Every finding on record at Linwood Meadows Care Center

Based on interview and record review, the facility failed to ensure the physician was notified when one of three sampled residents (Resident 1) medication was not administered per physician's orders. This failure resulted in Resident 1 not receiving enoxaparin sodium (medication used to prevent blood clots) and had the potential for Resident 1 to experience health complications.Findings:During a review of Resident 1's Order Summary Report (OSR) dated 7/10/25, the OSR indicated, enoxaparin sodium solution 30 mg (milligrams)/0.3 ml (milliliters) inject 30 mg subcutaneously one time a day for prevent blood clotting for 10 days.start date 7/10/25.end date 7/21/25.During a review of Resident 1's Medication Administration Record (MAR) dated 7/25, the MAR indicated, 7/17/25.9 (other/see nurses note).During a review of Resident 1's Progress Notes (PN) dated 7/17/25 at 11:57 a.m., the PN indicated, Enoxaparin Sodium Solution 30 mg/0.3ml inject 30 mg subcutaneously one time a day for prevent blood clotting for 10 days not available. Pending delivery.During an interview on 8/5/25 at 3:49 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated on 7/17/25 Resident 1's enoxaparin was not available for administration. LVN 1 stated the facility's policy and procedure was to notify the physician. LVN 1 was unable to provide documentation the physician was noted of the enoxaparin being unavailable.During an interview on 8/5/25 at 4 p.m. with Director of Nursing (DON), DON stated when the medication was not available for administration the physician should have been notified.During a review of the facility's policy and procedure (P&P) titled Medication Orders dated 2012, the P&P indicated, The prescriber is contacted for direction when delivery of a medication will be delayed or the medication is not or will not be available.

Based on interview and record review, the facility failed to report allegations of physical abuse to the California Department of Public Health (CDPH) within 24 hours for three of four sampled residents (Resident 1, Resident 2, and Resident 3). This failure had the potential for abuse allegations not being investigated and residents experiencing continued physical abuse. Findings: During an interview on 5/19/25 at 3:31 p.m. with Resident 1, Resident 1 stated during her last shower, a CNA (Certified Nursing Assistant 1) described as a big lady, put a lot of soap on her face, and was rubbing her face so hard she could not breathe. Resident 1 stated she tried to stop the CNA (1) but continued to rub soap on her face. Resident 1 stated the CNA did not stop until she screamed and yelled, Rape! Rape! Resident 1 stated, I could not do anything I was naked, and she was bigger than me, I am scared of her. Resident 1 stated she reported the incident to the head of the department and was informed, they were going to keep an eye on the CNA (1). Resident 1 stated CNA 1 still works in the facility and went to her room. During a review of Resident 1's Minimum Data Set (MDS-comprehensive assessment tool), dated 3/20/25, the MDS indicated Resident 1 had a Brief Interview for Mental Status (BIMS) score of 12 (score of 8-12 means moderate cognitive impairment). During an interview on 5/19/25 at 3:39 p.m. with Director of Nursing (DON), DON stated she was not aware of the abuse incident. During an interview on 5/20/25 at 8:29 a.m. with DON, DON stated she spoke with Resident 1 and the incident happened on 5/14/25 (six days ago). During an interview on 5/20/25 at 12:01 p.m. with Resident 2, Resident 2 stated the physical abuse happened two months ago. Resident 2 stated CNA 1 grabbed and pulled her right arm that was paralyzed (unable to move or feel certain part of the body due to a loss of nerve function) to get her out of the shower chair. Resident 2 stated, She [CNA 1] was very rough. Resident 2 stated couple of days after the incident, CNA 1 went to Resident 2's room and CNA 1 told Resident 2, I [CNA 1] know what you [Resident 2] did. You [Resident 2] reported me to the DON. During a review of Resident 2's MDS dated [DATE], the MDS indicated Resident 3 had a BIMS score of 13 (score of 13-15 means cognitively intact). During a review of Resident 2's IDT Note (Interdisciplinary note-multidisciplinary team meeting regarding resident's care), dated 5/26/25 indicated, [Resident 2] has not received shower from [CNA 1] in more than 30 days. The IDT Note indicated the abuse incident happened over 30 days ago. During an interview on 5/20/25 at 12:20 p.m. with Resident 3, Resident 3 stated, [CNA 1] was rough with me when she [CNA 1] gave me a shower. She [CNA 1] rubbed my back so bad it hurt me. I will never have her [CNA 1] give me shower again. So from the last six to seven months, she [CNA 1] has not showered me. During a review of Resident 3's MDS dated [DATE], the MDS indicated Resident 3 had a BIMS score of 15. During an interview on 5/20/25 at 2:30 p.m. with CNA 1, CNA 1 stated, His [Resident 3's] wife told me that he [Resident 3] does not want shower from me because he [Resident 3] does not like me. During a review of Resident 3's IDT Note, dated 5/26/25 indicated, [Resident 3] has not received shower from [CNA 1] in more than 30 days. The IDT Note indicated the abuse incident happened over 30 days ago. During an interview on 5/21/25 at 2:17 p.m. with CNA 1, CNA 1 stated there has been complaints about her being rough couple months ago, a resident (2) was not happy about the shower she (CNA 1) gave. CNA 1 stated she reported the allegation of physical abuse to the Director of Staff Development (DSD). CNA 1 stated she showered Resident 1 on 5/14/25 and was not happy and started screaming Rape! Rape! During an interview on 6/4/25 at 8:57 a.m. with DON, DON stated she was not aware of all of the three allegations of abuse prior to the survey on 5/19/25 and were not reported to the CDPH. During an interview on 6/4/25 at 9:53 a.m. with DSD, DSD stated she did not receive a report from CNA 1 regarding the allegations of abuse. During a review of the facility's policy and procedure titled, Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating dated September 2022, the P&P indicated, Reporting Allegations to the Administrator and Authorities: 3. Immediately as defined as: b. within 24 hours of an allegation that does not involve abuse or result in serious bodily injury.

Based on interview and record review, the facility failed to offer, obtain, and complete advance directives (AD- a written statement of a person's wishes regarding medical treatment when one is unable to make decisions for themselves) for 10 of 26 sampled residents (Resident 14, Resident 20, Resident 12, Resident 75, Resident 5, Resident 142, Resident 29, Resident 86, Resident 71, and Resident 243). This failure had the potential to result in a failure to provide care in accordance with the resident's treatment wishes. Findings: During a concurrent interview and record review on 5/20/25 at 8:35 a.m. with Assistant Director of Nursing (ADON), Resident 14's clinical record (CR) was reviewed. ADON was unable to provide documentation that AD information was offered, or an AD had been completed for Resident 14. ADON stated Resident 14 did not have an AD. During a concurrent interview and record review on 5/20/25 at 8:40 a.m. with ADON, Resident 20's CR was reviewed. ADON was unable to provide documentation that AD information was offered, or an AD had been completed for Resident 20. ADON stated Resident 20 did not have an AD. During a concurrent interview and record review on 5/20/25 at 8:42 a.m. with ADON, Resident 12's CR was reviewed. ADON was unable to provide documentation that AD information was offered, or an AD had been completed for Resident 12. ADON stated Resident 12 did not have an AD. During a concurrent interview and record review on 5/20/25 at 8:43 a.m. with ADON, Resident 75's CR was reviewed. ADON was unable to provide documentation that AD information was offered, or an AD had been completed for Resident 75. ADON stated Resident 75 did not have an AD. During a concurrent interview and record review on 5/20/25 at 8:58 a.m. with ADON, Resident 5's CR was reviewed. ADON was unable to provide documentation that AD information was offered, or an AD had been completed for Resident 5. ADON stated Resident 5 did not have an AD. During a concurrent interview and record review on 5/20/25 at 9:14 a.m. with ADON, Resident 142's CR was reviewed. ADON was unable to provide documentation that AD information was offered, or an AD had been completed for Resident 142. ADON stated Resident 142 did not have an AD. During a concurrent interview and record review on 5/20/25 at 9:19 a.m. with ADON, Resident 29's CR was reviewed. ADON was unable to provide documentation that AD information was offered, or an AD had been completed for Resident 29. ADON stated Resident 29 did not have an AD. 44134 During a review of Advanced Directive questionnaire (ADQ) for Resident 86, dated 4/1/25, the ADQ indicated, Resident 86 had executed an AD. During an interview on 5/21/25 at 8:57 a.m. with Social Services Director (SSD), SSD stated Resident 86's chart had been reviewed, and SSD was unable to provide a copy of Resident 86's AD. SSD stated there was no documentation in the chart that indicated staff followed up with Resident 86 to obtain Resident 86's AD. SSD stated Resident 86 should have had a copy of the AD in their chart. During an interview on 5/22/25 at 8:24 a.m. with Resident 86, Resident 86 stated upon admission he had filled out an ADQ. Resident 86 stated he marked the box that indicated he had an AD. Resident 86 stated the facility had not requested a copy of Resident 86's AD. During a review of ADQ for Resident 71's, dated 3/31/25, the ADQ indicated, Resident 71 had executed an AD. During an interview on 5/21/25 at 8:58 a.m. with SSD, SSD stated Resident 71's chart had been reviewed, and SSD was unable to provide a copy of Resident 71's AD. SSD stated there was no documentation in the chart that indicated staff followed up with Resident 71 to obtain Resident 71's AD. SSD stated Resident 71 should have had a copy of the AD in their chart. 46958 During a review of Resident 243's ADQ, dated 3/15/25, the ADQ indicated, Resident 243 had executed an AD. During an interview on 5/21/25 at 8:58 a.m. with SSD, SSD stated Resident 243's chart had been reviewed and SSD was unable to provide a copy of Resident 243's AD. SSD stated there was no documentation in the chart that indicated staff followed up with Resident 243 to obtain Resident 243's AD. SSD stated Resident 243 should have had a copy of the AD in their chart. During an interview on 5/22/25 at 4:49 p.m. with Resident 243, Resident 243 stated he did not have an AD and no one from the facility had requested a copy of his AD. Resident 243 stated he would like to receive more information on how to execute an AD. During a review of the facility's policy and procedure (P&P) titled, Advance Directive, dated 9/2022, the P&P indicated, Determining Existence of Advance Directives: 1. Prior to or upon admission of a resident, the social services director or designee inquires of the resident, his/her family members and/or his or her legal representative, about the existence of any written advance directives. 2. The resident or representative is provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so. 3. Written information about the right to accept or refuse medical or surgical treatment, and the right to formulate advance directive is provided in a manner that is easily understood by the resident or representative. If the Resident does not have an Advance Directive: 1. If the resident or representative indicates that he or she has not established advance directive, the facility will offer assistance in establishing advance directive. 2. Information about whether or not the resident has executed an advance directive is displayed prominently in the medical record in a section of the record that is retrievable by any staff.If the resident or the resident's representative has executed one or more advance directive(s), or executes one upon admission, copies of these documents are obtained and maintained in the same section of the resident's medical record and are readily retrievable by any facility staff.

Based on observation, interview, and record review, the facility failed to ensure activities of interest were provided for four of 11 sampled residents (Resident 86, Resident 14, Resident 56, and Resident 29). This failure had the potential to affect Resident 86, Resident 14, Resident 56, and Resident 29's physical, mental, social, emotional health and well-being, which could diminish quality of life and /or potentially cause depression (feeling of sadness). Findings: During a review of Resident 86's Admission Record (AR), dated 3/31/25, the AR indicated, Resident 86 had a diagnosis of Multiple Sclerosis (MS, an immune system disease that affects the brain and spinal cord and causes muscle weakness and vision problems), Paraplegia (partial or complete loss of movement and sensation in the lower half of the body, specifically both legs), and Monoplegia (partial or complete loss of movement to one limb) to upper right limb. During a review of Resident 86's Brief Interview for Mental Status (BIMS, an assessment that uses a point system to score cognitive impairment. 0-7 points suggest severe cognitive impairment, 8-12 points suggest moderate cognitive impairment and 13-15 points suggests cognition is intact.), dated 4/7/25, the BIMS indicated Resident 86 had a score of 15. During a review of Resident 86's Baseline Care Plan Person-Centered Care Planning (BCP), dated 4/15/25, the BCP indicated, Activity Preferences.1.Daily Routine.After lunch the resident likes to watch television and take a nap. After that the resident likes to go outside for a couple of hours.2. Activities and Hobbies: The resident loves to go outside on walks. During an interview on 5/19/25 at 10:10 a.m. with Resident 86, Resident 86 stated he felt cooped up and would like to be able to go outside to hear the birds chirp and have a change of atmosphere. During an interview on 5/22/25 at 8:27 a.m. with Resident 86, Resident 86 stated the only time he had went outside was when friends or family visited and took him out. Resident 86 stated activities staff have never offered to take him outside. During an interview on 5/22/25 at 8:37 a.m. with Activities Director (AD), AD stated Resident 86 did not participate in activities. AD stated sometimes she sees Resident 86 outside visiting with guests. AD stated she was not familiar with Resident 86's activity preferences. AD stated activity room rounds are logged on a paper chart. AD stated Activities used baseline care plans to get a general idea of what Residents activity preferences were. During a concurrent interview and record review on 5/22/25 at 8:40 a.m. with AD, Resident 86's BCP, dated 4/15/25 was reviewed. AD stated the BCP indicated Resident 86 liked to go outside and on walks. AD stated this was what she had seen Resident 86 doing when he had visitors. AD stated she was not sure if anyone from activities had asked Resident 86 if he would like to go outside. During a concurrent interview and record review on 5/22/25 at 8:47 a.m. with AD, Resident 86's clinical Record (CR) was reviewed. AD stated Resident 86's CR did not have any documentation that activities had been provided to Resident 86. AD stated Resident 86 should have been asked daily if he would like to go outside. AD stated, I own that going outside was an activity that had not been provided to Resident 86. 35649 During a review of Resident 14's AR, dated 1/23/23, the AR indicated, Resident 14 was admitted on [DATE] with diagnosis including Chronic Obstructive Pulmonary Disease (COPD- is a common lung disease causing restricted airflow and breathing problems), Palliative Care (specialized medical care that focuses on providing relief from pain and other symptoms of a serious illness), and Hearing Loss. During a review of Resident 14's BIMS, dated 1/9/25, the BIMS indicated, Resident 14's BIMS score was 13. During a concurrent observation on 5/19/25 at 12:52 p.m. in Resident 14's room, Resident 14 was seated at the edge of the bed, looking down at the floor. There were no books, magazines, reading materials, puzzles or arts and crafts on Resident 14's over-bed table or nightstand. Resident 14 stated she did not participate in activities, and watches television in her room. Resident 14 stated there were no in-room activities provided. During a concurrent interview and record review on 5/20/25 at 4:03 p.m. with the AD, AD stated Resident 14 typically does not participate in activities. AD stated the activity staff members go room-to-room to provide in-room activities. AD was unable to provide documentation of in-room activities provided for Resident 14. During a concurrent interview and record review on 5/20/25 at 4:05 p.m. with AD, Resident 14's Activities Care Plan, revised 3/11/25, was reviewed. The care plan indicated, Focus: Keeping up with the news, reading books, newspaper or magazines and word puzzle. Goal: Preferences for customary routine and activities will be honored to the extent possible. Interventions: Provide activity materials like books, magazines, newspapers, TV, radio, arts and crafts, etc. Support choices for preferences regarding customary routine and activities. AD stated activities staff do not leave reading materials in resident rooms. During a review of Resident 56's AR, dated 12/27/24, the AR indicated, Resident 56 was admitted on [DATE] with a diagnosis including unspecified Dementia (a group of symptoms affecting memory, thinking and social abilities), Anxiety (a feeling of fear, dread, and uneasiness), and Depression (feeling of sadness and changes in how one thinks, sleeps, eats and acts). During a concurrent observation and interview on 5/19/25 at 10:49 a.m. with Resident 56, Resident 56 was in her bed. Resident 56 had a sad look on her face. Resident 56 stated My husband just passed, I missed him, and she was feeling depressed. Resident 56 had tears in her eyes while talking about the death of her husband. Resident 56 stated she did not participate in group activities. Resident 56 stated she would like to have someone take her out to get some fresh air, but no one had taken her outside. During a concurrent interview and record review on 5/20/25 at 4:07 p.m. with AD, Resident 56's activities were reviewed. AD was unable to provide in-room activities for Resident 56. During a review of Resident 56's Minimum Data Set [MDS- resident assessment tool] Section F-Preferences for Customary Routine and Activities annual assessment, dated 11/2024, the MDS indicated, Very important for Resident 56 to be around animals, such as pets, very important to do favorite activities, and very important to go outside to get fresh air. During an interview on 5/20/25 at 4:10 p.m. with AD, AD stated Resident 56 had not been taken outside to get fresh air. During a review of Resident 56's Activities Care Plan dated 11/8/24, the care plan indicated, Focus: Resident has a need for activities that are consistent with abilities and interest. Enjoyable, meaningful activities of the resident include, but not limited to arts and crafts, Bingo, card games, nail care, television. Goal: Will have a positive response to 1:1 activity, will have socialization with staff or visitors, will participate in activities of choice. Interventions: Encourage socialization, encourage to attend activities of interest. During a review of Resident 29's AR, dated 7/12/22, the AR indicated, Resident 29 was admitted on [DATE] with a diagnosis including Dementia without behavioral disturbance and unspecified hearing loss. During a review of Resident 29's BIMS, dated 1/14/25, the BIMS indicated, Resident 29 had a BIMS score of at 99 (resident unable to complete BIMS interview). During an observation on 5/20/25 at 11:45 a.m. with the Ombudsman (an independent advocate or official, usually appointed by the government or an organization, to investigate and resolve complaints) and Resident 29, in the main dining room, Resident 29 was in her wheelchair and was wheeled inside the dining room. Resident 29 was taken to sit at one of the dining tables and was left alone. Resident 29 had a laminated communication board in her hand and was fiddling with the plastic lamination of the communication board. Resident 29 smiled when greeted, but did not verbally respond. Resident 29 was not with any activities staff member. During an interview on 5/20/25 at 4:10 p.m. with AD, During a concurrent interview and record review on 5/20/25 at 4:12 p.m. with AD, Resident 29's activities were reviewed. AD stated Resident 29 should have been accompanied by an activities staff member and should have been provided the dementia box (includes sand, sensory bottles filled with glitters, or anything that stimulates Resident 29) for her activity. AD stated whatever Resident 29 was doing with the laminated communication board was not considered an activity. During a review of Resident 29's Activities Care Plan, dated 5/10/23, the care plan indicated, Focus: 1:1 Intervention. Resident needs 1:1 activity intervention to (sic) activities help build trust and rapport and to support leisure and social participation. Interventions: Assist resident in 1:1 activity and pay attention to resident preferences as possible via body language and visual cues. Provide activity material in accordance with resident's interest. During a review of the facility's policy and procedure (P&P) titled, Activity Programs, dated 2018, the P&P indicated, Activity programs are designed to meet the interest of and support the physical, mental and psychosocial well-being of each resident.4. Activities are considered any endeavor, other than routine ADLs (activities of daily living), in which the residents participate, that is intended to enhance his or her sense of well-being and to promote or enhance physical, cognitive, or emotional health. 5. Our activity programs are designed to encourage maximum individual participation and are geared to the individual resident's needs.9. All activities are documented in the resident's medical record.12. Individualized and group activities are provided that: a. reflect the schedules, choices and rights of the residents; b. are offered at hours convenient to the residents, including evenings, holidays and weekends; c. reflect the cultural and religious interests, hobbies, life experiences and personal preferences of the residents.

Based on interview and record review, the facility failed to ensure a Registered Nurse (RN) worked at least eight hours a day, seven days a week on 11 of 21 sampled days. This failure had the potential to negatively affect residents care, clinical outcomes, and assessments. Findings: During an interview on 5/22/25 at 10:46 a.m. with Licensed Vocational Nurse (LVN) 3, LVN 3 stated there was one RN that works on the floor during night shift. During an interview on 5/22/25 at 2:43 p.m. with Assistant Director of Nursing (ADON), ADON stated RN 1 was the only RN currently hired at this facility that works as a floor nurse. ADON stated the other two RN's were the Director of Nursing (DON) and the Assistant Minimum Data Set (MDS- resident assesment tool) nurse (AMDS). ADON stated the DON and AMDS were not utilized to provide resident care. During a concurrent interview and record review on 5/22/25 at 2:53 p.m. with ADON, RN 1's Staffing Schedule (SS), dated May 2025 was reviewed. The SS indicated RN 1 did not work on 5/2/25, 5/3/25, 5/4/25, 5/7/25, 5/8/25, 5/12/25, 5/13/25, 5/16/25, 5/17/25, 5/18/25 and 5/19/25. ADON stated the facility did not have an RN working for eight hours on these dates. ADON stated the facility should have had an RN working at least eight hours per day/seven days per week. During a review of the facility's policy and procedure (P&P) titled, Staffing, Sufficient and Competent Nursing, dated 2022, the P&P indicated, Our facility provides sufficient numbers of nursing staff with the appropriate skills and competency necessary to provide nursing and related care and services for all residents in accordance with resident care plans and the facility assessment.3. A registered nurse provides services at least eight (8) consecutive hours every 24 hours, seven (7) days a week. RNs may be scheduled more than eight (8) hours depending on the acuity needs of the resident.

Based on interview and record review, the facility failed to have an effective Certified Nurse Assistant (CNA) performance evaluation (PE- a process to give employees feedback on their job performance) and annual in-service program when: 1. Three of six sampled CNA's (CNA 1, CNA 3,and CNA 4) had not received 12 hours of annual in-service education.This failure had the potential to result in CNA's not having appropriate knowledge to care for residents. 2. Two of eight sampled CNAs (CNA 1, CNA 2, CNA 3) had not received a performance evaluation every 12 months. This failure had the potential for the facility to not be able to validate the CNA's had the knowledge and skills to perform their job duties, which could negativly affect resident care. Findings: 1. During a concurrent interview and record review on 5/22/25 at 11:23 a.m. with Assistant Director of Nursing (ADON), CNA 1's INDIVIDUAL INSERVICE ATTENDANCE RECORD (IIAR), dated 2024 was reviewed. The IIAR indicated, CNA 1 had ten hours of in-service training in 2024. ADON stated CNA 1 should have had a total of 12 hours of training. During a concurrent interview and record review on 5/22/25 at 11:31 a.m. with ADON, CNA 3's IIAR, dated 2024 was reviewed. The IIAR indicated, CNA 3 had 11 hours of in-service training in 2024. ADON stated CNA 3 should have had a total of 12 hours of training. During a concurrent interview and record review on 5/22/25 at 11:41 a.m. with ADON, CNA 4's IIAR, dated 2024 was reviewed. The IIAR indicated, CNA 4 had six hours of in-service training in 2024. ADON stated CNA 4 should have had a total of 12 hours of training During a review of the facility's policy and procedure (P&P) titled, In-Service Training, Nurse Aide, dated 2022, the P&P indicated, All nurse aide personnel participate in regular in-service education.4. Annual in-services: a. ensure the continuing competency of nurse aides; b. are no less than 12 hours per employment year. 46958 2. During a concurrent interview and record review on 5/22/25 at 11:33 a.m. with Director of Staff Development Assistant (DSDA), CNA 1's PE was reviewed. The PE indicated it was completed on 1/16/23. DSDA was unable to provide a current PE. DSDA stated CNA 1 should have had a current PE. During a concurrent interview and record review on 5/22/25 at 11:41 a.m. with DSDA, CNA 2's employee file (EF) was reviewed. The EF indicated, CNA 2 was hired on 7/13/23. DSDA stated she was unable to find a completed PE. During a concurrent interview and record review on 5/22/25 at 11:52 a.m. with DSDA, CNA 3's employee file (EF) was reviewed. The EF indicated, CNA 3 was hired on 7/13/23. DSDA stated she was unable to find a completed PE During a review of the facility's policy and procedure (P&P) titled, Performance Evaluations, dated 9/2020, indicated, The job performance of each employee shall be reviewed and evaluated at least annually. 1. A performance evaluation will be completed on each employee at least annually. The performance evaluation meeting will occur at the same time as the employee's compensation review.

Based on observation, interview, and record review, the facility failed to: 1. Honor two of 25 sampled residents (Resident 31, Resident 73) food preferences. 2. Follow physician diet orders for one of 25 sampled residents (Resident 59). These failures had the potential to result in a decreased oral intake and unwanted weight loss. Findings: 1. During a concurrent observation, interview, and record review on 5/19/25 at 12:08 p.m. with IP in the main dining room, Resident 31's meal ticket indicated, Dislikes [NAME] Beans. Resident 31 was served green beans on her lunch meal tray. IP stated Resident 31 should not have been served green beans and it should have been caught during the tray CHECKS. During a concurrent observation, interview, and record review on 5/19/25 at 1:02 p.m. with LVN 5 in Resident 73's room, Resident 73's meal ticket indicated,No Bread. Resident 73 was served bread on the lunch tray. LVN 5 stated Resident 73 should not have been served bread. 2. During a concurrent observation, interview, and record review on 5/19/25 at 12:18 p.m. with Infection Preventionist (IP) in the main dining room, Resident 59 meal ticked indicated, 4 fl. oz. [fluid ounces] whole milk. Resident 59 did not have milk on her lunch meal tray. IP stated Resident 59's was not provided with milk and milk should have been on her meal tray.

Based on observation, interview, and record review, the facility failed to ensure: 1. Opened Food items were labeled with an open date. 2. Dented cans were properly discarded. These failures had the potential to cause foodborne illness (illness caused by the ingestion of contaminated food or beverages) for at-risk vulnerable residents. Findings: 1.During a concurrent observation, and interview on 5/19/25 at 9:23 a.m. with Dietary Manager Assistant (DMA) in the cold storage room, the following food items were found opened and undated: (1) one liter jar of lemonade, one bottle of ketchup, one bottle of mayonnaise, two bottles of sweet relish, and (1) one gallon jar of sliced pickles. DMA stated these opened food items should have been labeled and dated. During a review of the facility's policy and procedure (P&P) titled, Labeling and Dating of Foods, dated 2023, the P&P indicated, All food items in the storeroom, refrigerator, and freezer need to be labeled and dated. Food delivered to facility needs to be marked with a received date.Newly opened food items will need to be closed and labeled with an open date and used by the date that follows the various storage guidelines within this section specifically the Dry Goods Storage Guidelines.All prepared foods need to be covered, labeled, and dated. Items can be dated individually or in bulk stored on a tray.Produce is to be dated with received date. Leftovers will be covered, labeled and dated. 2.During a concurrent observation, and interview on 5/19/25 at 9:26 a.m. with DMA in the kitchen's dry storage room, a dented can of pinto bean was on the shelf with other canned foods. DMA stated the dented can should not have been stored with regular cans. DMA stated the dented can should have been put with the other dented cans to be discarded. During a review of the facility's P&P titled, Food Storage-Dented Cans, dated 2023, the P&P indicated, Food in unlabeled, rusty, leaking, broken, containers or cans with side seam dents, rim dents, or swells shall not be retained or used by the facility. Procedure: All dented cans (defined as side seam or rim dents) and rusty cans are to be separated from remaining stock and placed in a specified labeled area for return to purveyor [food vendor] for refund.

Based on observation, interview, and record review, the facility failed to ensure infection control practices were implemented when: 1. Three large barrels containing residents' clean personal laundry were stored in the dirty area of the laundry room. 2. One of one sampled Housekeeper (HSK 1) did not perform hand hygiene. These failures had the potential to spread infectious diseases to all residents, visitors, and staff. Findings: 1. During an observation on 5/22/25 at 8:23 a.m. in the laundry room, had three large barrels with gray lids containing resident's clean personal laundry were located next to the dirty area with three yellow barrels containing soiled linen. During an interview on 5/22/25 at 8:24 a.m. with Director of Maintenance (DM), DM stated the facility had no space for the storage of residents' clean personal laundry, that was why they were in the dirty area. DM stated he was working with Social Services Director (SSD) to manage the residents' clean personal laundry. During an interview on 5/22/25 at 12:02 p.m. with SSD, SSD stated the residents' clean personal laundry should not be stored in the dirty area. During a review of the facility's policy and procedure (P&P) titled, Departmental (Environmental Services) Laundry and Linen, dated 1/2014, the P&P indicated, Keep soiled and clean linen, and their respective hampers and laundry carts, separate at all times. 2. During a concurrent observation and interview on 5/22/25 at 9:20 a.m. with HSK 1 in a resident's room, HSK 1 was wearing gloves while holding a rag, a spray bottle, and a toilet brush. HSK 1 then entered the resident's restroom and started to clean it. HSK 1 came out of the restroom wearing the same gloves and placed the toilet brush and spray bottle back in the housekeeping cart. HSK 1 then removed her gloves and put on a new pair without performing hand hygiene. HSK 1 stated she failed to perform hand hygiene when she came from cleaning the restroom and in between glove changes. During a review of the facility's policy and procedure (P&P) titled, Handwashing/Hand Hygiene dated 8/2019, the P&P indicated, Applying and Removing Gloves: Perform hand hygiene before applying non-sterile gloves.

Based on interview and record review, the facility failed to: 1. Maintain an effective antibiotic stewardship (efforts to ensure that antibiotics are used only when necessary and appropriate) for one of three sampled residents (Resident 73) when the attending physician (MD) 1 was not notified of the results of the urine culture, including the susceptibility/sensitivity (determines how well a microbe [like bacteria or fungi] responds to a specific antimicrobial drug [antibiotic]) results. This failure resulted in Resident 73 not receiving the antibiotic that had the highest efficacy for the treatment of a urinary tract infection (UTI). 2. Follow the facility's policy and procedure on Antibiotic Stewardship when MD 1 did not evaluate one of one sampled resident (Resident 73) within 72 hours after ordering the antibiotic via telephone. This failure had the potential to result in Resident 73 not being prescribed the appropriate antibiotic. Findings: 1. During a concurrent interview and record review on 5/22/25 at 10:45 a.m. with Infection Preventionist (IP), Resident 73's Interdisciplinary Notes (IDT - a group of healthcare professionals from different disciplines who work together to provide comprehensive and coordinated care for patients), dated 5/15/25 were reviewed. The IDT Notes indicated, on 5/13/25, Resident 73 had an elevated temperature recorded at 100.8 degrees Fahrenheit and showed signs of confusion. MD 1 gave a telephone order for Cephalexin (antibiotic) 500 milligrams (mg) one tablet four times a day for five days for infection. The IDT Notes indicated, Risk Factors: Pulmonary Fibrosis (scarring in the lungs making it difficult to breathe), unspecified Methicillin Resistant Staphylococcus Aureus (MRSA-type of bacteria that has become resistant to many antibiotics). During a review of Resident 73's Urine Culture, results dated 5/15/25, the urine culture results indicated,50,000 cfu [colony forming unit-a unit of measurement to determine the number of viable microbial cells (bacteria, fungi, etc.) in a sample] /ml [per milliliter] Proteus Mirabilis [a common bacteria responsible for complicated urinary tract infections that sometimes causes bacteremia (bloodstream infection)]. Susceptibility results: Antibiotic: Ampicillin/Surbactam- intermediate [bacteria in the urine show some sensitivity to the antibiotic, not enough to be fully susceptible], Ampicillin - Resistant [antibiotic ineffective against the bacteria] Cefazolin- Resistant Ceftriaxone- Susceptible Cefuroxime -Susceptible Cefuroxime/Axetil -Susceptible Gentamycin - Susceptible Levofloxacin - Intermediate Nitrofurantoin - Resistant Piperacillin/Tazobactam - Susceptible Trimethoprim/Sulfa - Resistant. During an interview on 5/22/25 at 10:55 a.m. with IP, IP stated Resident 73 was already on the antibiotic cephalexin prior to the urine culture result. IP stated it was not her responsibility to notify the physician of the laboratory result. IP stated Resident 73's floor nurse was responsible for informing the physician. IP stated she called MD 1 on 5/19/25, which was the last day Resident 73's cephalexin treatment, and MD 1 did not provide any new orders. During a concurrent interview and record review on 5/22/25 at 3 p.m. with Infection Control Consultant (ICC), Resident 73's urinalysis and urine culture results, dated 5/15/25, were reviewed. ICC was unable to provide proof of evidence that MD 1 was notified of Resident 73's urine culture results. ICC was aware Resident 73 was not on any of the antibiotics listed on the culture and sensitivity report to treat Proteus Mirabilis bacteria. ICC stated there was no physician notification regarding the urine culture and sensitivity results. During a review of the facility's policy and procedure (P&P) titled, Antibiotic Stewardship, dated 12/2016, the P&P indicated, 1. The purpose of our antibiotic stewardship program is to monitor the use of antibiotics in our residents.11. When a culture and sensitivity (C&S) is ordered lab results and the current clinical situation will be communicated to the prescriber as soon as available to determine if antibiotic therapy should be started, continued, modified, or discontinued. 2. During a concurrent interview and record review on 5/22/25 with IP and ICC, Resident 73's MD 1's Physician Progress Notes (PPN), dated 5/19/25, were reviewed. The PPN indicated, Resident 73 had a suprapubic catheter (SPC-a medical device that helps drain urine from the bladder through a small incision in one's abdomen) and was sent to a local emergency room (ER) due to SPC dysfunction. ER physician replaced SPC on 5/13/25 and recommended monthly replacement. The PPN indicated, acute urinary retention (unable to urinate). IP and ICC stated Resident 73's PPN did not indicate MD 1's had evaluated Resident 73's UTI following the telephone order for the antibiotic cephalexin. ICC stated UTI was not addressed. During a review of the facility's P&P titled, Antibiotic Stewardship, dated 12/2016, the P&P indicated, 10. When antibiotics are prescribed over the phone, the primary care practitioner will assess the resident within 72 hours of the telephone order.

Based on interview and record review, the facility failed to provide in-service education on Covid-19 (severe respiratory illness) for 143 of 186 total staff. This failure had the potential for staff not knowing how to prevent the spread of Covid-19 in the event of a pandemic (widespread outbreak of an infectious disease) affecting all residents, staff, and visitors. Findings: During a review of the facility's in-service education on Covid-19 titled, Prevention of Covid-19 (PC), dated 1/22/25 until 4/11/25, the PC indicated there were only 43 staff who attended the in-service education on Covid-19 in the last 12 months. During an interview on 5/22/25 at 3:21 p.m. with Assistant Director of Nursing (ADON), ADON stated, I did not review that [in-service education on Covid-19]. I was not here when the in-service education [on Covid-19] was conducted. During an interview on 5/22/25 at 4:28 p.m. with Director of Nursing (DON), DON stated the facility has a total of 186 staff. DON stated the facility had no policy on providing in-service education to staff and residents on Covid-19.

Based on observation, interview, and record review, the facility failed to maintain an ambient (surrounding air) temperature for three of six sampled resident rooms (room [ROOM NUMBER] A/B, room [ROOM NUMBER] A/B, room [ROOM NUMBER] A/B). This failure resulted in the residents feeling warm and uncomfortable in their respective rooms. Findings: During a concurrent observation and interview on 5/19/25 at 9:59 a.m. with Resident 75, in room [ROOM NUMBER] A, Resident 75 was not wearing a gown or shirt and had a portable electric fan blowing by the left side of his bed. Resident 75 stated his room was hot. During an interview on 5/19/25 at 10:02 a.m. with Resident 5 in room [ROOM NUMBER] B, Resident 5 stated the room was hot. During a concurrent observation and interview on 5/19/25 at 10:05 a.m. with Assistant Maintenance Supervisor (AMS) in room [ROOM NUMBER], AMS stated the temperature was 82 degrees ( ) Fahrenheit (F) and felt warm. During an observation on 5/19/25 at 10:20 a.m. in Hallway B, AMS took the ambient temperatures in rooms [ROOM NUMBERS]. The following were the room temperatures taken: room [ROOM NUMBER] A/B: 82 F room [ROOM NUMBER] A: 82 F room [ROOM NUMBER] B: 84 F room [ROOM NUMBER] A: 85 F room [ROOM NUMBER] B: 84 F During an interview on 5/19/25 at 10:09 a.m. with AMS, AMS stated it had always been warm in this area of the facility. During an interview on 5/19/25 at 1:18 p.m. with AMS and Director of Maintenance (DM), AMS stated someone must have changed the temperature set on the thermostat box. DM stated it seemed like someone had altered the thermostat setting. During a review of the facility's document, [undated], the document indicated, All buildings are required to maintain an ambient temperature throughout resident and patient areas in a temperature range of 71 to 81 degrees Fahrenheit.

Based on interview and record review, the facility failed to ensure : 1. Six of Six sampled Certified Nursing Assistants (CNA 3, CNA 1, CNA 2, CNA 5, CNA 6 and CNA 4) attended a minimum of five hours of annual dementia (a general term for the loss of memory, language, and reasoning skills) care training. This failure had the potential for CNAs to not have the knowledge and skills on how to meet the care needs of residents with dementia. 2. One of five sampled CNA's (CNA 3) received annual abuse prevention training. This failure had the potential for CNA 3 to not have the knowledge and skills on how to recognize and report abuse. Findings: 1. During a concurrent interview and record review on 5/22/25 at 11:11 a.m. with Assistant Director of Nursing (ADON), CNA 3's Individual Inservice Attendance Record (IIAR), dated 2024 was reviewed. The IIAR indicated, CNA 3 had dementia training on 1/5/24 for one hour, 2/16/24 for one hour, 10/1/24 for one hour, and 11/18/24 for one hour. ADON stated CNA 3 had a total of four hours of dementia training in 2024 and should have had an additional hour of training. During a concurrent interview and record review on 5/22/25 at 11:23 a.m. with ADON, CNA 1's IIAR, dated 2024 was reviewed. The IIAR indicated, CNA 1 had dementia training on 1/5/24 for one hour, and on 10/1/24 for one hour. ADON stated CNA 1 had a total of two hours of dementia training in 2024 and should have had a total of five hours. During a concurrent interview and record review on 5/22/25 at 11:31 a.m. with ADON, CNA 2's IIAR, dated 2024 was reviewed. The IIAR indicated, CNA 2 had dementia training on 1/2/24 for one hour, 2/16/24 for one hour, 10/1/24 for one hour, and 10/4/24 for one hour. ADON stated CNA 2 did not complete a total of five hours of dementia training in 2024 and should have. During a concurrent interview and record review on 5/22/25 at 11:35 a.m. with ADON, CNA 5's IIAR, dated 2024 was reviewed. The IIAR indicated, CNA 5 had dementia training on 1/2/24 for one hour, 2/14/24 for one hour, 5/7/24 for 50 minutes, and 11/18/24 for one hour. ADON stated CNA 5 completed four hours of dementia training in 2024 and should have completed five hours. During a concurrent interview and record review on 5/22/25 at 11:38 a.m. with ADON, CNA 6's IIAR, dated 2024 was reviewed. The IIAR indicated, CNA 6 had dementia training on 1/2/24 for one hour, 5/7/24 for 50 minutes, and 11/19/24 for one hour. ADON stated CNA 6 completed a total of three hours of dementia training in 2024 and should have completed five hours. During a concurrent interview and record review on 5/22/25 at 11:41 a.m. with ADON, CNA 4's IIAR, dated 2024 was reviewed. The IIAR indicated CNA 4 had not completed any dementia training in 2024. ADON stated CNA 4 should have completed five hours of dementia training in 2024. 46958 During a concurrent interview and record review on 5/22/25 at 11:52 a.m. with Director of Staff Development Assistant (DSDA), CNA 3's personnel file (PF) was reviewed. The PF indicated CNA 3 had completed abuse training on 1/9/24. DSDA stated CNA 3 did not have abuse training in the last 12 months. During a review of the facility's policy and procedure (P&P) titled, In-Service Training, Nurse Aide, dated 2022, the P&P indicated, All nurse aide personnel participate in regular in-service education.9. Required training topics for all staff (including nurse aides) include.4. Annual in-services.e. include training that addresses the care of residents with cognitive impairment; and f. include training in dementia management and resident abuse prevention.

Based on interview and record review, the facility failed to: 1. Ensure Informed Consent (IC, a process in which a healthcare professional educates a patient about the risks, benefits, and alternatives of a given procedure or medication) for one of seven sampled resident (Resident 5's) Mirtazapine (Remeron-antidepressant medication) 15 milligrams (mg) was signed by the physician prior to medication administration. This failure had the potential to result in adverse consequence when the physician had not given the resident sufficient information about the drug, which may have negative effect on the resident. 2. Have accurate informed consent for a psychotropic (medication to treat mental disorders) medication for one of seven sampled residents (Resident 27). This failure had the potential for Resident 27 to not be aware of the risks and benefits of taking psychotropic medications. Findings: 1. During a review of Resident 5's Admission Record, (AR), dated 11/3/22, the AR indicated, Resident 5 was admitted on [DATE] with a diagnosis including anxiety disorder (characterized by excessive fear of or apprehension about real or perceived threats), psychotic disorder (significant loss of contact with reality), unspecified mood affective disorder (significant disturbances in emotional state, typically involving periods of extreme sadness). During a review of Resident 5's Order Summary Report, (OSR), dated 1/30/25, the OSR indicated, Mirtazapine [Remeron-antidepressant medication] oral tablet 15 mg one tablet by mouth at bedtime for depression/anorexia [eating disorder]. During a concurrent interview and record review on 5/20/25 at 8:44 a.m. with Assistant Director of Nursing (ADON), Resident 5's IC for Mirtazapine, dated 1/30/25 was reviewed. The IC indicated, Resident 5's representative signed the IC form but the IC form was not signed by Resident 5's physician. ADON stated the IC must be dated and signed by the physician. 46958 2. During a concurrent interview and record review on 5/22/25 at 3:05 p.m. with Assistant Regional Director (ARD), Resident 27's IC, dated 11/8/24 was reviewed. The IC indicated, Resident 27 gave verbal consent for Buspirone (medication to treat anxiety) 10 mg every 8 hours. ARD stated verbal consent was obtained from Resident 27. ARD stated if a resident is physically and mentally able to sign the IC, the IC should have a signature and not a verbal consent. During an interview on 5/22/25 at 4:35 p.m. with Resident 27, Resident 27 stated she was currently taking Buspirone and had been taking this medication prior to being admitted to this facility. Resident 27 stated her physician never discussed informed consent with her regarding Buspirone. Resident 27 stated she had not signed or gave verbal IC for Buspirone. ARD stated Resident 27's physician should have explained the risks, benefits and alternatives to resident for Buspirone. During a review of the facility's policy and procedure (P&P) titled, Psychotropic Medication Use, dated 2/2025, the P&P indicated, Informed Consent: 1. Prior to initiating the use of, increasing the dose of, or switching to a different psychotropic medication, the staff and the physician will review the following with the resident/representative prior to obtaining documented consent or refusal.c. the potential risks and benefits (including possible side effects, adverse consequences, and black box warnings).

Based on observation, interview, and record review, the facility failed to assess the effectiveness of the plan of care for the use of a communication board (a visual aid that facilitates communication between patients and their care team) for one of one sampled resident (Resident 29). This failure resulted in the facility not understanding, identifying, and determining Resident 29's needs and the potential to deprive her of maintaining the highest practicable physical, mental, and psychosocial well-being. Findings: During a review of Resident 29's Admission Record, (AR), the AR indicated, Resident 29 was admitted on [DATE] with a diagnosis including unspecified Dementia (a group of symptoms affecting memory, thinking and social abilities) and unspecified hearing loss. During a concurrent observation and interview on 5/19/25 at 11:12 a.m. with Infection Preventionist (IP) and Resident 29, in Resident 29's room, Resident 29 was lying in bed on her left side. Resident 29 did not respond verbally when greeted but had a smile on her face. IP entered the room and picked up the communication board from Resident 29's nigh stand and stated the staff use this communication board to communicate with Resident 29. Resident 29 held the communication board but blankly looked at the board. IP stated she did not think Resident 29 really understood the use of the communication board and what the pictures on the board meant. IP stated, I cannot definitely say I understood her needs. During a review of Resident 29's Order Summary Report, (OSR) dated 5/2025, the OSR indicated, On 7/12/22 [Resident 29] is not capable of understanding rights and responsibilities, and/or able to participate in treatment plan. During a review of Resident 29's Brief Interview for Mental Status (BIMS- assessment for cognitive impairment. The score 0-7 means severe impairment, 9-12, moderate impairment, and 13-15 cognition intact) dated 4/15/25. The BIMS indicated, Resident 29's BIMS score was 99 (resident was unable to complete the interview). During a concurrent observation and interview on 5/19/25 at 11:35 a.m. with Certified Nursing Assistant (CNA 7) in Resident 29's room, CNA 7 entered Resident 29's room and stated she was going to check if the communication board works for Resident 29. CNA 7 approached Resident 29 and placed the communication board in front of Resident 29. CNA 7 attempted to ask Resident 29 questions on how she felt, what she needed, and attempted to make Resident 29 point to the communication board. CNA 7 stated she was unable to understand what Resident 29 was saying. CNA 7 stated she did not think Resident 29 understood her. CNA 7 stated Resident 29 pointed at the picture on the communication board and her finger touched the symbol Stop. CNA 7 stated Resident 29 was able to point at the picture, but she was not certain that was what Resident 29 needed. CNA 7 stated, it did not mean anything. Facility staff continued to use the communication board knowing Resident 29 was unable to comprehend the pictures and instructions. During a concurrent interview and record review on 5/19/25, at 11:40 a.m. with CNA 7, Resident 29's communication board was reviewed. The communication board's size was 8 x 11 inches, with colorful pictures, identified in the English language. The communication board had symbols and pictures. CNA 7 stated she was not sure if Resident 29 spoke Japanese, but the family spoke Mandarin (Chinese language). CNA 7 stated she was not sure if Resident 29 could understand the English language. During an interview on 5/19/25 at 11:42 a.m. with CNA 8, CNA 8 stated, Resident 29 uses the communication board. CNA 8 stated Resident 29 does not seem to understand how to use it. CNA 8 stated Resident 29 touches the communication board, but CNA 8 was not sure what Resident 29 needed. CNA stated, I am not sure she really understands the picture board, but we continue to use it for her. During an interview on 5/21/25 at 9:47 a.m. with Director of Nursing (DON), DON stated Resident 29 had Dementia and she was severely impaired. DON stated no one in the facility spoke Mandarin. DON stated the facility used a communication board, but Resident 29 was unable to comprehend the pictures on the communication board. DON stated the staff communicated by showing Resident 29 items and through gestures. DON stated the facility had a interpretation phone service but it had not been used for Resident 29 because her cognition was severely impaired.

Based on interview and record review, the facility failed to act on a recommendation from the pharmacy consultant (a professional responsible for reviewing each resident's medication profile monthly to identify and report changes) for one of 10 sampled residents (Resident 71). This failure had the potential to result in Resident 71 not receiving a needed medication and possibly leading to medical complications that could diminish quality of life. Findings: During a review of Resident 71's Medication Regimen Review (MRR), dated 3/27/25, the MRR indicated, Please clarify the findings below with the MD 1 [medical doctor] and update orders accordingly: 1. Hospitalist recommended to continue with allopurinol [medication used to treat joint inflamation and prevent kidney stones] 100 mg [milligrams] PO [by mouth] daily. Pharmacy does not have this order. Please have MD 1 evaluate need for medication. During a concurrent interview and record review on 5/22/25 at 3:44 p.m. with Regional Director of Clinical Services (RDCS), Resident 71's Order Summary Report (OSR), dated 5/22/25 was reviewed. The OSR indicated, a list of Resident 71's current medication orders since admission on 3/24/25. RDCS stated Resident 71 did not have a physician order for Allopurinol 100 mg. During a concurrent interview and record review on 5/22/25 at 3:44 p.m. with RDCS, Resident 71's clinical record (CR), [undated] was reviewed. The CR indicated, there was no documentation that Resident 71's MD 1 had been made aware of the MRR recommendation on 3/27/25. RD stated she was unable to find documentation that Resident 71's MD had evaluated the MRR recommendation. During an interview on 5/22/25 at 3:52 p.m. with Director of Nursing (DON), DON stated she was responsible for making sure the MRR was completed monthly. DON stated she was unable to find any documentation that indicated Resident 71's MD 1 was made aware of the MRR recommendation for Allopurinol 100 mg. DON stated there should have been documentation that this recommendation was reviewed by Resident 71's MD 1. During a review of the facility's policy and procedure (P&P) titled, CONSULTANT PHARMACIST REPORTS, dated 2019, the P&P indicated, The consultant pharmacist performs a comprehensive medication regimen review (MRR) at least monthly.Findings and recommendations are reported to the director of nursing, the attending physician, and the medical director, and if appropriate the administrator.ROUTINE FINDINGS.i. NURSING: Items will be initially reviewed and addressed within 14 days and a final action taken in no more than 30 days or the date of next monthly pharmacy MRR. ii. PRESCRIBER: The facility will communicate the findings to the prescriber on a timely basis and the prescriber will identify their action, which may be to disagree with the recommendations, as they deem clinically appropriate but no later than the date of their next 30 day visit.G. Recommendations are acted upon and documented by the facility staff and or the prescriber.

Based on interview and record review, the facility failed to maintain accurate medical records for two of 38 sampled residents (Resident 3 and Resident 142) when the Nursing Weekly Summary (NWS) did not reflect the residents' skin condition, including toes and toenails. This failure resulted in Resident 3 and Resident 142's medical records to be incomplete and inaccurate, which could lead to misdiagnosis, inappropriate treatment, and delay in care. Findings: During a concurrent observation and interview on 5/19/25 at 12:23 p.m. with Resident 3 in Resident 3's room, Resident 3 was in her bed with her feet uncovered. Resident 3 was awake and alert and stated her right side was paralyzed (unable to move due to a loss of muscle function) and had no sensation on the right side. Resident 3's right great toe was red, swollen, and the toenail was yellowish in color, thick, and hard. Resident 3's left toenails were also yellowish in color and long. Resident 3 denied pain in her right foot due to her right sided paralysis. During a concurrent observation and interview on 5/19/25 at 12:30 p.m. with Licensed Vocational Nurse (LVN) 1, in Resident 3's room, LVN 1 looked at Resident 3's right foot and stated, It looks like she has that for a good while since I started in February 2025. LVN 1 assessed the right great toe and toenail and stated the toenail was yellow, discolored, thick, and hard and the right toe was swollen and red. LVN 1 stated Resident 3's left toenails were yellow, discolored, long, but not thick. LVN 1 stated Resident 3 denied pain, but she had no sensation on the right side. LVN 1 stated, I definitely need to talk to the doctor about it see if podiatry could see her. During a concurrent interview and record review on 5/19/21 at 12: 40 p.m. with LVN 1, Resident 3's NWS dated 5/5/25 and 5/12/25 were reviewed. LVN 1 stated the NWS both indicated Resident 3's skin was clear and intact. During a concurrent observation and interview on 5/21/25 at 8:26 a.m. with Treatment Nurse (TN) in Resident 3's room, TN assessed Resident 3's feet. TN stated Resident 3 had a foot drop (difficulty lifting the foot) on the right foot, the right great toe was red, swollen, and blanchable. TN stated Resident 3's right great toenail was yellow, hard, with protruding thickness. TN measured Resident 3's toenails with the following results: Right great toenail Length: 0.6 centimeter (cm) Width: 1.2 cm Thickness: 0.9 cm 2nd right toe: L 0.7 cm W: 0.9 cm 3rd right toenail L: 0.8 cm W: 0.8 cm 4th right toenail L: 0.9 cm W: 0.7 cm 5th right toenail: L: 0.8 cm W: 0.5 cm Left great toenail L: 1.5 cm W: 1.2 cm 2nd left toenail: L:1.9 cm W: 1cm 3rd left toenail: 1.1 cm W: 1 cm 4th left toenail: L:.0.8 cm W: 0.8 cm 5th left toenail L: 0.7 cm W: 0.6 cm During an interview on 5/21/25 at 8:43 a.m. with LVN 2, LVN 2 stated the NWS is completed weekly. LVN 2 stated NWS is the nursing assessment and documentation from the previous week resident assessments. During a concurrent interview and record review on 5/21/25 at 8:43 a.m. with Assistant Director of Nursing (ADON), Resident 3's Podiatry Notes (PN), dated 2/18/25, were reviewed. The PN indicated, trimming of dystrophic (any abnormal changes in the shape, color, texture, and growth of the fingernails or toenails) nails. All toenails were dystrophic, thickened nails, nail discoloration, pathology results for onychomycosis (fungal infection of the nails). During a concurrent interview and record review on 5/21/25 at 12:15 p.m. with ADON. Resident 3's NWS, dated 4/14/25, 4/21/25, 4/28/25, 5/5/25 and 5/12/25 were reviewed. The NWS dated 4/14/25 indicated, Skin: No new skin issues this week. The NWS dated 4/21/25 indicated, Skin: No new skin issues this week. The NWS dated 4/28/25 indicated, Skin: No new skin issues this week. The NWS dated 5/5/25 indicated, Skin: No new skin issues this week. The NWS dated 5/12/25 indicated, Skin: No new Skin Issues this week. ADON stated Resident 3's skin, toes, and toenail conditions were not addressed and documented in Resident 3's nursing weekly summary. 2. During a concurrent observation and interview on 5/20/25 at 10:05 a.m. with TN, in Resident 142's room, Resident 142's right great toenail was dark yellow in color, long, hard and thick, overlapping and layered, with a fungus like appearance. Resident 142 stated her toenails hurt. Resident 142's toes were deformed; the skin was dry and ashy. Resident 142's left great toe was yellow in color, raised and lifted from the nailbed. Resident 142's left toes were deformed, yellow in color, long, and thick. TN stated, I have not really looked at her toes and toenails. TN stated when residents have toenails in this condition, they are referred to podiatry for treatment, and we notify the social worker to arrange for the podiatry referral. TN measured Resident 142's toenails with the following results: Left great toe: Length (L): 1.1 cm Width (W): 0.9 cm Thickness (T): 0.1 cm 2nd left toenail L: 0.5 T: 0.6 cm 3rd left toenail L: 0.6 cm T: 0.5 cm 4th left toenail: L: 0.7 cm T: 0.4 cm 5th left toenail: L: 0.6 cm T: 0.4 cm Right great toenail: L: 1.5 cm W: 1.2 cm T: 0.4 cm 2nd right toenail: L:0.6 cm T: 0.5 cm 3rd right toenail L: 0.5 cm T: 0.6 cm 4th right toenail: L: 0.6 cm T: 0.6 cm 5th right toenail: L: 0.5 cm T: 0.5 cm During a review of Resident 142's Podiatry Evaluation (PE) dated 4/22/25, the PE indicated, Nail dystrophy, Tinea Ungulum (fungal infection of the nails), Hammer toe (a deformity where the toe bends at the middle joint [proximal interphalangeal joint] in a downward or hammer-like shape) right foot, hammer toe left foot. During a concurrent interview and record review on 5/21/25 at 12:30 a.m. with ADON, Resident 142's NWS dated 3/22/25, 3/31/25, 4/6/25, 4/13/25, 4/20/25, 5/4/25, and 5/12/25 were reviewed. The NWS dated 3/22/25 indicated, Skin: skin assessment Moisture-Associated Skin Damage (MASD- inflammation and erosion of the skin caused by prolonged exposure to moisture) to peri area (the region between the genitals and the anus). The NWS dated 3/31/25 indicated, MASD peri area and sacrococcygeal (tailbone). The NWS dated 4/6/25 indicated, MASD peri area and sacrococcygeal. The NWS dated 4/13/25 indicated, MASD on peri area and sacrococcygeal. The NWS dated 4/20/25 indicated, see TX (treatment). No skin assessment was documented. The NWS dated 5/4/25 indicated, MASD to peri area and sacrococcygeal. The NWS dated 5/12/25 indicated, MASD to peri area and sacrococcygeal. ADON stated the NWS did not reflect the condition of Resident 142's feet, toes, and toenails and should have been included in their nursing assessment and documented in Resident 142's medical record. During a review of the facility's policy and procedure (P&P) titled, Change in a Resident's Condition or Status, dated 2/2022, the P&P indicated, 8. The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status.

Based on interview and record review, the facility failed to ensure maintenance staff conducted bed rail risk assessments to include evaluation of the bed and measurements of siderails and potential bed entrapment zones for two of two newly admitted sampled residents (Resident 32 and Resident 142). This failure had the potential to place Resident 32 and Resident 142 at risk for harm. Findings: 1. During a review of Resident 32's Admission Record (AR), dated 4/7/25, the AR indicated, Resident 32 was admitted on [DATE] with a diagnosis including muscle wasting (decrease in the size of muscle tissue) and atrophy (tissue loss), and morbid obesity (weight is more than 80 to 100 pounds above their ideal body weight, and a body mass index [BMI- measure of body fat based on height and weight] of 40 and greater). During a review of Resident 32's Brief Interview for Mental Status (BIMS- assessment for cognitive impairment, 0-7 means severe cognitive impairment, 8-12 means moderate impairment, and 13-15, intact cognitive response) score. The BIMS indicated, Resident 32 had a BIMS score of 9. During a review of Resident 32's Physician's Order (PO), dated 4/8/25, the PO indicated, 1/4 siderails x [times] 2 to use as an enabler to turn and reposition self in bed. Does not restrict movement. During a concurrent interview and record review on 5/20/25 at 3:36 p.m. with Director of Maintenance (DM) and Assistant Maintenance Supervisor (AMS), Resident 32's bed rail evaluation, dated 4/7/25, was reviewed. AMS stated all bed rails were checked monthly and during resident admission. DM was unable to provide documentation of a bed rail evaluation with corresponding measurements for Resident 32 bed rail. During a review of the maintenance Monthly Maintenance Inspection (MMI), dated 4/2025, the MMI indicated, certain room numbers were inspected weekly and marked with a line without the actual bed rail measurements to identify risk of entrapment. DM stated they do not put the measurements on the form, but the line indicated the rooms were assessed with no risks for bed entrapment. The following are the potential zones of entrapment with the required measurements to prevent bed entrapment: Zone 1: within the rail = < (less than) 4 3/4 inches Zone 2: under the rail, between the rail supports or next to a single rail support = < 4 3/4 inches Zone 3: between the rail and the mattress: = < 4 3/4 inches Zone 4: under the rail, at the ends of the rail = < 2 3/8 inches Zone 5: between split bed. Rails and the mattress = < 4 3/4 inches (compressed by body weight) Zone 6: between the end of the rail and the edge of the head or footboard = < 4 3/4 inches Zone 7: between the head or the footboard and the mattress = < 4 3/4 inches 2. During a review of Resident 142's AR, dated 3/13/25, the AR indicated, Resident 142 was admitted on [DATE] with a diagnosis including osteoarthritis (degenerative joint disease) left knee, generalized muscle weakness, and unspecified polyneuropathy (damaged peripheral nerves). During a review of Resident 142's BIMS, dated 3/20/25, the BIMS indicated Resident 142 had a score of 12. During a review of Resident 142's PO, dated 3/14/25, the PO indicated, 1/4 siderails x 2 to use as an enabler to turn and reposition self in bed. Does not restrict movement. During an interview on 5/20/25 at 3:45 p.m. with DM and AMS, DM stated, No bed entrapment assessment of the bed was done in Resident 142's room because the machine to calibrate and measure bed rails broke on 3/23/25. DM stated it would take two weeks to fix the machine. Resident 142 was admitted on [DATE] and DM stated Resident 142's siderail evaluation for risk of bed entrapment was not done on admission. During a review of the facility's policy and procedure (P&P) titled, Bed Safety and Bed Rails, dated 8/2022, the P&P indicated, The use of bed rails is prohibited unless the criteria for use of bed rails have been met.3. Bed frames, mattresses and bed rails are checked for compatibility and size prior to use. 4. Bed dimensions are appropriate for resident's size. 6. Maintenance staff routinely inspect all beds and related equipment to identify risks and problems including potential entrapment risks.

Based on interview and record review, the facility failed to ensure a fall assessment was accurate for one of two sampled residents (Resident 1). This failure had the potential for staff to be unaware of Resident 1's risk for falls. Findings: During a review of Resident 1's S (Situation) B (Background) A (Appearance) R (Review and Notify) (SBAR), dated 12/31/24, the SBAR indicated, Resident was heard yelling from room, upon arrival resident was found on the floor. During a review of Resident 1's Nursing Post Fall Review (NPFR), dated 12/31/24, the NPFR indicated, History of Falls within last six months.no history. The NPFR indicated Resident 1 was a low fall risk. During a review of Resident 1's SBAR, dated 10/6/24 (approximately 2 1/2 months prior to 12/31), the SBAR indicated, Resident had a unwitnessed fall. During a review of Resident 1's SBAR, dated 11/21/24 (approximately 1 month prior to 12/31), the SBAR indicated, Resident had a fall while LOA (leave of absence). During an interview on 1/10/25 at 1:09 p.m. with Director of Nursing (DON), DON stated the NPFR was used to identify any increased risk factors for resident falls. DON stated the NPFR completed on 12/31/24 for Resident 1 was inaccurate due to Resident 1 having 3 falls in the last six months. During a review of the facility's policy and procedure (P&P) titled, Fall Risk assessment dated ,d+[DATE], the P&P indicated, Upon admission, the nursing staff and the physician will review a resident's record for a history of falls, especially falls in the last 90 days and recurrent or periodic bouts of falling over time.the staff will look for evidence of a possible link between the onset of falling (or an increase in falling episodes) and recent changes in the current medication regimen.

Based on interview and record review, the facility failed to follow its policy and procedure when staff in-service training records were incomplete. This failure resulted in incomplete training records and the potential for staff to be inadequately trained to care for residents. Findings: During a concurrent interview and record review on 12/13/24 at 12:44 p.m. with Director of Staff Development (DSD), three in-service training logs were reviewed. In-service training log one had three staff signatures and in-service training log two had one staff signature, both training logs did not contain a date, start time, end time, in-service course title, instructor name and instructor signature. In-service training log three contained the signature of five staff but did not contain the start time, end time, instructor name and instructor signature. DSD stated the in-service training logs must contain the date, the time the in-service started and ended, the topic and name and signature of the person giving the lesson to be complete. During a concurrent interview and record review on 12/13/24 at 1:24 p.m. with Director of Nursing (DON), DON reviewed the in-service training logs. DON stated the in-service training logs were not complete. During a review of the facility's policy and procedure (P&P) titled, Recordkeeping, Staff Development dated 2/08, the P&P indicated, An individual training record for each employee will be maintained. This record will be filed in the employee's personnel record or training record. Training records include, as a minimum.date of each training class attended.subject of class.class length.instructor of each class.individual training records are completed by the in-service training coordinator and/or department supervisor.

Based on observation, interview, and record review, the facility failed to ensure one of five sampled residents (Resident 1) was free from abuse when Certified Nursing Assistant (CNA) 1 was allowed to continue to care for Resident 1. This failure resulted in Resident 1 sustaining skin discoloration to hands, wrists, and abrasions (injury to the skin caused by force) to the left forearm and right shoulder which caused Resident 1 pain and emotional distress. Findings: During a review of Resident 1's Progress Notes, dated 9/8/21, at 10 PM, the Progress Notes indicated, At this time resident sitting at nursing station in geri chair [reclining chair on wheels]. Resident is sitting with legs hanging over the side of geri chair. When CN [charge nurse-Licensed Vocational Nurse (LVN) 1] attempted to reposition resident into geri chair correctly resident is noted with black/purplish discoloration to bilateral hands and wrists.Resident is grimacing (sign of discomfort) when left wrist is moved up and down. During a review of Report of Suspected Dependent Adult/Elder Abuse (SOC 341), dated 9/8/21, the SOC 341 indicated, Resident [1] was up in a geri chair 1:1 (1 staff to 1 resident) with a CNA [1] in the staff break room near the nurses station. LVN [1] witnessed CNA [1] lift resident's legs up causing him to fall back in the geri chair as he was trying to stand. The nurse overheard CNA [1] say, Im (sic) done watching you then walked away and went to sit in the staff break room. LVN [1] abserved [sic] new brusing [sic] to right and left hand/wrists and noted what appears to be brusing [sic] from fingers on the right hand.Reported types of abuse.Physical. During a review of the facility's Investigation Report, dated 9/9/21, the Investigative Report indicated, Upon further investigation, footage of surveillance camera revealed [CNA 1] sitting in the staff break room on the night of 9/8/21 with [Resident 1]. Resident [1] was sitting in a geri chair and made two attempts to rise from the chair. Resident [1] struck [CNA 1], [CNA 1] then stood up and appeared to strike resident in the upper body. [CNA 1] then walked out of the break room, then returned seconds later and pushed resident out into the hallway, in front of the nurse's station. [CNA 1] then returned to the break room and sat there until she left the building. During a review of Resident 1's Brief Interview for Mental Status (BIMS-screening tool used to assist with identifying a resident's current cognition, a score of 13-15 indicates cognitively intact, 8-12 indicates moderately impaired and 0-7 indicates severe cognitive impairment), dated 7/5/21, the BIMS indicated, Resident 1's BIMS score was 6. During an interview on 9/10/21, at 9 AM, with Director of Nursing (DON), DON stated, on 9/8/21, during the night staff telephoned her stating suspected staff of abusing Resident 1. DON stated, LVN 1 reported she was sitting at the nurse's station when CNA 1 came out of the staff break room with Resident 1 in his geri chair. DON stated, LVN 1 reported CNA 1 placed Resident 1 at the nurse's station and said I'm done watching you. DON stated, LVN 1 reported she attended Resident 1 when he attempted to get out of the geri chair that is when she saw bruising on Resident 1's hands. Resident 1's assessment indicated black/purplish discoloration to both hands, left wrist and, an abrasion to the left wrist and right shoulder. During an interview on 9/10/21, at 9:28 AM, with DON, DON stated, when she arrived at the facility that night (9/8/21), she assessed Resident 1. DON stated, the bruising on Resident 1's hands showed an imprint of three fingers to the top of both hands. DON stated, during her interview with CNA 1, CNA 1 said Resident 1 had hit her, spit on her and pinched her during the shift and she got frustrated. DON stated, CNA 1 said she protected herself by holding Resident 1's hands down with her hands over the top of his. During an interview on 9/10/21, at 9:35 AM, with DON, DON stated, during her investigation interview with LVN 4, LVN 4 reported during CNA 1's shift on 9/8/21, CNA 1 told her Resident 1 had hit, pinched and spat at her for the last few hours and she (CNA 1) was on the verge of fighting back. DON stated, LVN 4 offered CNA 1 a break, CNA 1 declined, said she was ok. DON stated, CNA 1was allowed to continue to care for Resident 1. During an observation and interview on 9/10/21, at 10:23 AM, with LVN 2 and Assistant Director of Nursing (ADON), in Resident 1's room, Resident 1 was observed with purplish discoloration to the top of both hands and an abrasion to the inner wrist area. LVN 2 stated, on the day of the incident, he was told CNA 1 was having problems that day and cried in the break room before the incident happened. LVN 2 stated, staff should notify the boss or DSD when staff were crying and upset, and the staff should be given the option to go home. During an interview on 9/10/21, at 11:18 AM, with LVN 5, LVN 5 stated, when an employee was upset, they should be offered a break, sent home, or switched to a different assignment. During an interview on 11/12/21, at 6:10 AM, with LVN 1, LVN 1 stated, on 9/8/21, CNA 1 was assigned to Resident 1. LVN 1 stated, CNA 1 pushed Resident 1, in the geri chair, out of the staff break room. LVN 1 stated, CNA 1 said to Resident 1 I'm done with you. LVN 1 stated, Resident 1 put his legs down on the side of the geri chair, as if he was going to stand as CNA 1 was about to walk away. LVN 1 stated, CNA 1 lifted Resident 1's legs straight up, Resident 1 went back into a laying position in the geri chair and CNA 1 walked away. LVN 1 stated, Resident 1 had purple bruises on his hands that he did not have before. LVN 1 stated, after further assessment Resident 1 was noted with bruising to both hands and an abrasion to his left wrist and right shoulder. LVN 1 stated, she could see something was wrong with Resident 1 because Resident 1 followed CNA 1 with his eyes, his demeanor changed, and he was very guarded when CNA 1 came out of the staff break room. LVN 1 stated, the facility regularly assigned CNA 1 to Resident 1. LVN 1 stated, Resident 1's behavior improved after CNA 1 no longer worked at the facility. During an interview on 11/12/21, at 6:34 AM, with LVN 3, LVN 3 stated, she translated for LVN 1 and Resident 1, after CNA 1 pushed Resident 1 out to the nurse's station. LVN 3 stated, Resident 1 was unable to state what happened. LVN 3 stated, she observed purple colored bruising to both the left and right hands of Resident 1. During an interview on 11/15/21, at 2:33 PM, with CNA 1, CNA 1 stated, on 9/8/21 she worked evening shift and the facility assigned her to Resident 1. CNA 1 stated, Resident 1 was very confused, non-weight bearing, very aggressive, and would hit, kick, spit, and scream. CNA 1 stated, she was left alone with Resident 1 during the whole shift. CNA 1 stated, Resident 1 was aggressive the whole time. CNA 1 stated, she took Resident 1 into the staff break room while she was on lunch because no one was helping her. CNA 1 stated, Resident 1 threw a blanket at her, tried to throw food at her, and caused her to become frustrated. CNA 1 stated, she kept Resident 1 from striking her by holding his hands. CNA 1 stated, she asked multiple co-workers for help and no one would help her. During an interview on 11/15/21, at 2:53 PM, with CNA 2, CNA 2 stated, on 9/8/21 she was working and heard CNA 1 say a couple of things about being frustrated and heard her say I'm done. CNA 2 stated, she did not inform anyone of CNA 1's verbal statements of frustration. During an interview on 11/15/21, at 3:09 PM, with DSD, DSD stated, on 9/8/21 CNA 1 asked to leave work early. DSD stated, she had talked to CNA 1 about her excessive call-ins and history of leaving early. DSD stated, staff complained about CNA 1 taking off early and disappearing during her shift. DSD stated, when staff were aware that another staff was frustrated, staff were expected to talk to them, offer them time off, provide the phone number for the Employee Assistance Program and notify her (DSD). DSD stated, after the incident the nurse reported the comments CNA 1 had made prior to the incident. During a review of the facility's policy and procedure (P&P) titled, Abuse Prevention Program dated 12/16, the P&P indicated, Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation.Protect our residents from abuse by anyone including.facility staff.Require staff training/orientation programs that include such topics as abuse prevention, identification and reporting of abuse, stress management, and handling verbally or physically aggressive resident behavior. During a review of the Lesson Plan titled, Mandated Reporting, dated 6/15/21, the Lesson Plan indicated, Course Objectives/Performance Standard.Participants will identify the signs of job stress.This includes short-temperedness.chronic absenteeism. notice signs of feeling of being overwhelmed. when at work-prioritize ask for help.if feeling stressed reach out to supervisor or HR [human resources] for assistance.

Based on observation, interview, and record review, the facility failed to limit the transmission of the COVID-19 (mild to severe illness caused by a coronavirus, is transmitted chiefly by contact with infectious material (such as respiratory droplet) and is characterized especially by fever, cough, and shortness of breath and may progress to pneumonia and [MEDICAL CONDITION]) virus for 29 of 29 (Resident 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, and 29) sampled residents in the COVID-19 dedicated units (A-wing and E-wing (units designated to be used and occupied by confirmed positive COVID-19 residents)) when: 1. The COVID-19 units were not being cleaned (removes germs, dirt, and other impurities from surfaces, but does not necessary kill them) and disinfected (kills germs on surfaces or objects). 2. Cleaning supplies were not provided to clean and disinfect the COVID-19 units. 3. Training was not provided to all staff responsible for cleaning and disinfecting the COVID-19 units. These failures had the potential to spread the COVID-19 virus to the other 27 residents on the non-COVID-19 units. Findings: 1. During an interview on 6/16/20, at 9 AM, with the Administrator, the Administrator stated there were two dedicated COVID-19 positive units in the facility, A-wing and E-wing, and currently there was a cumulative total of 29 COVID-19 positive residents on the units. The Administrator stated the nursing staff (Licensed Vocational Nurses and Certified Nursing Assistants) on the COVID-19 units were responsible for cleaning and disinfecting the units because the assigned Housekeeping Supervisor (HS), who was responsible for cleaning the COVID-19 units, tested positive for COVID-19 and has not worked since 6/8/20 (8 days ago). During a concurrent observation and interview on 6/16/20, at 10:51 AM, with LVN 2, in the A-wing, two orange buckets near the entrance of the unit were noted, one on the housekeeping cart and one on the floor next to the housekeeping cart. The bucket on the floor, next to the housekeeping cart contained a cloudy brown/black liquid and the bucket on the housekeeping cart contained cloth rags in a cloudy liquid. LVN 2 stated the buckets belonged to the HS assigned to clean the COVID-19 units but the HS has not worked since 6/8/20. LVN 2 stated there was no other staff using the buckets except for the HS. LVN 2 stated cleaning and disinfecting the COVID-19 unit was the nursing staffs' responsibility since 6/8/20, but it is not being done due to lack of time. During an interview on 6/16/20, at 12:07 PM, with Maintenance Supervisor (MS), MS stated the HS had been cleaning the COVID-19 positive units until he was taken off work on 6/8/20. MS stated there was currently one Housekeeper (HSK) 1 in the facility who was scheduled to work only in the non-COVID-19 units. MS stated he did not know who has been assigned to clean and disinfect the COVID-19 units after 6/8/20. During an interview on 6/16/20, at 12:32 PM, with the Infection Preventionist (IP) and MS, IP stated HS last worked on 6/8/20, and had designated licensed staff who were assigned to provide resident care in the COVID-19 units, to clean and disinfect the units during their shift. IP stated staff have been in-serviced to clean and disinfect residents rooms, bathrooms, and high touch areas (surfaces that have frequent contact with the hands such as tables, doorknobs, light switch, countertops, handles, toilets, faucets, sinks) with cleaning solutions. MS stated all rooms were to be cleaned daily, using multiple pre-mixed cleaning solutions that included a bleach solution with a contact time of five minutes (time that the disinfectant needs to stay wet on a surface to ensure efficacy). The IP was unable to provide documented evidence which nursing staff was assigned to clean and disinfect the COVID-19 units. The IP was not able to provide evidence the COVID-19 units had been cleaned and disinfected on 6/9/20, 6/10/20, 6/11/20, 6/12/20, 6/13/20, 6/14/20, 6/15/20, and 6/16/20. During an interview on 6/16/20, at 1 PM, with HSK 1, HSK 1 stated she was the only housekeeper currently on the schedule. HSK 1 stated the facility has five separate units, A, B, C, D, and E. She stated units A and E were COVID-19 positive units and she was not assigned to clean and/or enter the units. HSK 1 stated, I clean in unit B, C, and D. HSK 1 stated she did not know who was assigned to clean units A and E, she stated, All rooms are supposed to be clean everyday. During an interview on 6/16/20, at 2:01 PM, with CNA 1, CNA 1 stated no housekeeper has cleaned the COVID-19 units since HS was taken off work on 6/8/20. During an interview on 6/16/20, at 2:28 PM, with LVN 3, LVN 3 stated he was assigned to the COVID-19 E-wing unit for the last week. LVN 3 stated the nursing staff are responsible for cleaning and disinfecting the unit but he was unable to state when he last cleaned or disinfected the COVID-19 unit. During an interview on 6/17/20, at 8:13 AM, with LVN 4, LVN 4 stated she had worked in the COVID-19 units on the night shift. LVN 4 stated she was not sure who was assigned to clean the COVID-19 units after 6/8/20. LVN 4 stated staff assigned to provide resident care in the COVID-19 unit had started taking the trash out and tidy up. LVN 4 stated no staff mopped during the night shift on 6/9/20, 6/10/20, 6/11/20, 6/12/20, 6/13/20, 6/14/20, 6/15/20, and 6/16/20. LVN 4 stated she did the resident restrooms but not completely disinfected. LVN 4 provide no documented evidence of when and what she cleaned. 2. During a concurrent observation and interview on 6/16/20, at 10:38 AM, with LVN 1 and Director of Nursing (DON), in the E-wing COVID-19 unit, the housekeeping cart contained an unlabeled spray bottle filled with a yellow fluid, a mop bucket filled with fluid, and a small fluid filled bucket was on top of the housekeeping cart. No mop was found near or on the housekeeping cart. LVN 1 sniffed both fluids inside the mop bucket and small bucket and stated It's probably water. Both LVN 1 and DON stated there was no mop near or on the housekeeping cart. LVN 1 stated the housekeeper was responsible for providing housekeeping supplies such as mops, cleaning cloths, buckets, and disinfectant to the COVID-19 units. During an interview on 6/16/20, at 10:45 AM, with the DON, in the E-wing COVID-19 unit, the DON stated the expectation was for the assigned staff in the unit to perform housekeeping duties but it appeared it was not being done and stated there was no mop in the housekeeping cart. 3. During an interview on 6/16/20, at 9 AM, with the Administrator, the Administrator stated there were two dedicated COVID-19 positive units in the facility, A-wing and E-wing, and currently there was a cumulative total of 29 COVID-19 positive residents on the COVID-19 units. The Administrator stated the nursing staff in the COVID-19 units were responsible for cleaning and disinfecting the units because the HS who was assigned to clean and disinfect the COVID-19 units has not worked since 6/8/20. The Administrator stated the MS was covering for the HS but was not responsible to clean the COVID-19 units (A-wing and E-wing). The Administrator stated the HS trained the A-wing nursing staff prior to 6/8/20. During an interview on 6/16/20, at 10:51 AM, with LVN 2, in the A-wing, LVN 2 stated there were 16 residents in A-wing and there was no housekeeper assigned to clean and disinfect the unit. LVN 2 stated there was no training provided to nursing staff on how to clean and disinfect the COVID-19 unit. During an interview on 6/16/20, at 12:31 PM, with the Administrator, the Administrator was unable to provide evidence of nursing staff being trained on how to clean and disinfect the COVID-19 units. The Administrator stated the nursing staff should have been trained on how to clean and disinfect the COVID-19 units. During an interview on 6/16/20, at 1:03 PM, with the MS, the MS stated he did not provide any training to the nursing staff on how to clean and disinfect the COVID-19 units. During an interview on 6/16/20, at 2:01 PM, with CNA 1, CNA 1 stated she has worked in the COVID-19 unit A. CNA 1 stated staff assigned to provide resident care in the COVID-19 units cleaned hallway rails, door knobs, resident bed side table, and trash were picked up in the resident's restrooms. CNA 1 stated she has never been in-serviced on how to clean and disinfect resident rooms and restrooms. CNA 1 did not know the contact time for the unlabelled spray bottle used to disinfect the COVID-19 units. CNA 1 stated, No, never had someone to tell me step by step. The housekeeper that was here would say this spray is to kill this and that. He would tell me the contact time but he was just talking to pass time. I honestly don't remember. During an interview on 6/16/20, at 2:28 PM, with LVN 3, LVN 3 stated he was assigned to the E-wing COVID-19 unit and it was the nursing staffs' responsibility to clean the unit. LVN 3 stated he was not provided training on how to clean and disinfect the unit. During an interview on 6/17/20, at 8:13 AM, with LVN 4, LVN 4 stated she has worked in the COVID-19 unit during the night shift. LVN 4 stated staff assigned to provide resident care in the COVID-19 unit had started taking trash out and tidy up. LVN 4 did not know the contact time for the unlabelled disinfecting bleach solution, did not know high touch areas including but not limited to resident side rails, call lights, bedside tables. LVN 4 stated, Oh yeah that would be good, I never thought of that. LVN 4 stated she has never been in-serviced on cleaning and disinfecting residents' rooms and restrooms. She stated, Nobody ever comes and talks to me, I know my name is listed on getting in-serviced on everything but nobody has ever talked to me. During a review of the facility's policy and procedure (P&P) titled, Cleaning and Disinfecting Residents' Rooms, dated 8/13, the P&P indicated, The following equipment and supplies will be necessary when performing this procedure. 1. Supplies and equipment appropriate for the task.a. Disinfectant solution; b. Cleaning cloths; c. mop; d. Bucket; and e. Personal protective equipment.Resident Room Cleaning: 1. Gather supplies as needed. 2. Prepare disinfectant according to manufacturer's recommendations. 3. Discard disinfectant/detergent solutions that become soiled or clouded with dirt and grime and prepare fresh solution. 4. Change mop solution water at least every three (3) rooms, or as necessary. 5. Change cleaning cloths when they become soiled. Wash cleaning cloths daily and allow cloths to dry before reuse. 6. Clean horizontal surfaces.daily with a cloth moistened with disinfectant solution. 7. Clean personal use items.with disinfectant solution at least twice weekly. 8. When cleaning rooms of residents on isolation precautions, use personal protective equipment as indicated. 9. When possible, isolation rooms should be cleaned last and water discarded after cleaning room. 10. Utilize disinfectant solution based on type of precaution. 11. Clean curtains, window blinds, and walls when they are visibly soiled or dusty. During a review of the facility's policy and procedure (P&P) titled, Cleaning and Disinfection of Environmental Surfaces, undated, the P&P indicated, 10. Environmental surfaces will be disinfected (or cleaned) on a regular basis. and when surfaces are visibly soiled. 12. Disinfecting. solutions will be prepared as needed and replaced with fresh solution frequently.13. Mop heads and cleaning cloths will be decontaminated regularly.19. In units with.an outbreak setting, dilute solutions of 5.25 %-6.15 % sodium hypoclorite.will be used for routine environmental disinfection. According to Centers for Disease Control and Prevention (CDC-federal agency in the Department of Health and Human Services that investigates, [DIAGNOSES REDACTED]. Recommends use of EPA (Environmental Protection Agency- protects people and environment from significant health risks, sponsors and conducts research, and develops and enforces environmental regulations) registered disinfectant. Follow the instruction on the label to ensure safe and effective use of product.