning themselves. Some facility staff, including California Department of Public Health (CDPH) representative were sweating due to the humid and hot environment inside the facility. There were six (6) residents which complained of the heat in their rooms (Residents 14, 22, 31, 34, 42, and 54). Resident 42 ' s face was flushed and had heavy sweat on his forehead. He was naked from the waist up. He stated, It feels like 100 degrees here! Resident 42 was not clothed from the waist up. Resident 42 stated it was hot in the room. Other residents were in their beds and others were by the nursing stations near the 2 blower fans. During an interview on 9/6/22 at 5:10 p.m., with MS 1, DON, and ADM, MS 1 stated, All the AC units were working . When asked how often he checked the resident ' s ambient room temperatures, MS 1 stated, I used to do it 4 times a day but then I stopped when the AC units were fixed . I only do it once a week now. When asked when AC units last broke down, MS 1 stated, Two AC units and the swamp cooler (devices that cool air through the evaporation of water) were broken late July and [DATE] . the receipts and reports and billing were sent directly to the corporate people. At this time, at 5:15 p.m., the ADM and DON left the interview to purchase evaporator coolers and blower fans. MS 1 stated, The HVAC (Heating, Ventilation, Air Conditioning) is a [AGE] year-old HVAC unit & when broken, the old and defective parts were replaced by newly (manufactured) parts which break again . instead of just upgrading the entire HVAC unit. When asked how often the resident ' s ambient room temperatures were checked in August 2022 and during this week ' s heatwave, MS 1 stated, I was told by the ADM to check it once a week only . and that the temperatures in the residents ' rooms cannot exceed 84 degrees F . I don ' t know what the plans are to keep the facility temperatures within safe and comfortable range during the heatwave . MS 1 stated it was difficult to keep the facility cool because the nurses left the resident ' s sliding doors open and there was constant coming in and going out the entrance door by staff, visitors, and by the residents who smoked outside in front by the entrance door. During a review of the room temp check log (RTCL) dated 8/2022 and 9/6/22, indicated MS 1 had checked the residents ' ambient room temperatures on 8/8/22, 8/22/22, 8/29/22 and 9/6/22. A weekly check that was due on 8/15/22 was not done. The room temperatures measured on 8/8/22 was 71-81 degrees F; for 8/22/22 it was 76-84 degrees F; and for 8/29/22, it was 67-77 degrees F. The 9/6/22 ambient room temperatures on 9/6/22 at 11:00 a.m. measured between 75-81 degrees F. During a concurrent observation and interview on 9/6/22 from 8:40 p.m. to 9:00 p.m., with MS 2, MS 2 measured all room temperatures with the surveyor ' s ITG. MS 2 stated the following rooms continued to have ambient room temperatures above the safe and comfortable range of 71-81 degrees F: Room 1A: 85 degrees F Room 3C: 82.5 degrees F Room 4 4A: 82.2 degrees F 4C: 82 degrees F Room 5 (Red Zone Room), door closed. 5A: 86 degrees F 5B: 86.2 degrees F 5C: 86 degrees F Room 6 (RZR), door closed 6A: 82.8 degrees F 6B: 84.4 degrees F 6C: 84 degrees F Room 7 (RZR), door closed 7A: 83.6 degrees F 7B: 82.8 degrees F Room 8 8 B: 83 degrees F 8C: 84 degrees F Room 11 11A: 84 degrees F 11B: 82 degrees F 11C: 84 degrees F Room 12 12B: 82 degrees F 12C: 83 degrees F Room 13 13A: 84 degrees F 13B: 85 degrees F 13C: 85 degrees F Room 14 14A: 84 degrees F 14B: 83 degrees F 14C: 83 degrees F Room 15A: 84 degrees F Room 16C: 84 degrees F Room 17 17A: 85 degrees F 17B: 87 degrees F 17C: 89 degrees F Room 18 18A: 82 degrees F 18B: 82 degrees F Room 19 19A: 83 degrees F 19B: 85 degrees F Room 21 21A: 87 degrees F 21B: 89 degrees F 21C: 90 degrees F Room 22 22A: 84 degrees F 22B: 85 degrees F Room 23: 23A: 82 degrees F 23B: 83 degrees F 23C: 85 degrees F During an interview, on 9/6/22 at 9:05 p.m., with MS 1 and MS 2, MS 2 stated the room temperatures still exceeded the normal ambient room temperatures which was 71 to 81 degrees F. During an interview, on 9/6/22 at 9:10 p.m., the DON stated the LPH (local public health) instructed them to limit Hydration Station (HS) due to COVID-19 outbreak at the facility. The DON stated, I stopped the hydration station . The DON stated nursing had not done resident assessments for heat-related symptoms of residents since the heatwave started and should have conducted an assessment to all residents ' to ensure they would not have any heat related illness or injury because of the high temperatures due to the heat wave. The DON stated residents' should have been assessed for signs and symptoms of dehydration and their vital signs should have been taken when the ambient room temperature was above 81 degrees F and was not done by the facility. During an interview, on 9/7/22 at 10:28 a.m., with the cook/dietary aide (C/DA), C/DA stated, .The AC machine keeps on breaking down . During a concurrent observation, on 9/7/22 from 9:45 a.m. to 10:30 a.m., with MS 1 & 2, MS 1 and MS 2 stated the following rooms continued to had ambient room temperatures above the safe and comfortable range of 71-81 degrees F. The first measurements were taken with the surveyor ' s ITG and the second measurement, enclosed in ( ) were taken by MS 1 & 2 with their ITG: Room 5 (Red Zone Room - RZR), door closed. 5C: 81.6 (80.6) degrees F Room 11C: 81.4 degrees F Room 13 13A: 83 (81.3) degrees F 13B: 83.4 (82.7) degrees F 13C: 84 (82.9) degrees F Room 14 14A: 82 (80.6) degrees F 14B: 81.2 (80.4) degrees F Room 15A: 81.6 (80.7) degrees F Room 17 17A: 83.8 (80.2) degrees F 17B: 83.2 (80.9) degrees F 17C: 83 (82) degrees F Room 19 19A: 81.2 (80.6) degrees F 19B: 82.8 (80.6) degrees F Room 20 20A: 81.4 (80.9) degrees F 20B: 81.2 (80.4) degrees F 20C: 81.4 (80.2) degrees F Room 21 21A: 84.8 (80.7) degrees F 21B: 83.6 (80.9) degrees F 21C: 84 (81.5) degrees F Room 22B: 81.2 (81.3) degrees F Room 23C: 82.4 (80.7) degrees F Medication Room: 84 degrees F Activity Room: 78 (82) degrees F During an interview, on 9/7/22 at 11:16 a.m., with the activity staff (AS), AS stated, AC keeps on failing for the past two years . yesterday was very warm .we have not had in service on how to take care of residents during hot or warm temperatures . During an interview, on 9/7/22 at 11:30 a.m., with certified nursing assistant (CNA) 2, CNA 2 stated, This is my 3rdweek here as a floater (from a sister-facility) . last Friday (9/2/22), resident in room 21-B told me the room was too hot . rooms 22 and 23 were very hot .I informed my charge nurse .I don ' t know if they acted on my report. During an interview, on 9/7/22 at 12:06 p.m., with CNA 3, CNA 3 stated the ventilation problem was an on-going problem but yesterday (9/6/22) was the worst. CNA 3 stated she attended an in service on 9/6/22, regarding signs and symptoms of dehydration, to offer fluids to the residents every 2 hours and as needed, and to provide cooling measures such as wet towels, offer popsicles, ice water, and turn the fan on. CNA 3 stated doors should be closed, and curtain pulled to keep the cool air in the building. CNA 3 stated she was told during the in-service to report temperature related problem to the maintenance staff, DON, ADM, and Charge Nurse. CNA 3 stated she was told temperatures should be comfortable for the resident and should be between 70 and 80 degrees. CNA 3 stated prior to 9/6/22, there was no in-service provided by the facility to the staff what interventions should be done in the event the ambient temperatures were above 81 degrees F. During an interview, on 9/7/22 at 1:05 p.m., with vendor (V), V1 stated the cause of the elevated ambient temperature could be the heat wave and staff not closing the sliding doors in resident rooms. During a concurrent observation and interview, on 9/7/22, from 1:55 p.m. to 2:30 p.m., MS 1 and MS 2 stated the following rooms continued to have ambient room temperatures above the safe and comfortable range of 71-81degrees F. The first measurements were taken with the surveyor ' s ITG and the second measurement, enclosed in ( ) )were taken by MS 1 & 2 with their ITG: Room 1 A: 85.2 (85.4) degrees F Room 2 2A: 82 (83.8) degrees F 2B: 81.6 (83.8) 2C: 82 (82.4) Room 5 (Red Zone Room), door closed. 5A: 82.8 (81.3) 5B: 83.4 (82) 5C: 84 (82.2) Room 6 (RZR), door closed 6A: 82.2 (82) degrees F 6B: 82.3 (81.2) degrees F 6C: 83 (81.8) degrees F Room 7 (RZR), door closed 7A: 83 (81.6) degrees F 7B: 83 (81.6) degrees F Room 8 8A: 83.6 (82.9) degrees F 8B: 84 (83.1)degrees F 8C: 84.8 (83.6) degrees F Room 9 9B: 84 (83.1) degrees F 9C: 84 (83.1) degrees F Room 10 10A: 82.8 (82.5) degrees F 10B: 82.8 (82.5) degrees F Room 11 11A: 85.8 (82.5) degrees F 11B: 85.4 (82.5) degrees F 11C: 85 (83.4) degrees F Room 12 12A: 84.4 (83.6) degrees F 12B: 84.4 (83.6) degrees F 12C: 85.6 (84.5) degrees F Room 13 13A: 86.4 (85.2) degrees F 13B: 87 (85.2) degrees F 13C: 87 (86.0) degrees F Room 15A: 85.2 (84.9) degrees F Room 16 16B: 84 (83.6) degrees F 16C: 84 (83.4) degrees F Room 17 17A: 85.6 (84.5) degrees F 17B: 86 (85.2) degrees F 17C: 87 (84.4) degrees F Room 18 18A: 84.6 (84.5) degrees F 18B: 84.6 (84.5) degrees F Room 19 19A: 84 (83.8) degrees F 19B: 84 (83.8) degrees F Room 20 20A: 83 (82.5) degrees F 20B: 83 (82) degrees F 20C: 82.6 (81.8) degrees F Room 21 21A: 86 (82) degrees F 21B: 86 (82) degrees F 21C: 86.2 (82.4) degrees F Room 22 22A: 82.4 (82.7) degrees F 22B: 83 (82.7) degrees F Room 23 23A: 82.6 (82.5) degrees F 23B: 83.2 (82.5) degrees F 23C: 84 (82.7) degrees F Medication Room: 82 degrees F Activity Room: 83 (82.2) degrees F During an interview, on 9/7/22 at 2:52 p.m., with CNA 4, CNA 4 stated the warm temperature inside the building was an on-going problem. CNA 4 stated she just learned from the in-service yesterday to report any AC or ventilation problem to the Licensed Nurse (LN), DON, DSD, or maintenance. CNA 4 stated prior to 9/6/22 she did not know the normal ambient temperature should be between 70 to 85 degrees and prior to 9/6/22, she did not know the process to report any AC or ventilation problem to the LN. During a record review of Resident 1, 11, 12, 13, 14, 15, 16, and 17's Electronic Medical Record (EMR), the EMR indicated the following: Resident 1 was in room 1, which had an ambient room temperature which measured 85.2 to 85.4 degrees F on 9/6/22 and 9/7/22. Resident 1 ' s diagnoses included dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), chronic kidney disease (kidneys are damaged and can ' t filter blood the way they should) and COVID-19 on 9/1/22. The minimum data set (MDS, a federally mandated process for clinical assessment of each resident's functional capabilities and health needs) dated 9/5/22, Section C for BIMS (Brief Interview for Mental Status), indicated Resident 1's BIMS score was 99 (unable to complete interview). Section G for functional status indicated Resident 1 required extensive assistance with activities of daily living (ADL) such as getting dressed and washing face, bathing, or showering. The COVID Skilled Note dated 9/2/22, indicated c. Increase food and fluid intake to sustain nutrition and hydration thus reducing occurrence of weight loss or dehydration. Resident 11 was in RZ (red zone) room 5A (closed door), with ambient room temperature which measured 86 to 89.8 degrees F on 9/6/22. Resident 11 ' s diagnoses included chronic obstructive pulmonary disease ([CONDITION(S)], [CONDITION(S)] lung disease which causes obstructed airflow from the lungs thus making it hard to breathe), lung cancer, and COVID-19 on 9/1/22. The MDS dated [DATE], Section C indicated Resident 11's BIMS score was 08 (unable to recall words or remember day, month, or year), Section G for functional status indicated Resident 11 required extensive assistance with activities of daily living (ADL) such as washing face, bathing, or showering. The COVID Skilled Note dated 9/5/22, indicated c. Increase food and fluid intake to sustain nutrition and hydration thus reducing occurrence of weight loss or dehydration. Resident 12 was in RZ room 5B (closed door), with ambient room temperatures which measured 82.8 to 86.2 degrees F on 9/6/22 and 9/7/22. Resident 12 ' s diagnoses included muscle weakness, type 2 diabetes (high blood sugar) , and COVID-19 on 8/29/22. The MDS dated [DATE], Section C indicated Resident 12's BIMS score was 13 (able to recall words and remembers the day and year). Section G for functional status indicated Resident 12 required limited assistance with activities of daily living (ADL) such as washing face, bathing, or showering. The COVID Skilled Note dated 8/29/22, indicated c. Increase food and fluid intake to sustain nutrition and hydration thus reducing occurrence of weight loss or dehydration. Resident 13 was in RZ room 5C (closed door), with ambient room temperature which measured 84 to 89 degrees F on 9/6/22 and 9/7/22. Resident 13 ' s diagnoses included unspecified cough, [CONDITION(S)] ([CONDITION(S)] or sudden temporary loss of consciousness), seizures (a sudden, uncontrolled electrical disturbance in the brain which can cause changes in behavior, movements or feelings, and in levels of consciousness), and COVID-19 on 8/29/22. The MDS 9/5/22, Section C indicated Resident 13's BIMS score was 15 (good recall, memory, and orientation). Section G for functional status indicated Resident 13 required limited assistance with activities of daily living (ADL) such as getting dressed and washing face, bathing, or showering. The COVID Skilled Note dated 9/2/22, indicated c. Increase food and fluid intake to sustain nutrition and hydration thus reducing occurrence of weight loss or dehydration. Resident 14 was in RZ room 6A (closed door), with ambient room temperature which measured 82.2 to 85 degrees F on 9/6/22 and 9/7/22. Resident 14 ' s diagnoses included end-stage renal disease (the kidneys stop functioning permanently and requires [CONDITION(S)] (treatment to filter wastes and water from the blood) or kidney transplant to maintain life), muscle weakness, Alzheimer ' s (a brain disorder that slowly destroys memory and thinking skills and eventually, the ability to carry out the simplest task) and COVID-19 on 9/1/22. The MDS dated [DATE], Section C indicated Resident 14's BIMS score was 3 (unable to recall, poor memory). Section G for functional status indicated Resident 14 required extensive assistance with activities of daily living (ADL) such as getting dressed and washing face, bathing, or showering. The COVID Skilled Note dated 9/2/22, indicated c. Increase food and fluid intake to sustain nutrition and hydration thus reducing occurrence of weight loss or dehydration. Resident 15 ' s was in RZ room 6B (closed door) with ambient room temperature which measured 84.4 to 86 degrees F on 9/6/22 and 9/7/22. Resident 15 ' s diagnoses included dementia , [CONDITION(S)], unspecified nausea and vomiting, and COVID-19 on 8/26/22. The MDS dated [DATE], Section C indicated Resident 15's BIMS score was 9 (unable to recall, poor memory). Section G for functional status indicated Resident 15 required extensive to total assistance by one to two staff to reposition, dress or undress, and to wash face, bathe, or shower. The COVID Skilled Note dated 8/26/22, indicated c. Increase food and fluid intake to sustain nutrition and hydration thus reducing occurrence of weight loss or dehydration. Resident 16 was in RZ room 6C (closed door) with ambient room temperature which measured 83 to 86 degrees F on 9/6/22 and 9/7/22. ' Resident 16 ' s diagnoses included chronic respiratory failure (a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon [MEDICATION(S)] from the body), [CONDITION(S)] (low levels of oxygen in the body tissues causing rapid heart rate, confusion, restlessness and difficulty in breathing), and COVID-19 on 9/1/22. The MDS dated [DATE], Section C, indicated Resident 16's BIMS score was 15 (good recall, memory, and orientation). Section G for functional status indicated Resident 16 required limited assistance with activities of daily living (ADL) to get dressed, wash face, bathe, or shower. The COVID Skilled Note dated 9/2/22, indicated c. Increase food and fluid intake to sustain nutrition and hydration thus reducing occurrence of weight loss or dehydration. Resident 17 was in RZ room 7A (closed door) with ambient room temperature which measured 83 to 85 degrees F on 9/6/22 and 9/7/22. Resident 17 ' s diagnoses included hypertension, anxiety disorder, and COVID-19 on 9/1/22. The MDS dated [DATE], Section C indicated Resident 17's BIMS score was 10 (cuing required for the resident to recall or remember). Section G for functional status indicated Resident 17 required extensive assistance with activities of daily living (ADL) for dressing, washing face, bathing, or showering. The COVID Skilled Note dated 9/2/22, indicated c. Increase food and fluid intake to sustain nutrition and hydration thus reducing occurrence of weight loss or dehydration. During a review of the online California Weather History- Excessive Heat Warning for Merced County dated 9/1/22 to 9/9/22, indicated the following temperatures during the heatwave: 9/1/22: 105 degrees F 9/2/22: 107 degrees F 9/3/22: 106 degrees F 9/4/22: 106 degrees F 9/5/22 108 degrees F high at 4:53 p.m. 9/6/22: 115 degrees F high at 4:53 p.m. 9/7/22: 108 degrees F high at 5:00 p.m. 9/8/22: 109 degrees F high at 4:00 p.m. 9/9/22: 106 degrees F high at 4:00 p.m. During a review of the hourly temperature on 9/6/22 (IJ), indicated the following: 10:53 a.m.: 101 degrees F 11:53 a.m.: 105 degrees F 12:53 p.m.: 107 degrees F 1:53 p.m.: 109 degrees F 2:53 p.m.: 110 degrees F 3:53 p.m.: 112 degrees F 4:53 p.m.: 115 degrees F 5:53 p.m.: 114 degrees F 6:53 p.m.: 108 degrees F 7:53 p.m.: 97 degrees F 8:53 p.m.: 92 degrees F During a review of the California Department of Public Health All Facilities Letter 22-18 - Level II Extreme Heat Alert -All Facilities Letter (AFL) Summary, dated 9/1/22, indicated the following bullet points: This AFL notifies health care facilities that the National Weather Service has issued Level II Excessive Heat Warnings for California. These Heat Warnings are in effect from 9:00 a.m., Wednesday, August 31, through 8:00 p.m., Tuesday, September 6, 2022, with much of California at high risk for widespread, continuous triple-digit temperatures. Facilities must implement recommended precautionary measures to keep individuals safe and comfortable during extremely hot temperatures and must have contingency plans in place to deal with the loss of air conditioning, or in the case when no air conditioning is available, take measures to ensure patients and residents are free of adverse conditions that may cause heat-related health complications. Facilities must report extreme heat conditions that compromise patient health and safety and/or require an evacuation, transfer, or discharge of patients. From August 31, 2022 through September 6, 2022, California will be experiencing a significant warming trend that will bring moderate risk to very high-risk heat impacts across portions of Inland, Coastal, and Southern Regions. This will result in multiple excessive heat warnings and watches throughout the state through September 6, 2022, with more predicted to come. While heat events such as this one is not unusual during the summer months, an extended heat wave, with poor cooling overnight, can lead to dangerous conditions. The California Department of Public Health (CDPH) reminds all health care facilities that the elderly and other health compromised individuals are more susceptible to temperature extremes and possible dehydration. Facility administrators should monitor weather predictions for fluctuations in extreme temperatures and take extra precautions to be sure appropriate air conditioning equipment is well maintained and operating effectively. Facilities must have contingency plans in place to deal with the loss of air conditioning, or in the case when no air conditioning is available, take measures to ensure patients and residents are free of adverse conditions that may cause heat-related health complications. Facilities should use portable fans and other temporary cooling devices when indicated. CDPH recommends facilities review CDPH's Fast Facts: Preventing Summer Heat Injuries and implement the following measures to keep residents and clients comfortable during extremely hot weather: Dress in lightweight, loose-fitting clothing Keep residents well hydrated with particular attention to dependent residents Minimize physical activities during the hottest parts of the day Stay indoors and out of the sun during the hottest parts of the day Use fans as indicated in the Fast Facts page on preventing summer heat injuries Open windows where feasible if screens are intact, to allow fresh air to circulate Use cool compresse

Based on observation, interview, and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, for 58 of 58 sampled residents (Residents 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, and 58), when the ambient (surrounding area) room temperatures in 23 resident rooms (1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 15, 17, 18, 19, 20, 21, 22, and 23) exceeded the safe and comfortable levels of 71 to 81 degrees Fahrenheit (F- a scale for measuring temperature in which water freezes at 32 degrees and boils at 212 degrees) and the residents were not immediately assessed for symptoms of heat-related illness, had their vital signs checked, provided with extra fluids if not contraindicated, provided with cooling measures including cool wet cloths, baths or showers, additional fans, and assisted to put on weather-appropriate clothing. The measured ambient room temperatures reached up to 97.8 degrees F in residents whose beds were in the middle (bed B) or next to the glass sliding doors (bed C) and the facility failed to monitor, prepare, plan, implement interventions, and provide sufficient cooling equipment that would ensure each residents ' health, comfort, and safety at all times. These failures placed Residents 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54 55, 56, 57, and 58), at risk for dehydration (a condition that occurs when the body loses too much water and other fluids caused by illness, not drinking enough water or other fluids, sweating too much during hot weather conditions, or taking certain medicines), heat related illnesses such as heat exhaustion (manifested by weakness, headache, vomiting, cramps, loss of consciousness) or heat-stroke (a serious heat-related illness manifested by high body temperature of 104 degrees F or higher, rapid breathing, increased heart rate); and reduced ability to participate in normal activities of daily living. Because of the potential serious harm to Residents 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, and 58 related to the facility ' s failure to provide prompt and appropriate assessment of needs and interventions to relieve the resident ' s discomfort, an Immediate Jeopardy (IJ) (a situation in which entity or facility non-compliance has placed the health and safety of residents or patients in its care at risk for serious injury, harm, impairment, or death; and involves immediate action to remove the threat of harm or potential harm) was called onsite, with a scope and severity of L under 42 CFR S CFR 483.25 F 684 Quality of Care on 9/6/22 at 7:34 p.m., with the Regional Director of Operation (RDO), Administrator (ADM), and Director of Nursing (DON). The facility was provided the IJ template which listed the identified regulatory non-compliance, the potential or actual outcomes of the non-compliance, and the requirement for the facility to develop, implement, and submit a Plan of Removal (POR, a plan consisting of interventions or action items that must be immediately implemented by the facility to correct and remove the IJ situation). The facility submitted an acceptable IJ POR (Version 2) on 9/7/22, which addressed the actions needed to remove the IJ situation. The IJ POR included but was not limited to the following: 1) Immediate assessment of all residents, including their hydration status, vital signs (heart rate, temperature, respiration rate, blood pressure), and implementation of cooling measures, provision of lightweight clothing, additional fans, hydration stations (a designated area strategically placed to promote and provide fluids for hydration) and extra fluids if not contraindicated, 2) Development of a monitoring tool to assess and document room temperatures to ensure the ambient temperatures were safe, comfortable, and within the acceptable ranges of 71 degrees F to 81 degrees F, 3) Immediate training and in-service of all staff for awareness of safe and comfortable ambient temperature levels and signs and symptoms of heat stroke, heat exhaustion, and dehydration, 4) Immediate implementation of scheduled rounds (act of visiting the residents and other living spaces or areas) to monitor residents and medications in the affected areas with corresponding documentation, and 5) Inspection and maintenance of the facility's chiller/cooling systems by a reputable vendor to ensure the systems were properly functioning and able to maintain safe and comfortable ambient temperatures at all times. On 9/8/22, the components of the IJ POR were validated onsite through observations, interviews, and record review. The IJ was removed on 9/8/22 at 2:55 p.m. with the RDO, ADM, DON, and Director of Staff Development (DSD). Findings: During a concurrent observation and interview, on 9/6/22, at 4:20 p.m., with the Administrator (ADM), the resident rooms were measured for ambient temperatures using the surveyor ' s infrared temperature gun (ITG, a tool that can measure temperatures from a distance). The rooms whose temperatures were not measured (TNM) had the doors closed during provision of care or were out of their room. All temperature measurement were shown to, viewed, and confirmed by the ADM. The ADM asked five of the six residents (Residents 18, 27, 30, 38, and 50) and the residents' stated it was hot in their room. The ADM stated the following rooms measured temperatures above the normal ambient range which was supposed to be 71 to 81 degrees F. room [ROOM NUMBER] 1A: TNM 1B: Vacant (V) 1C: V 1D: V room [ROOM NUMBER] 2A: 83.8 degrees F 2B: TNM 2C: TNM room [ROOM NUMBER] 3C: 84.2 degrees F room [ROOM NUMBER] 4A: 81.4 degrees F 4B: 82.2 degrees F 4C: 82.6 degrees F room [ROOM NUMBER] (Red Zone Room - RZR, room dedicated to quarantine residents who are positive for COVID - 19, an infectious disease caused by the corona virus), door closed. 5A: 89.8 degrees F 5B: 86 degrees F 5C: 89 degrees F room [ROOM NUMBER] (RZR), door closed 6A: 85 degrees F, Resident 14 stated, It is hot here! 6B: 86 degrees F 6C: 86 degrees F room [ROOM NUMBER] (RZR), door closed 7A: 85 degrees F 7B: 86 degrees F room [ROOM NUMBER] 8A: 86.8 degrees F 8B: 86 degrees F 8C: 92 degrees F room [ROOM NUMBER] 9B: 83.4 degrees F, Resident 22 stated, It is hot. 9C: 87 degrees F room [ROOM NUMBER] 10A: 86 degrees F 10B: 87.4 degrees F room [ROOM NUMBER]A: TNM B: TNM C: TNM room [ROOM NUMBER] 12A: 87 degrees F 12B: 87 degrees F 12C: 87.8 degrees F, Resident 31 stated, It is hot. room [ROOM NUMBER] 13A: 91 degrees F 13B: 92.6 degrees F 13C: 95.8 degrees F, Resident 34 stated, it is hot! room [ROOM NUMBER] 14A: 84.6 degrees F 14B: 85.2 degrees F 14C: 87 degrees F room [ROOM NUMBER] 15A: 88 degrees F room [ROOM NUMBER] 16B: 85 degrees F 16C: 89.2 degrees F room [ROOM NUMBER] 17A: 90 degrees F 17B: 92 degrees F, Resident 42 stated, It feels like 100 degrees here! Resident 42 was observed with flushed face and sweat on forehead and did not have his shirt on. 17C: 95.2 degrees F, room [ROOM NUMBER] 18A: 86 degrees F 18B: 86 degrees F room [ROOM NUMBER] 19A: 86.2 degrees F room [ROOM NUMBER] 21A: 91 degrees F 21B: 92 degrees F 21C: 97.8 degrees F room [ROOM NUMBER] 22A: 84.2 degrees F, Resident 54 stated, It is hot here! 22B: 87.6 degrees F room [ROOM NUMBER] 23: A: 83.67 degrees F 23B: 85 degrees F 23C: 85.8 degrees F During a concurrent observation and interview, on 9/6/22 at 4:36 p.m., with Licensed Vocational Nurse (LVN) 1, at the nurses ' station, LVN 1 stated it had been very hot and humid inside the facility for about a week and the facility had only 2 blowers. LVN 1 stated, It is hard to breathe especially with the PPEs (personal protective equipment such as gowns, face shield, and masks) . During an interview, on 9/6/22 at 4:45 p.m., with the ADM, the ADM stated, We have heatwave . The ADM stated she had just instructed staff at this time to provide ice water and cooling washcloths to the residents. When asked if she was aware or had been made aware of problems with the air-conditioning (AC) units and of the high ambient temperatures inside the facility, the ADM stated maintenance supervisor (MS) 1 had informed her all the AC units were working well. The ADM then requested to measure the AC vent in the nursing station, and the temperature of the air blowing in measured at 84 degrees Fahrenheit. The ADM stated no other nursing interventions (such as assisting or encouraging residents to dress in lightweight, loose-fitting clothing, keeping the residents well hydrated with particular attention to dependent residents, temporarily suspending smoking schedules during the hottest parts of the day, encouraging showers and baths, keeping a hydration station readily available, instructing staff to be alert to adverse changes in resident conditions, and conduct an environmental assessment to determine the root cause of the elevated ambient room temperatures) were planned and implemented during the heatwave. During observation on 9/6/22 at 5:00 p.m., there were 2 large blowers in the opposite hallways of the facility. There were no hydration stations in the two nursing stations. Six (6) residents complained of the heat in their rooms (Residents 14, 22, 31, 34, 42, and 54). Resident 42 ' s face was flushed and had heavy sweat on his forehead. Resident 42 was naked from the waist up. Resident 42 stated, It feels like 100 degrees here! Resident 42 was not clothed from the waist up. He stated it was hot in the room. Other residents were in their beds and others were by the nursing stations near the 2 blower fans. During an interview on 9/6/22 at 5:10 p.m., with MS 1, DON, and ADM, MS 1 stated, All the AC units were working . When asked how often he checked the resident ' s ambient room temperatures, MS 1 stated, I used to do it 4 times a day but then I stopped when the AC units were fixed . I only do it once a week now. When asked when AC units last broke down, MS 1 stated, Two AC units and the swamp cooler were broken late July and [DATE] . the receipts and reports and billing were sent directly to the corporate people. MS 1 stated, The HVAC (Heating, Ventilation, Air Conditioning) is a [AGE] year-old HVAC unit & when broken, the old and defective parts were replaced by newly (manufactured) parts which break again . instead of just upgrading the entire HVAC unit. When asked how often the resident ' s ambient room temperatures were checked in August 2022 and during this week ' s heatwave, MS 1 stated, I was told by the ADM to check it once a week only . and that the temperatures in the residents ' rooms cannot exceed 84 degrees F . I don ' t know what the plans are to keep the facility temperatures within safe and comfortable range during the heatwave . MS 1 stated it was difficult to keep the facility cool because the nurses left the resident ' s sliding doors open and there was constant coming in and going out the entrance door by staff, visitors, and by the residents who smoked outside in front by the entrance door. During a concurrent observation on 9/6/22 from 8:40 p.m. to 9 p.m., with MS 2, MS 2 measured all the room temperatures with the surveyor ' s ITG. MS 2 stated the following rooms continued to have ambient room temperatures above the safe and comfortable range of 71-81 degrees F: room [ROOM NUMBER] A: 85 degrees F room [ROOM NUMBER] C: 82.5 degrees F room [ROOM NUMBER] 4A: 82.2 degrees F 4C: 82 degrees F room [ROOM NUMBER] (Red Zone Room), door closed. 5A: 86 degrees F 5B: 86.2 degrees F 5C: 86 degrees F room [ROOM NUMBER] (RZR), door closed 6A: 82.8 degrees F 6B: 84.4 degrees F 6C: 84 degrees F room [ROOM NUMBER] (RZR), door closed 7A: 83.6 degrees F 7B: 82.8 degrees F room [ROOM NUMBER] 8 B: 83 degrees F 8C: 84 degrees F room [ROOM NUMBER] 11A: 84 degrees F 11B: 82 degrees F 11C: 84 degrees F room [ROOM NUMBER] 12 B: 82 degrees F 12C: 83 degrees F room [ROOM NUMBER] 13A: 84 degrees F 13B: 85 degrees F 13C: 85 degrees F room [ROOM NUMBER] 14A: 84 degrees F 14B: 83 degrees F 14C: 83 degrees F room [ROOM NUMBER] A: 84 degrees F room [ROOM NUMBER] C: 84 degrees F room [ROOM NUMBER] 17A: 85 degrees F 17B: 87 degrees F 17C: 89 degrees F room [ROOM NUMBER] 18A: 82 degrees F 18B: 82 degrees F room [ROOM NUMBER] 19A: 83 degrees F 19B: 85 degrees F room [ROOM NUMBER] 21A: 87 degrees F 21B: 89 degrees F 21C: 90 degrees F room [ROOM NUMBER] 22A: 84 degrees F 22B: 85 degrees F room [ROOM NUMBER] 23A: 82 degrees F 23B: 83 degrees F 23C: 85 degrees F During an interview, on 9/6/22 at 9:10 p.m., the DON stated the LPH (local public health) instructed them to limit Hydration Station (HS) due to COVID-19 outbreak at the facility. The DON stated, I stopped the hydration station . The DON stated nursing had not done resident assessments for heat-related symptoms of residents since the heatwave started and should have conducted an assessment to all residents ' to ensure they would not have any heat related illness or injury because of the high temperatures due to the heat wave. The DON stated residents' should have been assessed for signs and symptoms of dehydration and their vital signs should have been taken when the ambient room temperature was above 81 degrees F and was not done by the facility. During an interview, on 9/7/22 at 10:28 a.m., with the cook/dietary aide (C/DA), C/DA stated, The AC machine keeps on breaking down . During a concurrent observation and interview, on 9/7/22 from 9:45 a.m. to 10:30 a.m., MS 1 & 2 measured the following rooms and stated the ambient room temperatures continued and remained to be above the safe and comfortable range of 71-81 degrees F. The first measurements were taken with the surveyor ' s ITG and the second measurement, enclosed in ( ) were taken by MS 1 & 2 with their ITG : room [ROOM NUMBER] (Red Zone Room - RZR), door closed. 5C: 81.6 (80.6) degrees F room [ROOM NUMBER] C: 81.4 degrees F room [ROOM NUMBER] 13A: 83 (81.3) degrees F 13B: 83.4 (82.7) degrees F 13C: 84 (82.9) degrees F room [ROOM NUMBER] 14A: 82 (80.6) degrees F 14B: 81.2 (80.4) degrees F room [ROOM NUMBER] A: 81.6 (80.7) degrees F room [ROOM NUMBER] 17A: 83.8 (80.2) degrees F 17B: 83.2 (80.9) degrees F 17C: 83 (82) degrees F room [ROOM NUMBER] 19A: 81.2 (80.6) degrees F 19B: 82.8 (80.6) degrees F room [ROOM NUMBER] 20A: 81.4 (80.9) degrees F 20B: 81.2 (80.4) degrees F 20C: 81.4 (80.2) degrees F room [ROOM NUMBER] 21A: 84.8 (80.7) degrees F 21B: 83.6 (80.9) degrees F 21C: 84 (81.5) degrees F room [ROOM NUMBER] B: 81.2 (81.3) degrees F room [ROOM NUMBER] C: 82.4 (80.7) degrees F Medication Room: 84 degrees F Activity Room: 78 (82) degrees F During an interview, on 9/7/22 at 11:16 a.m., with the activity staff (AS), AS stated, AC keeps on failing for the past two years . yesterday [9/6/22] was very warm .we have not had in service on how to take care of residents during hot or warm temperatures . During an interview, on 9/7/22 at 11:30 a.m., with certified nursing assistant (CNA) 2, CNA 2 stated, This is my 3rd week here as a floater (from a sister-facility) . last Friday (9/2/22), resident in room [ROOM NUMBER]-B told me the room was too hot . rooms [ROOM NUMBERS] were very hot .I informed my charge nurse .I don ' t know if they acted on my report. During an interview, on 9/7/22 at 12:06 p.m., with CNA 3, CNA 3 stated the ventilation problem was an on-going problem but yesterday [9/6/22] was the worst. CNA 3 stated she attended an in service on 9/6/22, regarding signs and symptoms of dehydration, to offer fluids to the residents every 2 hours and as needed, and to provide cooling measures such as wet towels, offer popsicles, ice water, and turn the fan on. CNA 3 stated doors should be closed and curtain pulled to keep the cool air in the building. CNA 3 stated she was told during the in-service to report temperature related problem to the maintenance staff, DON, ADM, and Charge Nurse. CNA stated she was told temperatures should be comfortable for the resident and should be between 71 to 81 degrees F. CNA 3 stated prior to 9/6/22, there was no education or training conducted to prepare for the heatwave or what symptoms to monitor for heat related illness or injury. CNA 3 stated she was not aware prior to 9/6/22 that the normal ambient room temperature should be between 71 to 81 degrees F. During an interview, on 9/7/22 at 1:05 p.m., with vendor (V), V1 stated the cause of the elevated ambient temperature could be the heat wave and the facility staff not closing the sliding doors in resident rooms. During a concurrent observation and interview, on 9/7/22, from 1:55 p.m. to 2:30 p.m., MS 1 and MS 2 stated the following rooms remained to have ambient room temperatures above the safe and comfortable range of 71-81 degrees F. The first measurements were taken with the surveyor ' s ITG and the second measurement, enclosed in ( ) )were taken by MS 1 & 2 with their ITG: room [ROOM NUMBER] A: 85.2 (85.4) degrees F room [ROOM NUMBER] 2A: 82 (83.8) degrees F 2B: 81.6 (83.8) degrees F 2C: 82 (82.4) degrees F room [ROOM NUMBER] (Red Zone Room), door closed. 5A: 82.8 (81.3) degrees F 5B: 83.4 (82) degrees F 5C: 84 (82.2) degrees F room [ROOM NUMBER] (RZR), door closed 6A: 82.2 (82) degrees F 6B: 82.3 (81.2) degrees F 6C: 83 (81.8) degrees F room [ROOM NUMBER] (RZR), door closed 7A: 83 (81.6) degrees F 7B: 83 (81.6) degrees F room [ROOM NUMBER] 8A: 83.6 (82.9) degrees F 8B: 84 (83.1)degrees F 8C: 84.8 (83.6) degrees F room [ROOM NUMBER] 9B: 84 (83.1) degrees F 9C: 84 (83.1) degrees F room [ROOM NUMBER] 10A: 82.8 (82.5) degrees F 10B: 82.8 (82.5) degrees F room [ROOM NUMBER] 11A: 85.8 (82.5) degrees F 11B: 85.4 (82.5) degrees F 11C: 85 (83.4) degrees F room [ROOM NUMBER] 12A: 84.4 (83.6) degrees F 12B: 84.4 (83.6) degrees F 12C: 85.6 (84.5) degrees F room [ROOM NUMBER] 13A: 86.4 (85.2) degrees F 13B: 87 (85.2) degrees F 13C: 87 (86.0) degrees F room [ROOM NUMBER] A: 85.2 (84.9) degrees F room [ROOM NUMBER] 16B: 84 (83.6) degrees F 16C: 84 (83.4) degrees F room [ROOM NUMBER] 17A: 85.6 (84.5) degrees F 17B: 86 (85.2) degrees F 17C: 87 (84.4) degrees F room [ROOM NUMBER] 18A: 84.6 (84.5) degrees F 18B: 84.6 (84.5) degrees F room [ROOM NUMBER] 19A: 84 (83.8) degrees F 19B: 84 (83.8) degrees F room [ROOM NUMBER] 20A: 83 (82.5) degrees F 20B: 83 (82) degrees F 20C: 82.6 (81.8) degrees F room [ROOM NUMBER] 21 A: 86 (82) degrees F 21B: 86 (82) degrees F 21C: 86.2 (82.4) degrees F room [ROOM NUMBER] 22A: 82.4 (82.7) degrees F 22B: 83 (82.7) degrees F room [ROOM NUMBER] 23A: 82.6 (82.5) degrees F 23B: 83.2 (82.5) degrees F 23C: 84 (82.7) degrees F Medication Room: 82 degrees F Activity Room: 83 (82.2) degrees F During an interview, on 9/7/22 at 2:52 p.m., with CNA 4, CNA 4 stated the warm temperature inside the building was an on-going problem. CNA 4 stated she just learned from the in-service yesterday to report any AC or ventilation problem to the nurse, DON, DSD, or maintenance. CNA 4 stated the inside temperature should be between 70 to 85 degrees. During review of Resident 1, 11, 12, 13, 14, 15, 16, and 17 ' s electronic health records (EHR), the EHR indicated the following information: Resident 1 was in room [ROOM NUMBER], with ambient room temperature which measured 85.2 to 85.4 degrees F on 9/6/22 and 9/7/22. Resident 1 ' s diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The minimum data set (MDS, a federally mandated process for clinical assessment of each resident's functional capabilities and health needs) dated 9/5/22, Section C for BIMS (Brief Interview for Mental Status), indicated Resident 1's BIMS score was 99 (unable to complete interview). Section G for functional status indicated Resident 1 required extensive assistance with activities of daily living (ADL) such as getting dressed and washing face, bathing, or showering. The COVID Skilled Note dated 9/2/22, indicated c. Increase food and fluid intake to sustain nutrition and hydration thus reducing occurrence of weight loss or dehydration. Resident 11 was in RZ (red zone) room [ROOM NUMBER]A (closed door), with ambient room temperature which measured 86 to 89.8 degrees F on 9/6/22. Resident 11 ' s diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS dated [DATE], Section C indicated Resident 11's BIMS score was 08 (unable to recall words or remember day, month, or year), Section G for functional status indicated Resident 11 required extensive assistance with activities of daily living (ADL) such as washing face, bathing, or showering. The COVID Skilled Note dated 9/5/22, indicated c. Increase food and fluid intake to sustain nutrition and hydration thus reducing occurrence of weight loss or dehydration. Resident 12 was in RZ room [ROOM NUMBER]B (closed door), with ambient room temperature which measured 82.8 to 86.2 degrees F on 9/6/22 and 9/7/22. Resident 12 ' s diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS dated [DATE], Section C indicated Resident 12's BIMS score was 13 (able to recall words and remembers the day and year). Section G for functional status indicated Resident 12 required limited assistance with activities of daily living (ADL) such as washing face, bathing, or showering. The COVID Skilled Note dated 8/29/22, indicated c. Increase food and fluid intake to sustain nutrition and hydration thus reducing occurrence of weight loss or dehydration. Resident 13 was in RZ room [ROOM NUMBER]C (closed door), with ambient room temperature which measured 84 to 89 degrees F on 9/6/22 and 9/7/22. Resident 13 ' s diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS 9/5/22, Section C indicated Resident 13's BIMS score was 15 (good recall, memory, and orientation). Section G for functional status indicated Resident 13 required limited assistance with activities of daily living (ADL) such as getting dressed and washing face, bathing, or showering. The COVID Skilled Note dated 9/2/22, indicated c. Increase food and fluid intake to sustain nutrition and hydration thus reducing occurrence of weight loss or dehydration. Resident 14 was in RZ room [ROOM NUMBER]A (closed door), with ambient room temperature which measured 82.2 to 85 degrees F on 9/6/22 and 9/7/22. Resident 14 ' s diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS dated [DATE], Section C indicated Resident 14's BIMS score was 3 (unable to recall, poor memory). Section G for functional status indicated Resident 14 required extensive assistance with activities of daily living (ADL) such as getting dressed and washing face, bathing, or showering. The COVID Skilled Note dated 9/2/22, indicated c. Increase food and fluid intake to sustain nutrition and hydration thus reducing occurrence of weight loss or dehydration. Resident 15 ' s was in RZ room [ROOM NUMBER]B (closed door) with ambient room temperature which measured 84.4 to 86 degrees F on 9/6/22 and 9/7/22. Resident 15 ' s diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS dated [DATE], Section C indicated Resident 15's BIMS score was 9 (unable to recall, poor memory). Section G for functional status indicated Resident 15 required extensive to total assistance by one to two staff to reposition, dress or undress, and to wash face, bathe, or shower. The COVID Skilled Note dated 8/26/22, indicated c. Increase food and fluid intake to sustain nutrition and hydration thus reducing occurrence of weight loss or dehydration. Resident 16 was in RZ room [ROOM NUMBER]C (closed door) with ambient room temperature which measured 83 to 86 degrees F on 9/6/22 and 9/7/22. ' Resident 16 ' s diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS dated [DATE], Section C, indicated Resident 16's BIMS score was 15 (good recall, memory, and orientation). Section G for functional status indicated Resident 16 required limited assistance with activities of daily living (ADL) to get dressed, wash face, bathe, or shower. The COVID Skilled Note dated 9/2/22, indicated c. Increase food and fluid intake to sustain nutrition and hydration thus reducing occurrence of weight loss or dehydration. Resident 17 was in RZ room [ROOM NUMBER]A (closed door) with ambient room temperature which measured 83 to 85 degrees F on 9/6/22 and 9/7/22. Resident 17 ' s diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS dated [DATE], Section C indicated Resident 17's BIMS score was 10 (cuing required for the resident to recall or remember). Section G for functional status indicated Resident 17 required extensive assistance with activities of daily living (ADL) for dressing, washing face, bathing, or showering. The COVID Skilled Note dated 9/2/22, indicated c. Increase food and fluid intake to sustain nutrition and hydration thus reducing occurrence of weight loss or dehydration. During a review of the online California Weather History- Excessive Heat Warning for Merced County dated 9/1 to 9/9/22, indicated the following: 9/1/22: 105 degrees F 9/2/22: 107 degrees F 9/3/22: 106 degrees F 9/4/22: 106 degrees F 9/5/22 108 degrees F high at 4:53 p.m. 9/6/22: 115 degrees F high at 4:53 p.m. 9/7/22: 108 degrees F high at 5:00 p.m. 9/8/22: 109 degrees F high at 4:00 p.m. 9/9/22: 106 degrees F high at 4:00 p.m. During a review of the hourly temperature on 9/6/22 (IJ), indicated the following: 10:53 a.m.: 101 degrees F 11:53 a.m.: 105 degrees F 12:53 p.m.: 107 degrees F 1:53 p.m.: 109 degrees F 2:53 p.m.: 110 degrees F 3:53 p.m.: 112 degrees F 4:53 p.m.: 115 degrees F 5:53 p.m.: 114 degrees F 6:53 p.m.: 108 degrees F 7:53 p.m.: 97 degrees F 8:53 p.m.: 92 degrees F During a review of the California Department of Public Health All Facilities Letter 22-18 - Level II Extreme Heat Alert -All Facilities Letter (AFL) Summary, dated 9/1/22, indicated the following bullet points: This AFL notifies health care facilities that the National Weather Service has issued Level II Excessive Heat Warnings for California. These Heat Warnings are in effect from 9:00 a.m., Wednesday, August 31, through 8:00 p.m., Tuesday, September 6, 2022, with much of California at high risk for widespread, continuous triple-digit temperatures. Facilities must implement recommended precautionary measures to keep individuals safe and comfortable during extremely hot temperatures and must have contingency plans in place to deal with the loss of air conditioning, or in the case when no air conditioning is available, take measures to ensure patients and residents are free of adverse conditions that may cause heat-related health complications. Facilities must report extreme heat conditions that compromise patient health and safety and/or require an evacuation, transfer, or discharge of patients. From August 31, 2022 through September 6, 2022, California will be experiencing a significant warming trend that will bring moderate risk to very high-risk heat impacts across portions of Inland, Coastal, and Southern Regions. This will result in multiple excessive heat warnings and watches throughout the state through September 6, 2022, with more predicted to come. While heat events such as this one is not unusual during the summer months, an extended heat wave, with poor cooling overnight, can lead to dangerous conditions. The California Department of Public Health (CDPH) reminds all health care facilities that the elderly and other health compromised individuals are more susceptible to temperature extremes and possible dehydration. Facility administrators should monitor weather predictions for fluctuations in extreme temperatures and take extra precautions to be sure appropriate air conditioning equipment is well maintained and operating effectively. Facilities must have contingency plans in place to deal with the loss of air conditioning, or in the case when no air conditioning is available, take measures to ensure patients and residents are free of adverse conditions that may cause heat-related health complications. Facilities should use portable fans and other temporary cooling devices when indicated. CDPH recommends facilities review CDPH's Fast Facts: Preventing Summer Heat Injuries and implement the following measures to keep residents and clients comfortable during extremely hot weather: Dress in lightweight, loose-fitting clothing Keep residents well hydrated with particular attention to dependent residents Minimize physical activities during the hottest parts of the day Stay indoors and out of the sun during the hottest parts of the day Use fans as indicated in the Fast Facts page on preventing summer heat injuries Open windows where feasible if screens are intact, to allow fresh air to circulate Use cool compresses, misting, showers, and baths to promote cooling Avoid hot foods and heavy meals Encourage frozen treats such as popsicles between meals Keep a hydration station readily available to residents, family, and staff Be alert to adverse changes in patient and resident conditions that may be heat related Develop and implement a system to monitor hydration status and be prepared to take appropriate interventions Pay special attention to patients with medications that make the patient susceptible to high temperatures, e.g., [CONDITION(S)] medications While implementing these measures, healthcare providers and facilities should continue to follow the latest Coronavirus Disease 2019 (COVID-19) guidance from the Centers for Disease Control and Prevention (CDC) and CDPH AFLs. Facilities can follow current warnings and watches through the National Weather Service (NWS) CA Hazards Summary. Licensing regulations require facilities to report all emergency and/or disaster-related occurrences that threaten the welfare, safety, or health of patients to CDPH. If the extreme heat conditions affect your facility by compromising patient health and safety and/or require an evacuation, transfer, or discharge of patients, you must contact your CDPH district office. During a review of the facility document titled, Job Description: Maintenance Supervisor undated, indicated, .The purpose of your job position is to assist in supervising the day to day activities (installing, repairing and upkeep) of the facility in accordance with current applicable federal, state and local standard

Based on observation, interview and record review, the facility failed to provide care in accordance with professional standards of practice for four of four sampled residents (Residents 1, 6, 7, and 8) when: 1. Resident 1's burn wound to the left foot was infested with maggots and no documentation of wound appearance or wound size was completed by Licensed Vocational Nurse (LVN) 3 on 7/12/19, one day prior to the infestation of maggots. 2. Residents 6, 7, and 8 were not identified to be at high risk for possible infestation of maggots to their wounds. The facility was aware of an increased number of flies in the facility since (MONTH) 2019 and did not conduct an environmental risk assessment (a review of the facility's points of entrance for pests to enter the facility) for flies in order to implement interventions to prevent flies affecting wounds (cross reference F925). These failures resulted in Resident 1's burn wound to the left foot to be found infested with maggots on 7/13/19 with subsequent hospitalization to treat the maggot infestation and associated pain and suffering and the potential for Residents 6, 7, and 8's wounds to become infested with maggots. Because of the actual serious harm to Resident 1 and the potential serious harm to Residents 6, 7, and 8 from not having additional interventions in place to prevent maggot infestation to their wounds an Immediate Jeopardy Situation (IJ) was called on 7/19/19 at 2:15 p.m., with the facility Administrator (ADM) and Director of Nursing (DON). The facility submitted an acceptable IJ Removal Plan on 7/20/19, to conduct a skin assessment of residents with wounds for maggots or infections, conduct licensed nurses training and education on wound management including performing dressing changes, wound care documentation and monitoring, weekly communication to physicians regarding wound care, conduct an environmental assessment of the facility to ensure all screens to windows and doors were closed, recommendation for additional pest control measures to minimize the number of flies in the facility, implement training and education regarding fly prevention to reduce the flies in the facility, and address the potential risks flies can cause to a resident with wounds. The components of the IJ Removal Plan were validated as implemented and the IJ situation was removed on 7/21/19, at 10:45 a.m., with the ADM and DON. Findings: During a concurrent observation and interview with Resident 1, on 7/17/19, at 11:50 a.m., in Resident 1's hospital room, she was sitting up in bed with her legs extended on the bed. Resident 1 stated she had fallen at home on 6/12/19 and was on the patio cement for about two and one-half hours. Resident 1 stated she went to the hospital for care related to [MEDICAL CONDITION] suffered to both lower legs and breast. Resident 1 stated on 6/20/19 she was then transferred to the skilled nursing facility (SNF) for continued wound care of the burns. Resident 1 stated on the day she was again hospitalized (7/13/19) the nurses did her dressing changes to her legs and feet. Resident 1 stated she experienced burning pain to the left foot on 7/13/19. Resident 1 stated I hate flies. Flies were so bad (in her room at the SNF) that I would cover up my head so the flies wouldn't get on me. I have a fly swatter in my room (in the SNF) to kill them. During a review of the facility's clinical record for Resident 1, the facesheet (a document with personal identifiable information) indicated Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. During a concurrent observation and interview with Resident 9, on 7/17/19, at 1:36 p.m., in Resident 9's room, there was an orange fly swatter next to Resident 9's bed. Resident 9 stated he sometimes had flies in his room. Resident 9 stated the facility had a problem with flies for a long time and the facility had not done anything to decrease the amount of flies in the facility. Resident 9 stated the smoking patio door was constantly opened and closed and he could hear the patio door from his room. Resident 9 stated the door being opened caused flies to come into the facility and into his room. During an observation, on 7/17/19, between 1:41 p.m. and 2:20 p.m., there were flies observed on Station 2 nursing station, in the hallway next to room [ROOM NUMBER] and DON office. During an interview with Certified Nursing Assistant (CNA) 3, on 7/17/19, at 1:59 p.m., she stated she had taken care of Resident 1 when she was in the facility. CNA 3 stated Resident 1 was alert and able to understand simple commands from staff. CNA 3 stated Resident 1 required extensive assistance (resident involved with activity and staff provide weight bearing support) with bed mobility. CNA 3 stated on 7/13/19 before lunch time around 10 a.m., Registered Nurse (RN) 1 told her to get the charge nurse for Resident 1. CNA 3 stated she went to get Licensed Vocational Nurse (LVN) 4 and told her to go to Resident 1's room. CNA 3 stated she went into Resident 1's room after getting LVN 4 and stated she saw one leg that did not have a bandage on. CNA 3 stated she did not know which leg it was. CNA 3 stated she resumed working with other residents once the charge nurse came to the room. During an interview with CNA 3, on 7/17/19, at 2:10 p.m., she stated she was aware of the increase of flies in the facility. CNA 3 stated Resident 1 had cookies and snacks on her bedside table which would attract flies into the room. CNA 3 stated, The flies are just there in the room. Two to three flies. When you walk in the room you see them flying. That's why I take out my trash (trash from residents' rooms). The patio door is always being opened. CNA 3 stated since (MONTH) when it became warmer, the patio door fan was turned on because warmer temperatures attract more flies in the facility. During a concurrent interview with RN 1 and record review of Resident 1's progress notes and treatment orders, on 7/17/19, at 2:23 p.m., she stated on 7/13/19 around 10 a.m., she was at Nursing Station 1 when CNA 4 told her that Resident 1's right lower extremity dressing was loose. RN 1 stated she changed the dressing to the right leg and during the dressing change, Resident 1 complained of burning pain to the left foot. RN 1 stated when she took the dressing off the left foot, she observed the top of the left foot with so many maggots and more than what she documented in the progress note on 7/13/19. RN 1 stated, The maggots were covering the whole wound on the left foot. RN 1 stated the dressing to the left foot was not covering the toes. RN 1 stated she went to her treatment cart and obtained normal saline. RN 1 stated she then flushed the wound with normal saline and removed the maggots from the wound bed. RN 1 stated she pressed on the blackened part of the skin on the top of the left foot and three to four maggots came out of the wound bed. RN 1 stated she told CNA 3 to get LVN 4. RN 1 stated she called the DON and told her about what she observed on Resident 1's left foot wound. RN 1 stated she completed the treatment order for the left foot because she did not want the resident to be sent out to the hospital with no wound dressing on her left foot. RN 1 stated Resident 1 was transferred to the hospital per Resident 1's request. RN 1 reviewed the physician's treatment order dated 7/1/19 which indicated, .Burns to left foot, ankle, anterior (front) calf: Cleanse with normal saline, pat dry, apply xeroform (non-stick sterile wound gauze used to treat burns), cover with ABD (abdominal) pad (absorbent sterile dressing), and wrap with kerlix (woven gauze used to cover wounds) every day shift every other day for 14 days. RN 1 stated the last treatment to the left foot was on Resident 1's shower day, 7/12/19. RN 1 stated LVN 3 performed the dressing change on 7/12/19. RN 1 stated the charge nurses were responsible to complete the treatment orders for Resident 1'[MEDICAL CONDITION] her right and left lower extremities and right breast. RN 1 stated she was assigned as the facility treatment nurse for the past three to four months and completed the treatment orders for residents in the facility with pressure ulcers. During an interview with RN 1, on 7/17/19, at 2:50 p.m., she stated she had seen flies in Resident 1's room. RN 1 stated I try to put a fan in the room to push the flies away. She even had a fly swatter. During a review of the clinical record for Resident 1, the Nursing Home to Hospital Transfer Form dated 7/13/19 by LVN 4, indicated . Key Clinical Information Reason(s) for transfer Other-left foot wound noted with redness and maggots . Additional Relevant Information Tx (treatment) nurse went in to change bandages to wounds when resident stated they (dressing) are (loose) and I feel a burning sensation. Upon removing bandages wound noted with redness around area accompanied with maggots in wound . During a concurrent interview with RN 1 and record review of Resident 1's daily skilled documentation, on 7/17/19, at 3 p.m., RN 1 stated she only assessed the lower extremities and did not assess Resident 1's wound to the right breast for maggots before transferring to the hospital. RN 1 reviewed the clinical record for Resident 1's most recent wound measurements and stated there were no wound measurements documented for Resident 1's wounds to the right and left lower extremities and right breast. RN 1 reviewed the Daily Skilled Documentation dated 7/12/19 at 2:49 p.m. by LVN 3 which indicated, . Narrative nurses note . Resident (1) is on charting [MEDICAL CONDITION] bilateral (both) feet and right thigh and right breast did all treatments as ordered d/t (due to) resident having shower. Tolerated well. No redness or swelling. right foot has mass amount of eschar (black, dead tissue). resident is extensive ADLs (activities of daily living) . Resident tolerated Tx (treatment) well. Will cont (continue) to monitor . RN 1 stated the narrative note did not detail what the left foot wound bed appearance was nor the treatment done for the left foot. RN 1 stated LVN 3 should have documented the left foot treatment and assessment in the note, but did not. During a review of the clinical record for Resident 1, the care plan dated 6/22/19, indicated (Resident 1) has actual impairment for skin integrity [MEDICAL CONDITION] left foot, ankle and anterior thigh . Goal (Resident 1) will be free from complications [MEDICAL CONDITION] left foot, ankle and anterior thigh through next review date . Target Date: 10/7/19 .Interventions Any changes in color, size, or smell notify (doctor) immediately . During a concurrent interview with LVN 3 and record review of Resident 1's daily skilled documentation and progress notes, on 7/17/19, at 3:29 p.m., LVN 3 stated she did wound treatments for Resident 1. LVN 3 stated the charge nurse who did the wound treatment would complete a nursing note regarding the healing process of the wound treated. LVN 3 reviewed the clinical record for wound measurements for Resident 1'[MEDICAL CONDITION] stated there were no documented measurements. LVN 3 stated measurements were used to monitor if the wounds were healing. LVN 3 stated licensed nurses would not know if the wounds were getting better if there were no measurements. LVN 3 stated she treated Resident 1's wounds on 7/12/19 after her shower between 1:30 p.m. and 1:45 p.m. LVN 3 stated she did not notice any maggots on the left foot wound bed. LVN 3 stated she wrapped the left foot with kerlix and left the tips of the left toes open to air. LVN 3 reviewed the Daily Skilled Documentation dated 7/12/19 which indicated, Resident (1) got shower today and writer moved on to treatment for [REDACTED]. left leg eschar was moist, no s/sx (signs or symptoms) of infection no redness warmth or swelling noted around wound bed. Upper right thigh granulated (new connective tissue and microscopic blood vessels that form on the surfaces of a wound during the healing process) and [MEDICATION NAME] tissues (thin tissues that cover all the exposed surfaces of the body) noted in wound bed. Right side breast eschar moist noted, edges are granulating. Cleaned with NS (normal saline) and pat dry apply Xeroform and non adherent pad covered ABD pad and wrapped with kerlix. LVN 3 stated she did not include the left foot in the assessment note because it looked the same as the last time she had seen it. LVN 3 stated she should have documented what the wound bed appeared like on the day she treated her on 7/12/19. LVN 3 reviewed the progress note dated 7/12/19 and stated she did not include the left foot wound assessment in the progress note. LVN 3 stated there should have been documentation of what the wound to the left foot looked like during the dressing change. LVN 3 stated there were flies in the facility and in Resident 1's room. LVN 3 stated there were a lot of flies and would see more flies between 12 p.m. to 1 p.m. when it would get warmer outside the facility. LVN 3 stated residents complained about flies and did not know what the facility was doing to minimize the flies in the facility besides closing the doors or keeping the rooms clean. LVN 3 stated Resident 1 would have snacks in her room and that could have caused flies to go into her room. During an interview with Resident 2 in her room, on 7/18/19, at 11:59 a.m., she stated, There is a lot of flies in the room. It's been a couple of weeks. In the evening at 5:30 p.m., there's a lot of flies. I told my CNA about it. I don't remember her name. She works in the evening and morning (shift) . I was worried they were going to make me sick. I don't know where the flies come from . They (the facility) spray (chemicals) but (flies) still come in. During an interview with the Housekeeping Supervisor (HKS), on 7/18/19, at 12:05 p.m., she stated she had observed an increased amount of flies in the facility for the past weeks. HKS stated she informed the Maintenance Supervisor (MS) several times verbally. During an interview with CNA 1, on 7/18/19, at 12:08 p.m., she stated, I noticed a lot of flies in the past week. I don't know where they came from. CNA 1 pointed at the patio door near the kitchen and stated, Probably from the door (flies come inside the facility). Residents come in and out. Maybe that's how the flies came in. I told the Maintenance guy verbally. I don't know what he did but I told him verbally. During a concurrent interview with LVN 4 and record review of Resident 1's progress notes, on 7/18/19, at 12:10 p.m., she stated she was the charge nurse for Resident 1 on 7/13/19. LVN 4 reviewed the progress note dated 7/13/19 at 10:36 a.m. which indicated, . upon entering (Resident 1's room) wound noted to have been cleaned by tx (treatment) nurse but couple maggots were coming out of wound which were then cleansed again. Wound was also noted with slight redness . LVN 4 stated she had assessed the left foot, but did not assess the right leg nor right breast for maggots before Resident 1 transferred to the hospital. LVN 4 stated it only takes one fly to become infected with maggots or infections to the wound. LVN 4 stated We have flies everywhere. LVN 4 stated she thought that since the left foot was wrapped that a fly could not get inside. LVN 4 stated Resident 1 was at risk for infections from the maggots. LVN 4 stated she had noticed the flies in Resident 1's room and the flies coming in through the patio door. LVN 4 stated Resident 1's room was next to the kitchen and it was warm from the heat of the kitchen that can attract flies. LVN 4 stated the residents were always in and out of the patio door all day and employees during the night shift use the door. LVN 4 stated she would see between two to three flies in Resident 1's room and sometimes in the bathroom flying around. LVN 4 stated residents complained about the flies and she would try to get rid of them by using a newspaper. LVN 4 stated there was a fan above the patio door that turns on when opened to prevent flies from getting inside. LVN 4 stated she would verbally notify the MS about the flies in the facility and did not know what was done to decrease the flies in the facility. During a concurrent observation and interview with Restorative Nursing Assistant (RNA), on 7/18/19, at 12:12 p.m. in the facility's hallway, a fly was observed entering the patio door near the kitchen. RNA stated, There's a fly just right now . I noticed a lot of flies during the summer here . I did not tell the charge nurse because everybody (facility staff) knows there are flies here. RNA stated he had not informed the MS he had observed several flies in the facility. During an interview with Resident 3, on 7/18/19, at 12:28 p.m., she stated, There's a lot of flies in the morning and every night. The nurses know. I feel upset about the flies. They (the facility) are not doing anything about it. During an interview with Resident 4, on 7/18/19, at 12:30 p.m., she stated, Flies, they are everywhere here. It's terrible. It doesn't matter, day, evening, night, there's a lot of flies in the facility. They go inside my room. They are everywhere. It's just terrible. Sometimes it goes to my food and I just don't eat it. I don't know where the flies came from or what disease they would bring. All the nurses and staff knew about it. I don't have to be telling them about flies. They should do something about it. It makes me so upset seeing a lot of flies. Please do something about it. During an interview with Resident 5, on 7/18/19, at 12:35 p.m., she stated, There's a lot of flies in the building. It's terrible because they go inside my room. They come in to my food. They get in the food before (residents) do. It's so hard to get things done in this place. The staff knows about how the flies get bad here and they don't do anything. It makes me so upset seeing flies in the room. During an interview with CNA 2, on 7/18/19, at 1 p.m., she stated, I have been here for [AGE] years as a CNA. I noticed a lot of flies here and there. It's in the dining room, hallways and sometimes in the residents' rooms. I know (Resident 1). I took care of her but I called in (sick) that day they found the maggots (in Resident 1's wound bed). It's terrible and (maggots) grow big. I saw some flies in (Resident 1's) room. That's why she has the fly swatter. (Resident 1's) son brought her the fly swatter. With the flies, (staff) never told the Maintenance (Supervisor) because he knows about the flies. There is a fan blower for the flies on top of the (patio) door but it has been here for a long time. I didn't see anything new that the Maintenance did with the flies. It's still the same . Everybody knows about the flies . During an interview with LVN 4, on 7/18/19, at 1:05 p.m., she stated on 7/13/19 around 9:40 a.m., CNA 3 asked her to go to Resident 1's room. LVN 4 stated when she entered Resident 1's room, RN 1 was on the phone and pointed to Resident 1's left foot. LVN 4 stated she saw two maggots between the left toes and next to the top of the wound bed. LVN 4 stated she contacted the physician by fax and notified him the resident requested to go to the hospital. LVN 4 stated RN 1 cleansed the wound and wrapped the foot before the resident went to the hospital. LVN 4 stated she did not see how many maggots were in the dressing. LVN 4 stated there was a bedside trash can used to put the dressings and maggots inside. LVN 4 stated CNA 4 threw the bag of dressings and maggots away, and could not estimate how many maggots there were. During an interview with Housekeeping Aide (HKA) 1, on 7/18/19, at 1:21 p.m., HKA 1 stated she had been working in the facility for a month and she had noticed a lot of flies in the facility especially when the weather became hot and humid. HKA 1 stated she had not notified the MS she observed flies in the facility. HKA 1 stated, Everybody knows about the flies. During an interview with CNA 4, on 7/18/19, at 1:35 p.m., she stated Resident 1 complained about the flies in her room located near the patio door. CNA 4 stated Resident 1 had snacks in her room on the bedside table that would attract flies. CNA 4 stated Resident 1's family member brought Resident 1 a fly swatter for her to use in the facility. CNA 4 stated flies were everywhere in the facility. CNA 4 stated the patio door was opened and closed all the time during the day by residents. CNA 4 stated she would see one or two flies in Resident 1's room. CNA 4 stated on 7/13/19 she had seen a fly on Resident 1's pillow and on the curtain. CNA 4 stated Resident 1 had a fly swatter on the floor next to her bed to kill the flies. CNA 4 stated she would try to kill the flies in the room and clean the resident's area such as removing food that did not have a cover. CNA 4 stated flies would increase during the latter part of the day. CNA 4 stated management knew about the increase in flies because everyone in the facility talked about it. CNA 4 stated sometimes it is impossible to keep the flies out of the facility because it takes some residents extra time to propel in or out the patio door. CNA 4 stated the patio door will stay open for a good five minutes before it closed. CNA 4 stated she had not communicated to anyone specifically in the facility about the increase in flies. CNA 4 stated in the past three months, rooms 1 through 7 had more flies than in the back rooms in the facility. CNA 4 stated during the day when it became hot or humid, the flies would increase and residents would complain about the flies. CNA 4 stated she was not aware of any interventions the facility was implementing to minimize the flies in the facility. During an interview with CNA 4, on 7/18/19, at 1:45 p.m., she stated on 7/13/19, around 9 a.m., she performed care for Resident 1. CNA 4 stated the left foot dressing had an open area through the gauze to her toes. CNA 4 stated Resident 1 had told her that her foot was burning and noticed the dressings were loose to the right leg. CNA 4 told RN 1 about the loose dressing and then told LVN 4. CNA 4 stated about an hour later RN 1 treated Resident 1's wounds. CNA 4 stated when she came back from lunch around 10:30 a.m., Resident 1 was being taken out of the facility by EMS. CNA 4 stated she went to Resident 1's room and stripped the room by removing the linens. CNA 4 stated she saw a small maggot at the foot board of the bed when removing the linens. CNA 4 stated the trash bag that had the gauze and maggots in it was tied in a knot. CNA 4 stated she threw away three bags from Resident 1's room into the main trash can outside the facility. During an interview with CNA 5, on 7/18/19, at 1:50 p.m., she stated she gave Resident 1 a shower on 7/12/19. CNA 5 stated Resident 1 had dressings to both legs and would put a plastic bag around the dressings. CNA 5 stated she noticed the flies in the facility and increase in flies in the facility in the last couple of months. CNA 5 stated last year and this year has been worse with the number of flies and the flies increase with the warmer weather. CNA 5 stated the smoking patio area was where residents came in and out of the facility. CNA 5 stated MS in-serviced staff to keep the doors closed. During an interview with the Activities Director (AD), on 7/18/19, at 2:30 p.m., he stated the flies in the facility have been bad in the last month. The AD stated there should not be flies in the facility. The AD stated he told dietary and nursing about the increase of flies he had seen. The AD stated the front door did not close all the way which could cause flies to come into the facility. The AD stated he would see one to two flies in the residents' rooms. The AD stated Resident 1 should not have maggots in her wound bed and the incident could have been prevented if the facility was proactive and installed an additional air curtain (a fan installed above a door frame used to decrease flying insects from entering an opened door) on top of the main door entrance. The AD stated the main front door should have been fixed so it would close automatically and prevent more flies from coming inside the facility and the residents' rooms. During a telephone interview with LVN 2, on 7/18/19, at 2:49 p.m., she stated three weeks ago when she worked during the evening shift, she noticed an increase number of the flies in the facility. LVN 2 stated she has seen two or more flies in resident rooms and at the nursing stations. LVN 2 stated Resident 1's room was warmer and would attract flies. LVN 2 stated on 7/13/19, she went to Resident 1 to give her pain medication because she had complained of burning to the left leg. LVN 2 stated she administered pain medication to Resident 1 at 3 a.m. LVN 2 stated Resident 1's dressing to the left foot had her toes visible. LVN 2 stated staff knew about the flies and she did not tell management about the increase number of flies in the facility. LVN 2 stated the facility did not do enough for the resident to have kept the flies away from Resident 1's wounds. LVN 2 stated the infestation of the maggots could have been avoided and Resident 1 could be harmed emotionally from seeing the maggots in her wound. During an interview with MS, on 7/18/19, at 3:13 p.m., he stated he noticed an increase in flies in the facility when the weather became warmer. The MS stated staff communicated verbally to him about pest issues and he had a log for the staff to notify him. The MS stated the facility had air curtains to reduce the risk of the flies from coming into the facility. The MS stated the residents come in and out of the patio door and flies came inside the facility. The MS stated the front door did not have an air curtain because he would have to remodel the top of the door frame for the air curtain to fit. The MS stated there was an emergency door used by staff to take out the trash and to get oxygen tanks. The MS stated the trash can outside the facility was picked up daily from the city. The MS stated the flies were coming from outside, but did not know from where. The MS stated residents eat outside and that will attract flies. The MS stated the back patio was attracting a lot of flies and the back patio door was opened and closed all the time causing flies to come inside. The MS stated he visually checked the screens to the windows and patio doors, but did not document his environmental checks. The MS stated the screen door was not going to prevent flies from coming into the facility unless the glass door was closed. The MS stated the pest control vendor last visited the facility on 7/16/19. The MS showed the receipt from the pest control service vendor which indicated the fly glue pads were 25% full. The MS stated two months ago, the staff turned off the air curtain by the patio door. The MS stated he educated staff not to turn off the air curtain and that the air curtain should be on nonstop. The MS stated he disabled the off-switch on the air curtain so no one could turn it off. The MS stated there were flies at night and if the air curtain was off, the flies would come into the facility. The MS stated he did not have any other ideas to minimize the increased flies in the facility. The MS stated he had seen residents with fly swatters. The MS stated the facility did not allow the residents to have fly swatters because it was an infection control issue if they kill the fly and not clean up afterwards. The MS stated he did not know about the maggots until today (7/18/19) and he should have been told about the maggots since he was responsible for pest control in the facility. During a facility tour with the MS, on 7/18/19, at 3:44 p.m., the front door to the facility was observed to have a gap between the door frame and the door. The MS stated the front door was loose and needed to be adjusted. There were two visitors who exited the front door and the front door did not fully close. The MS measured the gap and stated the gap was 42 long from the top of the door frame by 3/8 of an inch-wide gap. The MS identified an Ultraviolet (UV) light next to the front door and opened the UV light hood. The MS took out two glue pads used in the UV light. There were approximately 16 large flies on one glue pad and approximately three large flies on one glue pad. The MS observed the UV light next to shower room F and opened the UV light hood. There were approximately eight large flies on one glue pad. The MS observed the UV light next to room [ROOM NUMBER] and opened the UV light hood. There were approximately 25 large flies on one glue pad and approximately eight large flies on one glue pad. The MS observed the UV light next to the emergency door and opened the UV light hood. There were approximately 12 large flies and multiple smaller gnats on one glue pad. The MS stated the outside area in the back of the facility could be the source where flies were coming into the facility. During a concurrent interview and facility tour with the MS, on 7/18/19, at 4 p.m., there was an opened sliding glass door observed in the therapy room. There was no screen door on the door track. There was a screen door observed placed on the right side of the sliding glass door propped against the wall. The MS stated the screen door should be on the track and therapy should not have the sliding glass door open without the screen. During a concurrent interview and facility tour with the MS, on 7/18/19, at 4:06 p.m., room [ROOM NUMBER]'s screen door did not fit on the track and did not close fully. The MS stated the screen door needed to be adjusted. During a concurrent interview and facility tour with the MS, on 7/18/19, at 4:09 p.m., room [ROOM NUMBER]'s screen door did not fit on the track and did not close fully. The MS stated the screen door needed to be adjusted. During a facility tour with the MS, on 7/18/19, at 4:15 p.m., the MS observed the UV light next to the kitchen and opened the UV light hood. There were approximately 74 large flies on one glue pad. There were two flies observed coming in from the opened patio door. During an interview with the ADM, on 7/18/19, at 4:28 p.m., he stated he was made aware of the maggots in Resident 1's wound on Monday, 7/15/19. The ADM stated flies have been an issue in the facility off and on. The ADM stated the area surrounding the facility had more flies when it heats up outside. The ADM stated the environmental interventions the facility had for pest control were air curtains on the patio door and kitchen exit door, pest control services, and the UV lights with the glue pads. The ADM stated the Interdisciplinary Team (a group of individuals including, but not limited to the DON, Social services, and MD to discuss a resident's plan of care) met on Monday, 7/15/19, regarding the incident on 7/13/19 and stated MS was not involved in the meeting. The ADM stated the maggots in the wound was a nursing issue and not an environmental issue. The ADM did not think about reporting the unusual occurrence to the California Department of Public Health (CDPH) because the resident was already out to the hospital. The ADM stated he should have reported this incident to CDPH. The ADM stated the staff were educated on keeping the screen doors closed to minimize the flies. During an interview with the DON, on 7/18/19, at 4:41 p.m., stated on 7/13/19, RN 1 called her and told her Resident 1 did not look good. The DON stated she called the facility back about 30 minutes later to get more details from RN 1. The DON stated RN 1 told her the wound was hot to touch. The DON stated she became aware the wound had maggots on 7/15/19 when she reviewed nursing documentation. The DON stated in the IDT meeting, the staff present were the ADM, Minimum Data Set Coordinator (MDSC), and herself. The DON stated IDT did not identify the wound being infested with maggots as an environmental issue. The DON stated MS did not know about the maggots in the resident's wound until today, 7/18/19. The DON stated a fly should not have been able to lay an egg on the wound bed if the

Based on observation, interview, and facility document review, the facility failed to maintain an effective pest control program when there were increased number of flies in the facility (cross reference F684). This failure resulted in Resident 1's burn wound to the left foot to be found infested with maggots on 7/13/19 with subsequent hospitalization to treat the maggot infestation and associated pain and suffering. Findings: During a concurrent observation and interview with Resident 1, on 7/17/19, at 11:50 a.m., in Resident 1's hospital room, she was sitting up in bed with her legs extended on the bed. Resident 1 stated she had fallen at home on 6/12/19 and was on the patio cement for about two and one-half hours. Resident 1 stated she went to the hospital for care related to [MEDICAL CONDITION] suffered to both lower legs and breast. Resident 1 stated on 6/20/19 she was then transferred to the skilled nursing facility (SNF) for continued wound care of the burns. Resident 1 stated on the day she was again hospitalized (7/13/19) the nurses did her dressing changes to her legs and feet. Resident 1 stated she experienced burning pain to the left foot on 7/13/19. Resident 1 stated I hate flies. Flies were so bad (in her room at the SNF) that I would cover up my head so the flies wouldn't get on me. I have a fly swatter in my room (in the SNF) to kill them. During a review of the facility's clinical record for Resident 1, the facesheet (a document with personal identifiable information) indicated Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. During a concurrent observation and interview with Resident 9, on 7/17/19, at 1:36 p.m., in Resident 9's room, there was an orange fly swatter next to Resident 9's bed. Resident 9 stated he sometimes had flies in his room. Resident 9 stated had a problem with flies for a long time and the facility had not done anything to decrease the amount of flies in the facility. Resident 9 stated the smoking patio door was constantly opened and closed and he could hear the patio door from his room. Resident 9 stated the door being opened caused flies to come into the facility and into his room. During an observation, on 7/17/19, between 1:41 p.m. and 2:20 p.m., there were flies observed on Station 2 nursing station, in the hallway next to room [ROOM NUMBER] and DON office. During an interview with Certified Nursing Assistant (CNA) 3, on 7/17/19, at 2:10 p.m., she stated she was aware of the increase of flies in the facility. CNA 3 stated Resident 1 had cookies and snacks on her bedside table which would attract flies into the room. CNA 3 stated, The flies are just there in the room. Two to three flies. When you walk in the room you see them flying. That's why I take out my trash (trash from residents' rooms). The patio door is always being opened. CNA 3 stated since (MONTH) when it became warmer, the patio door fan was turned on because warmer temperatures attract more flies in the facility. During a concurrent interview with Registered Nurse (RN) 1 and record review of Resident 1's progress notes, on 7/17/19, at 2:23 p.m., she stated on 7/13/19 around 10 a.m., she was at Nursing Station 1 when CNA 4 told her that Resident 1's right lower extremity dressing was loose. RN 1 stated she changed the dressing to the right leg and during the dressing change, Resident 1 complained of burning pain to the left foot. RN 1 stated when she took the dressing off the left foot, she observed the top of the left foot with so many maggots and more than what she documented in the progress note on 7/13/19. RN 1 stated, The maggots were covering the whole wound on the left foot. RN 1 stated the dressing to the left foot was not covering the toes. RN 1 stated she went to her treatment cart and obtained normal saline. RN 1 stated she then flushed the wound with normal saline and removed the maggots from the wound bed. RN 1 stated she pressed on the blackened part of the skin on the top of the left foot and three to four maggots came out of the wound bed. During an interview with RN 1, on 7/17/19, at 2:50 p.m., she stated she had seen flies in Resident 1's room. RN 1 stated I try to put a fan in the room to push the flies away. She even had a fly swatter. During an interview with Licensed Vocational Nurse (LVN) 3, on 7/17/19, at 3:29 p.m., LVN 3 stated there were flies in the facility and in Resident 1's room. LVN 3 stated there were a lot of flies and would see more flies between 12 p.m. to 1 p.m. when it would get warmer outside the facility. LVN 3 stated residents complained about flies and did not know what the facility was doing to minimize the flies in the facility besides closing the doors or keeping the rooms clean. LVN 3 stated Resident 1 would have snacks in her room and that could have caused flies to go into her room. During an interview with Resident 2 in her room, on 7/18/19, at 11:59 a.m., she stated, There is a lot of flies in the room. It's been a couple of weeks. In the evening at 5:30 p.m., there's a lot of flies. I told my CNA about it. I don't remember her name. She works in the evening and morning (shift) . I was worried they were going to make me sick. I don't know where the flies come from . They (the facility) spray (chemicals) but (flies) still come in. During an interview with the Housekeeping Supervisor (HKS), on 7/18/19, at 12:05 p.m., she stated she had observed an increased amount of flies in the facility for the past weeks. HKS stated she informed the Maintenance Supervisor (MS) several times verbally. During an interview with CNA 1, on 7/18/19, at 12:08 p.m., she stated, I noticed a lot of flies in the past week. I don't know where they came from. CNA 1 pointed at the patio door near the kitchen and stated, Probably from the door (flies come inside the facility). Residents come in and out. Maybe that's how the flies came in. I told the Maintenance guy verbally. I don't know what he did but I told him verbally. During an interview with LVN 4, on 7/18/19, at 12:10 p.m., LVN 4 stated We have flies everywhere. LVN 4 stated she did not think the licensed nurses could have done anything else for Resident 1 to prevent flies from infesting the wound with maggots. LVN 4 stated she thought that since the left foot was wrapped that a fly could not get inside. LVN 4 stated Resident 1 was at risk for infections from the maggots. LVN 4 stated she had noticed the flies in Resident 1's room and the flies coming in through the patio door. LVN 4 stated Resident 1's room was next to the kitchen and it was warm from the heat of the kitchen that can attract flies. LVN 4 stated the residents were always in and out of the patio door all day and employees during the night shift use the door. LVN 4 stated she would see between two to three flies in Resident 1's room and sometimes in the bathroom flying around. LVN 4 stated residents complained about the flies and she would try to get rid of them by using a newspaper. LVN 4 stated there was a fan above the patio door that turns on when opened to prevent flies from getting inside. LVN 4 stated she would verbally notify the MS about the flies in the facility and did not know what was done to decrease the flies in the facility. During a concurrent observation and interview with Restorative Nursing Assistant (RNA), on 7/18/19, at 12:12 p.m. in the facility's hallway, a fly was observed entering the patio door near the kitchen. RNA stated, There's a fly just right now . I noticed a lot of flies during the summer here . I did not tell the charge nurse because everybody (facility staff) knows there are flies here. RNA stated he had not informed the MS he had observed several flies in the facility. During an interview with Resident 3, on 7/18/19, at 12:28 p.m., she stated, There's a lot of flies in the morning and every night. The nurses know. I feel upset about the flies. They (the facility) are not doing anything about it. During an interview with Resident 4, on 7/18/19, at 12:30 p.m., she stated, Flies, they are everywhere here. It's terrible. It doesn't matter, day, evening, night, there's a lot of flies in the facility. They go inside my room. They are everywhere. It's just terrible. Sometimes it goes to my food and I just don't eat it. I don't know where the flies came from or what disease they would bring. All the nurses and staff knew about it. I don't have to be telling them about flies. They should do something about it. It makes me so upset seeing a lot of flies. Please do something about it. During an interview with Resident 5, on 7/18/19, at 12:35 p.m., she stated, There's a lot of flies in the building. It's terrible because they go inside my room. They come in to my food. They get in the food before (residents) do. It's so hard to get things done in this place. The staff knows about how the flies get bad here and they don't do anything. It makes me so upset seeing flies in the room. During an interview with CNA 2, on 7/18/19, at 1 p.m., she stated, I have been here for [AGE] years as a CNA. I noticed a lot of flies here and there. It's in the dining room, hallways and sometimes in the residents' rooms. I know (Resident 1). I took care of her but I called in (sick) that day they found the maggots (in Resident 1's wound bed). It's terrible and (maggots) grow big. I saw some flies in (Resident 1's) room. That's why she has the fly swatter. (Resident 1's) son brought her the fly swatter. With the flies, (staff) never told the Maintenance (Supervisor) because he knows about the flies. There is a fan blower for the flies on top of the (patio) door but it has been here for a long time. I didn't see anything new that the Maintenance did with the flies. It's still the same . Everybody knows about the flies . During an interview with Housekeeping Aide (HKA) 1, on 7/18/19, at 1:21 p.m., HKA 1 stated she had been working in the facility for a month and she had noticed a lot of flies in the facility especially when the weather became hot and humid. HKA 1 stated she had not notified the MS she observed flies in the facility. HKA 1 stated, Everybody knows about the flies. During an interview with CNA 4, on 7/18/19, at 1:35 p.m., she stated Resident 1 complained about the flies in her room located near the patio door. CNA 4 stated Resident 1 had snacks in her room on the bedside table that would attract flies. CNA 4 stated Resident 1's family member brought Resident 1 a fly swatter for her to use in the facility. CNA 4 stated flies were everywhere in the facility. CNA 4 stated the patio door was opened and closed all the time during the day by residents. CNA 4 stated she would see one or two flies in Resident 1's room. CNA 4 stated on 7/13/19 she had seen a fly on Resident 1's pillow and on the curtain. CNA 4 stated Resident 1 had a fly swatter on the floor next to her bed to kill the flies. CNA 4 stated she would try to kill the flies in the room and clean the resident's area such as removing food that did not have a cover. CNA 4 stated flies would increase during the latter part of the day. CNA 4 stated management knew about the increase in flies because everyone in the facility talked about it. CNA 4 stated sometimes it is impossible to keep the flies out of the facility because it takes some residents extra time to propel in or out the patio door. CNA 4 stated the patio door will stay open for a good five minutes before it closed. CNA 4 stated she had not communicated to anyone specifically in the facility about the increase in flies. CNA 4 stated in the past three months, rooms 1 through 7 had more flies than in the back rooms in the facility. CNA 4 stated during the day when it became hot or humid, the flies would increase and residents would complain about the flies. CNA 4 stated she was not aware of any interventions the facility was implementing to minimize the flies in the facility. During an interview with CNA 5, on 7/18/19, at 1:50 p.m., CNA 5 stated she noticed the flies in the facility and increase in flies in the facility in the last couple of months. CNA 5 stated last year and this year has been worse with the number of flies and the flies increase with the warmer weather. CNA 5 stated the smoking patio area was where residents came in and out of the facility. CNA 5 stated MS in-serviced staff to keep the doors closed. During an interview with the Activities Director (AD), on 7/18/19, at 2:30 p.m., he stated the flies in the facility have been bad in the last month. The AD stated there should not be flies in the facility. The AD stated he told dietary and nursing about the increase of flies he had seen. The AD stated the front door did not close all the way which could cause flies to come into the facility. The AD stated he would see one to two flies in the residents' rooms. The AD stated Resident 1 should not have maggots in her wound bed and the incident could have been prevented if the facility was proactive and installed an additional air curtain (a fan installed above a door frame used to decrease flying insects from entering an opened door) on top of the main door entrance. The AD stated the main front door should have been fixed so it would close automatically and prevent more flies from coming inside the facility and the residents' rooms. During a telephone interview with LVN 2, on 7/18/19, at 2:49 p.m., she stated three weeks ago when she worked during the evening shift, she noticed an increase number of the flies in the facility. LVN 2 stated she has seen two or more flies in resident rooms and at the nursing stations. LVN 2 stated Resident 1's room was warmer and would attract flies. LVN 2 stated staff knew about the flies and she did not tell management about the increase number of flies in the facility. LVN 2 stated the facility did not do enough for the resident to have kept the flies away from Resident 1's wounds. LVN 2 stated the infestation of the maggots could have been avoided and Resident 1 could be harmed emotionally from seeing the maggots in her wound. During an interview with MS, on 7/18/19, at 3:13 p.m., he stated he noticed an increase in flies in the facility when the weather became warmer. The MS stated staff communicated verbally to him about pest issues and he had a log for the staff to notify him. The MS stated the facility had air curtains to reduce the risk of the flies from coming into the facility. The MS stated the residents come in and out of the patio door and flies came inside the facility. The MS stated the front door did not have an air curtain because he would have to remodel the top of the door frame for the air curtain to fit. The MS stated there was an emergency door used by staff to take out the trash and to get oxygen tanks. The MS stated the trash can outside the facility was picked up daily from the city. The MS stated the flies were coming from outside, but did not know from where. The MS stated residents eat outside and that will attract flies. The MS stated the back patio was attracting a lot of flies and the back patio door was opened and closed all the time causing flies to come inside. The MS stated he visually checked the screens to the windows and patio doors, but did not document his environmental checks. The MS stated the screen door was not going to prevent flies from coming into the facility unless the glass door was closed. The MS stated the pest control vendor last visited the facility on 7/16/19. The MS showed the receipt from the pest control service vendor which indicated the fly glue pads were 25% full. The MS stated two months ago, the staff turned off the air curtain by the patio door. The MS stated he educated staff not to turn off the air curtain and that the air curtain should be on nonstop. The MS stated he disabled the off-switch on the air curtain so no one could turn it off. The MS stated there were flies at night and if the air curtain was off, the flies would come into the facility. The MS stated he did not have any other ideas to minimize the increased flies in the facility. The MS stated he had seen residents with fly swatters. The MS stated the facility did not allow the residents to have fly swatters because it was an infection control issue if they kill the fly and not clean up afterwards. The MS stated he did not know about the maggots until today (7/18/19) and he should have been told about the maggots since he was responsible for pest control in the facility. During a concurrent interview and facility tour with the MS, on 7/18/19, at 3:44 p.m., the front door to the facility was observed to have a gap between the door frame and the door. The MS stated the front door was loose and needed to be adjusted. There were two visitors who exited the front door and the front door did not fully close. The MS measured the gap and stated the gap was 42 long from the top of the door frame by 3/8 of an inch-wide gap. The MS identified an Ultraviolet (UV) light next to the front door and opened the UV light hood. The MS took out two glue pads used in the UV light. There were approximately 16 large flies on one glue pad and approximately three large flies on one glue pad. The MS observed the UV light next to shower room F and opened the UV light hood. There were approximately eight large flies on one glue pad. The MS observed the UV light next to room [ROOM NUMBER] and opened the UV light hood. There were approximately 25 large flies on one glue pad and approximately eight large flies on one glue pad. The MS observed the UV light next to the emergency door and opened the UV light hood. There were approximately 12 large flies and multiple smaller gnats on one glue pad. The MS stated the outside area in the back of the facility could be the source where flies were coming into the facility. During a concurrent interview and facility tour with the MS, on 7/18/19, at 4 p.m., there was an opened sliding glass door observed in the therapy room. There was no screen door on the door track. There was a screen door observed placed on the right side of the sliding glass door propped against the wall. The MS stated the screen door should be on the track and therapy should not have the sliding glass door open without the screen. During a concurrent interview and facility tour with the MS, on 7/18/19, at 4:06 p.m., room [ROOM NUMBER]'s screen door did not fit on the track and did not close fully. The MS stated the screen door needed to be adjusted. During a concurrent interview and facility tour with the MS, on 7/18/19, at 4:09 p.m., room [ROOM NUMBER]'s screen door did not fit on the track and did not close fully. The MS stated the screen door needed to be adjusted. During a facility tour with the MS, on 7/18/19, at 4:15 p.m., the MS observed the UV light next to the kitchen and opened the UV light hood. There were approximately 74 large flies on one glue pad. There were two flies observed coming in from the opened patio door. During an interview with the ADM, on 7/18/19, at 4:28 p.m., he stated he was made aware of the maggots in Resident 1's wound on Monday, 7/15/19. The ADM stated flies have been an issue in the facility off and on. The ADM stated the area surrounding the facility had more flies when it heats up outside. The ADM stated the environmental interventions the facility had for pest control were air curtains on the patio door and kitchen exit door, pest control services, and the UV lights with the glue pads. The ADM stated the Interdisciplinary Team (a group of individuals including, but not limited to the DON, Social services, and MD to discuss a resident's plan of care) met on Monday, 7/15/19, regarding the incident on 7/13/19 and stated MS was not involved in the meeting. The ADM stated the maggots in the wound was a nursing issue and not an environmental issue. The ADM did not think about reporting the unusual occurrence to the California Department of Public Health (CDPH) because the resident was already out to the hospital. The ADM stated he should have reported this incident to CDPH. The ADM stated the staff were educated on keeping the screen doors closed to minimize the flies. During an interview with the DON, on 7/18/19, at 4:41 p.m., DON stated she became aware Resident 1's wound had maggots on 7/15/19 when she reviewed nursing documentation. The DON stated in the IDT meeting, the staff present were the ADM, Minimum Data Set Coordinator (MDSC), and herself. The DON stated IDT did not identify the wound being infested with maggots as an environmental issue. The DON stated MS did not know about the maggots in the resident's wound until today, 7/18/19. The DON stated a fly should not have been able to lay an egg on the wound bed if the dressing was wrapped properly. The DON stated this incident should have been reported to CDPH, but was not. The DON stated the ADM was guiding her on what to report to CDPH. The DON stated the treatment nurse was responsible for pressure ulcers in the facility, but should be involved with all wounds. The DON stated the licensed nurses should be assessing and documenting wounds after treatment was completed including measurements of the wound. The DON stated a couple of weeks ago the flies became an issue. The nurses at night were keeping the emergency door open and staff were in-serviced to keep the door closed. During an observation, on 7/19/19, at 7:30 a.m., the front door was not fully closed and had a gap opening in the closed position. During an interview with DSD 1 and MDSC, on 7/19/19, at 8:10 a.m., DSD 1 stated she noticed flies in the facility. The MDSC stated she in-serviced staff on keeping the doors and windows closed. DSD 1 stated the fly problem was not a consistent issue in the facility. The MDSC stated management did not think the flies in the facility was a problem. DSD 1 stated the facility did not see the flies in the facility as a major issue. The MDSC stated management should have been aware of the risks of infection from flies for residents being treated for [REDACTED]. During a telephone interview with pest control technician (PCT) 1 on 7/19/19, at 8:18 a.m., he stated he was not aware the facility had increased number of flies during the past weeks. PCT 1 stated, Prior to yesterday, I was not aware of the flies. We installed UV lights about a year ago but after that, I haven't heard of anything about the flies. (The facility) could have done more to prevent flies like making sure staff should close the door at night. There should be more air curtains in the kitchen and main front door especially (since) it's the front door and people are going inside and out all the time. During an interview with Resident 8, on 7/19/19, at 8:23 a.m., Resident 8 stated there were flies sometimes in his room when he had meals. Resident 8 stated flies would land on his shirt or pant leg sometimes. Resident 8 stated everyone in the facility knew about the flies and nothing was done about it. During an interview with MS, on 7/19/19, at 8:36 a.m., he stated he did not check the UV light glue pads. The MS stated that was the responsibility of the pest control vendor. The MS stated he could check the glue pads more often and make a log to document the increase need to change the glue pads. The MS stated he did not keep inspection logs for the glue pads located inside the UV lights. During an interview with the ADM and the DON, on 7/19/19, at 8:45 a.m., the DON stated the management team did not conduct an environmental inspection of the facility after the maggots were identified on 7/13/19 to identify where the flies were coming from. The DON stated she considered the maggots in the wound as a nursing issue due to improper dressing application. The DON stated the flies were not an issue. The DON stated when selecting rooms for new admission to the facility, she did not consider the environment as a risk for residents with wounds. The DON stated she did not consider the risk of increase number of flies can impose on residents with wounds. The DON stated the facility should have moved residents who had wounds or dependent residents away from areas with increased flies. The ADM stated he told MS to look into the increased flies in the rooms on 7/17/19. The ADM stated MS should be changing the glue pads at least once a week, but was not. The ADM stated he never considered putting the risk flies impose on residents with wounds or dependent residents on the facility assessment. During a concurrent interview with the ADM and facility document review, on 7/19/19, at 9:18 a.m., he provided a copy of the facility assessment. The ADM stated there was no pest control assessment completed during the facility assessment revision on 3/11/19. The ADM stated the facility did not have pest control as an identified concern during Quality Assurance and Performance Improvement (QAPI) meetings. The ADM stated the facility assessment can be updated as needed and pest control was not considered an issue. During a concurrent interview and facility document review with DSD 1, on 7/19/19, at 9:38 a.m., she reviewed the facility assessment with the revision date of 3/11/19 and stated she was involved with the revision of the facility assessment. DSD 1 stated she did not bring to attention the flies during the revision of the facility assessment. DSD 1 stated she should have included the pest control issue regarding the increase flies in the facility during the revision of the facility assessment and will moving forward. During a review of the hospital record for Resident 1, the ED (Emergency Department) Physician Notes Final Report dated 7/13/19, indicated .Chief Complaint ED: Wound .PT (patient) brought in by EMS (emergency medical service) from (SNF). Pt is receiving wound care there [MEDICAL CONDITION] happened one month ago. Per EMS the wound nurse noted maggots to the wound on the LLE (left lower extremity) .History of Present Illness . Symptoms since visit: pain, redness, severe maggots . presents to the ED via EMS with complaint of maggots in wound onset of 1 day. Pt was seen here (MONTH) 12th for 2nd [MEDICAL CONDITION] blisters after falling into a kiddy pool on a hot day. Pt has no other sx (symptoms). Pt notes wound nurse changed her dressing today and found maggots, nurse attempted to remove most of them before calling EMS . Review of Systems . Skin symptoms: Burns, maggots in wound . Physical Examination . Skin . multiple (maggots) . Review of the job description titled Maintenance Supervisor undated, indicated . Duties and Responsibilities . Assist the Director in setting maintenance standards. Assist in developing procedures for performing daily maintenance tasks . Perform administrative requirements (i.e. (in other words), completing necessary forms, reports, etc. (so forth)) and submit to the Director as necessary . Implement recommendations from the Infection Control, Safety, and QA (Quality Assurance) Committees, etc., as directed/necessary . Recommend equipment and supply needs to the Director . Review of the the facility policy and procedure titled Pest Control dated 5/08, indicated, .Our facility shall maintain an effective pest control program . 1. This facility maintains an on-going pest control program to ensure that the building is kept free of insects . 6. Maintenance service assist, when appropriate and necessary, in providing pest control services .