Every finding on record at Lompoc Valley Medical Center Comprehensive Care Ce

Based on observation, interview, and record review, the facility failed to prepare food in accordance with professional standards on food safety when the cook (Cook 1) was observed using his apron to wipe his face with a gloved hand during food tray preparation.This failure had the potential for contamination that may cause Foodborne illness (food poisoning - results from consuming food or drinks contaminated by bacteria, viruses, or parasites).During an observation on 3/23/26 at 12 p.m., in the kitchen during food tray preparation, [NAME] 1 was observed grabbing his apron and wiping his face with his left gloved hand.During an interview on 3/23/26 at 3:30 p.m., with the Food Service Director (FSD), FSD stated that [NAME] 1 should have removed his gloves, washed hands, and then donned on new gloves before proceeding with the food preparation.During the review of the facility's policy and procedure (P&P) titled Proper Handwashing and Glove Use dated, 2020, the P&P indicated Employees will wash hands before and after handling foods, after touching any part of the uniform, face, or hair, and before and after working with an individual resident.

Based on observation, interview, and record review, the facility failed to ensure medications were stored and labeled according to the manufacturer's specifications and facility process/practice.This failure could potentially expose residents to expired supplies with questionable efficacy and the facility could not ensure medications were safely stored to ensure their integrity. During an observation on [DATE], at 7 a.m., in the middle station, a medication cart was observed with the following medications not labeled with the dates of opening:Metamucil 15 oz (425 gram) (a laxative to relieve constipation)Docusate Sodium 100 mg (milligram) (stool softener)Docusate Sodium 50 mg (stool softener)Glucosamine Chondroitin 250 mg (supplement to help ease pain and improve function in osteoarthritis [breakdown of cartilage])Oysco 500 + D3 (supplement for low calcium levels)Vitamin D3 10 mcg (micrograms) (400 IU [International Units]) (supplement that promotes calcium absorption)Folic Acid 400 mcg (supplement for producing new cells and red blood cell formation)Genteal Tears (eye lubricant)Two Systane eye drops (eye lubricant)Three Refresh eye drops (eye lubricant)Pataday Opthalmic Solution (for itchy, allergic eyes)In addition, Insulin Lispro (manages high blood sugar levels) 100 units/ml (milliliters). box, unopened, was observed in the medication cart drawer. The manufacturer's recommendation on the box was reviewed, and indicated, Store refrigerated at 36 F to 46 F until time of use.During an interview on [DATE], at 7:05 a.m., with the Registered Nurse Supervisor (RNS), the RNS reviewed the observed medications and stated, The medications should have an opening date, and the insulin should have been stored in the refrigerator and not in the medication cart drawer.During an interview on [DATE], at 8 a.m., with the Director of Nursing (DON), the DON said the facility does not have a policy and procedure on labeling with opening dates on medications, but it was facility practice to label medications with dates upon opening medications. The DON further confirmed that the insulin vial should have been stored in the refrigerator.

Based on interview and record review, the facility failed to submit required staffing and payroll data to the Centers for Medicare & Medicaid Services (CMS) through the Payroll Based Journal (PBJ) system (the federally mandated mechanism used by long term care facilities to report staffing information regularly to ensure completeness and accuracy of data submitted to CMS).This facility failure has the potential to result in not having accurate and timely staffing information necessary to evaluate the facility's compliance with federal staffing requirements. Findings:During a review of the PBJ Staffing Data Report, CASPER (Certification and Survey Provider Enhanced Reports) Report 1705D for Quarter 1 of 2025 (October 1 - December 31), it was indicated that the facility failed to submit data for the quarter and subsequently received a one star staffing rating.During an interview conducted on 3/25/26 at 11 a.m. with the Director of Nursing (DON), the DON verbalized they were responsible for submitting staffing information to CMS. The DON further stated that the facility had been undergoing a change in administration and did not realize the staffing data had not been uploaded until the one star staffing rating was observed.

Based on interview and record review, facility failed to administer a prescribed medication (Bimatoprost - medicine to lower pressure in the eye) and notify the physician per professional standards of practice and facility policy and procedure (P&P) for one of three sampled residents (Resident 2). This failure led to Resident 2 missing 22 doses of the prescribed medication, and had the potential to cause worsening glaucoma (condition that damages the optic (eye) nerve due to high eye pressure), vision changes, and increased eye pressure.During a review of Resident 2's admission Record (AD), the AD indicated Resident 2 was admitted to the facility on [DATE] with diagnoses including diabetes (disease that affects how the body uses glucose) dementia (brain disorder that affects memory), anxiety, open-angle glaucoma (chronic eye condition characterized by increased pressure in the eye, potentially leading to optic (eye) nerve damage and vision loss) and legal blindness. During a review of Resident 2's physician order dated 3/12/25, the physician order indicated, Bimatoprost Solution 0.03% Instill 1 (one) drop in both eyes in the evening for increased IOP (intraocular [inside the eye] pressure). During a concurrent interview and record review on 7/17/25 at 2:35 p.m. with the Director of Nursing (DON), Resident 2's Medication Administration Record (MAR) dated June 2025 was reviewed. The MAR indicated Bimatoprost was not administered on the following dates: 6/1/25, 6/5/25, 6/6/25, 6/7/25, 6/8/25, 6/9/25, 6/10/25, 6/11/25, 6/12/25, 6/13/25, 6/14/25, 6/15/25, 6/16/25, 6/17/25, 6/18/25, 6/19/25, 6/20/25, 6/21/25, 6/22/25, 6/23/25, 6/24/25, and 6/25/25. DON acknowledged the Bimatoprost medication was not administered to Resident 2 for 22 days. During a concurrent interview and record review on 7/17/25 at 2:42 p.m. with DON, Resident 2's progress notes were reviewed. The progress notes indicated there was no documented evidence that the physician was notified of the missed Bimatoprost medication doses on the above said dates. DON stated, There is nothing documented. Review of [NAME] and [NAME], Tenth Edition, Fundamentals of Nursing, page 640 in the section titled Medication Errors indicated, Medication errors include . failing to administer a medication .Medication errors can be caused by many factors such as . medication distribution systems. notify the health care provider of the incident as soon as possible. During a review of the facility's policy and procedure (P&P) titled Medication Administration dated 6/24, the P&P indicated Policy's purpose: to have all medications administered according to the physicians order. If a medication error is made the physician is notified by telephone .

Based on observation, interview, and facility policy review, the facility failed to follow professional food storage standards for labeling food in 1 of 1 walk-in freezer in the facility kitchen. Findings included: An undated facility policy titled Procedure For Refrigerated Storage revealed, 10. Leftovers will be covered, labeled and dated. (See leftover policy section 7.). The policy also revealed, 13. Individual packages of refrigerated or frozen food taken from the original packing box need to be labeled and dated. An undated facility policy titled, Food Preparation - Leftover Foods, indicated, Leftover foods are those that have been prepared for a meal and not served. 1. Storage of food B. Label and date. An initial tour of the kitchen was conducted on 02/03/2025 at 8:47 AM with the Food Nutrition Director (FND). During the tour of the facility's walk-in freezer, one clear, gallon-sized freezer bag of fruit slices and one clear, quart-sized freezer bag with a leftover waffle were observed without any description of the contents or the date the products were opened. During an interview on 02/03/2025 at 8:47 AM, the FND stated that they were unsure why the fruit slices and waffle were not labeled or dated. A follow-up tour of the kitchen was conducted on 02/04/2025 at 11:22 AM with the Food Production Supervisor (FPS). During an observation of the walk-in freezer, one clear package containing deli meat slices was observed without any description of the contents or date the product was opened. During an interview on 02/04/2025 at 11:22 AM, the FPS stated that they had forgotten to label and date the package. During an interview on 02/05/2025 at 9:16 AM, Food Service Worker (FSW) #3 stated that, when a food item was opened, they must ensure the package was labeled with the date it was opened, a description of contents, and a best by date. During an interview on 02/05/2025 at 9:23 AM, [NAME] #2 stated they had a sticker they used to label food items. [NAME] #2 stated when a food package was opened, they had to label the item with the date that it was opened, a best by date, and a description of contents. She stated after six days, they had to remove those items and discard any food item that did not have a date. [NAME] #2 further stated it was their responsibility to check for food items that were not labeled and throw them away. Per [NAME] #2, she was not sure why there were food items that were not labeled in the walk-in freezer. During an interview on 02/05/2025 at 9:29 AM, [NAME] #1, the lead cook, stated that leftover food should be doubled bagged and labeled with the date it was opened and the date that it should be used by. [NAME] #1 stated that it was [NAME] #2's responsibility to discard all non-labeled items or items stored past their use by dates. [NAME] #1 stated they had new staff who she believed did not know their process. During an interview on 02/05/2025 at 9:36 AM, the FPS stated left over food items should be labeled with the date it was opened and a use by date. The FPS further stated that it was the responsibility of [NAME] #2 to ensure all food items were properly labeled and stored. During an interview on 02/05/2025 at 9:45 AM, the FND stated they expected all food to be stored in a plastic bag and labeled with the contents and the date it was opened. The FND stated after seven days, the food should be thrown away. Per the FND, it was everyone's responsibility to ensure food items were labeled, dated, and stored properly. During an interview on 02/05/2025 at 2:43 PM, the Director of Nursing (DON) stated they expected staff to label food items with the date it was opened and to discard all items past their expiration dates. The Administrator was interviewed on 02/05/2025 at 2:46 PM. The Administrator stated all food items should be labeled with the date it was opened and discarded by the expiration date or within five days of the opened date.

Based on interview and record review the facility failed to implement abuse prevention policy when two residents (Resident 1 and 2) had an alleged abuse incident on 7/17/24 for which no interventions were implemented for two days after the alleged physical abuse incident occured. The facility's failure had the potential for the physical abuse incident to reoccur within those two days. Findings: A review of the facility's policy and procedure titled Prevention of Abuse , dated 3/24, indicated 1. It is the policy of this facility to take every proactive measure to prevent the occurrence of alleged abuse of any resident. 2. Residents must not be subject to abuse by anyone, including . other residents. 10. If suspected perpetrator is another resident: Separate the residents so that they do not interact with each other until the circumstances of the reported incident can be determined. 11. All incidents of witnessed, suspected, or alleged abuse are investigated . Facility shall report all incidents of alleged abuse/neglect or suspected abuse/neglect to CDPH within 24 hours and the results of the investigation are reported to CDPH within 5 working days of the incident .12. 1) Abuse: the willful infliction of injury . Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. 2) Abuse by one resident to another: Abuse by one resident to another can be a serious situation. This incidents are reported immediately to the nursing team leader and supervisor and immediate steps are taken. This steps may include: Temporarily separating the Residents from each other. Determine the cause for the abuse and intervene as appropriate. Notify the physicians and responsible parties. Closely monitor the residents. Care plan the interventions . Physical Abuse: Hitting, slapping, pushing, shoving, twisting, squeezing, pinching, and kicking. The California Department of public health (CDPH) received a facility reported incident (FRI) on 7/19/24 reporting that 7/19/24 at 1:15 p.m., Resident 2 reported Resident 1 grabbed and squeezed her arm 7/17/24 around 4:00 p.m., in the activities room. Resident 1's medical record was reviewed on 8/1/24. Record indicated resident's BIMS score was 14. A score of 13 to 15 suggests the resident is cognitively intact, 8 to 12 suggests moderately impaired and 0 to 7 suggests severe impairment. Diagnosis included stroke (brain damage) with expressive aphasia (difficulties verbally expressing needs), right side of body impaired and uses wheelchair for mobility. During an interview with Resident 1 on 8/1/24 at 2:52 p.m., resident stated She (Resident 2) ranned me over with her wheelchair. She did it intentionally, on purpose. I thought the way to handle matters was to grab her by the arm. Resident 1 was asked if he was temporary separated from Resident 2 after the incident. Resident 1 stated No, I see her (Resident 2) during breakfast, at activities, I see her (Resident 2) all the time . Resident 2's medical record was reviewed on 8/1/24. Record indicated resident's BIMS score was 15. Diagnosis included left side of upper body impaired due to a brain stroke and psychoactive substance abuse. During an interview with Resident 2 on 8/1/24 at 3:03 p.m., resident stated He (Resident 1) grabbed my arm so hard that I was saying aww, aww. During an interview with activities leader (AL) on 8/1/24 at 12:42 p.m., AL confirmed witnessing the alleged abuse incident between the two residents (Resident 1 and 2) on 7/17/24 around 4: 00 p.m., AL stated [Resident 1's name] was on the pathway when [Resident 2's name] was going towards the door to the patio, to go smoke. [Resident 2's name] intentionally charged and ran into [Resident 1's name] wheelchair, running over his feet. It was like [Resident 2's name] said you're in my way so I'm going to run over you . She (Resident 2) did this intentionally. [Resident 1's name] then grabbed her (Resident 2) arm and squeezed it. [Resident 2's name] was saying ouch ouch. I intervened and separated them. I called and reported this to the supervisor [Supervisor's name], she said she will follow up later. Later, I checked on [Resident 1's name] , he said She (Resident 2) ran into me on purpose. During a concurrent review of Resident 2's document titled Activity Dining Room Code of Conduct and interview with the activities director (AD) on 8/1/24 at 12:52 p.m., the AD reported that on 7/12/24 the Code of Conduct rules were reviewed with Resident 2 because resident had been loud, use foul language and disturbing others, in the past. However, on 7/12/24, the resident was out of control, especially, with the use of foul language that necessitated for the AD to review and remind the resident of the rules listed on the Code of Conduct document. During an interview with the nursing supervisor (NS) on 8/1/24 at 2:10 p.m., NS confirmed being notified by activities leader (AL) regarding Resident 1 and Resident 2 alleged abuse incident (altercation) on 7/17/24. NS reported, later, checking on Resident 1. Resident 1 was upset with Resident 2 but with his expressive aphasia it was difficult to understand him and was getting frustrated. Later, NS checked on Resident 2 who was up on the front of the facility, at the time. According to NS, Resident 2 denied being hurt. Therefore, NS did not think this was a resident -to-resident abuse and nothing was done about this. On 7/19/24, Resident 2 reported to nursing staff that on 7/17/24 Resident 1 had grabbed her arm and hurt her. An investigation was initiated on 7/19/24 where details were discovered that on 7/17/24 Resident 2 intentionally ran into Resident 1's wheelchair, running over his feet. Then, Resident 1 grabbed Resident 2's arm and squeezed it. Resident 2 was saying ouch, ouch . NS was asked if on 7/17/24 when she checked on Resident 1 and 2, did she asked residents if there was any physical contact between them or did she asked the details of the incident. NS stated No, I did not . NS was asked if she performed an assessment of both residents on 7/17/24 and documented the assessment in the medical record. NS stated No I did not. I did not document any assessment or incident details etc. I did not write any notes in the residents record. I didn't think I needed to since they were both fine. During a concurrent review of the facility policy titled Prevention of Abuse and interview with the facility manager (FM) on 8/1/24 at 3:45 p.m., the FM acknowledged and confirmed for two days, from 7/17/24 to 7/19/24, the facility did not implemented their policy and procedure related to abuse by one resident to another. FM confirmed on 7/17/24, date of the alleged abuse incident, the facility did not 1. Temporarily separated the residents so they do not interact with each other until investiagtion was completed. 2. Determine the cause for the abuse. 3. Notify the physicians and responsible parties. 4. Closely monitor the residents. 5. Initiate care plan with interventions. 6. Physical assessment of residents involved was not completed with findings documented in the record. Facility did not report alleged abuse incident to CDPH within 24 hours of incident. Furthermore, FM agreed the facility cannot account for Resident 1 and Resident 2 whereabouts and interactions between the two of them from 7/17/24 to 7/19/24, two days from the alleged abuse incident.

Based on observation, interview, and record review, the facility failed to ensure staff was available to answer a resident's call light for one of two residents (Resident 1), when the resident requested assistance to go to the bathroom for toileting needs. This failure had the potential for the resident to be incontinent and also cause psychosocial harm. Findings: During a review of the facility document titled, Nursing Staff Sheet (NSS), dated 4/28/24, the NSS indicated for 3-11 shift (afternoon), the census was 88 and seven certified nursing assistants (CNAs) were scheduled for patient care. The NSS further indicated, each CNA had approximately 12 to 13 residents each to care for. During an interview on 5/13/24 at 10:43 am with the director of nursing (DON), the DON stated, We are not understaffed .We currently do not have any staffing waivers . In this facility the expectation is that anyone that works here and sees or hears a call light they are expected to go in and at least see what the resident needs . During a review of Resident 1's Face Sheet, dated 5/13/24, the face sheet indicated, Resident 1 was admitted on [DATE], with diagnoses that included, hemiplegia (paralysis of one side of the body) and hemiparesis (inability to move one side of the body) following acerebral infarction (stroke-disrupted blood flow to the brain) affecting left non-dominant side. During a review of Resident 1's Minimum Data Set (MDS-assessment of current health conditions), dated 5/8/24, the MDS indicated, a BIMS (brief interview of mental status) score of 15, which indicated intact cognition (alert mental processes), no behavioral issues, with upper and lower impairment on one side (left of the body), continent of bladder but requiring maximum assistance for toileting. During a review of Resident 1's Care Plan (CP), revised 9/21/23, the CP indicated, Resident 1 had impaired functional abilities related to left hemiparesis, full dependence on toileting, potential elimination concerns related to hemiparesis with interventions including but not limited to, answer all call bells promptly to ensure continued continence of bowel and bladder; and scheduled/habit toileting program: upon awakening, before and after breakfast, before and after lunch, before or after supper, at bedtime, and during the night if resident is awake. During a concurrent observation and interview on 5/13/24 at 11:53 am with Resident 1 inside the resident's room, Resident 1 was sitting on a wheelchair, and a urinal (plastic container to urinate in) was hanging on a bedside rail. Resident 1 attested to an incident on 4/28/24 and stated in part, They seem to treat people like cattle here. When they ignore my call light, I went on my wheelchair to the nurses station and told (name of licensed nurse 1 -LN1), I need help going to the bathroom. (Name of LN1) said, I have an assigned CNA and to go back to my room and wait. But I told (name of LN1) I need to go but she keep arguing with me about their staffing. One CNA has like 17 people to care for and they don't help each other out, the supervisors just sits and don't help, and since my time here, their answering of the call light is a constant problem. I stopped going to my care meetings as it's just a big show, I am going to be rude when they treat me like a piece of meat, I have started taking notes regarding response time, if I am in bed, I can use the urinal, but if I am on the wheelchair I can't. My left arm and leg has been affected by stroke and it is hard for me to use the urinal. During an interview on 5/13/24 at 12:26 pm with CNA1, CNA1 stated, .I was on dinner break that night . the resident was upset about staff getting him to the bathroom . his biggest complaint was that the light was on and nobody got there quick enough for him . I know he uses the urinal, but I don't think he uses it when he is in his chair. When he is in the chair, he uses the call light then we take him to the bathroom. We use the easy stand with him to get him to the toilet, and off the toilet. On the weekends we can be shorter staffed, on the weekends there should be ten CNA's, and sometimes people call in, I stayed that day for a double shift and had him (Resident 1) the entire time. As far as the time to get to a room with a call light on I do not know an actual time frame .Usually I would have ten residents, but it can change due to the census .that night he was in his chair not the bed when he used the call light .

Based on interview, record review, and facility policy and procedure (P/P), the facility failed to ensure the environment was free of accidents when one of three residents (Resident 1's) wheelchair was not safely maintained. Resident 1's wheelchair left lock was broken. This facility failure resulted in Resident 1's wheelchair sliding backwards and the resident sustaining an assisted fall from the wheelchair. Findings: During a record review of Resident 1's Face Sheet, (a document that gives a patient's information at a quick glance) the Face Sheet indicated, Resident 1 was admitted to the facility on [DATE] with diagnoses that included, dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), Chronic Kidney Disease (when kidneys cannot filter blood as they should), and Diabetes (too much sugar in the blood). During a review of an assessment form titled, Resident Assessment Instrument (RAI - a document utilized to assess the nursing need of a resident), dated 10/23, the RAI indicated, Definitions . Fall: Unintentional change in position coming to rest on the ground or onto the next lower surface (e.g., onto a bed, chair, or bedside mat), but not as a result of an overwhelming external force. During a record review of Resident 1's Morse Fall Scale (MFS - rapid and simple method of assessing a patient's likelihood of falling), dated 12/2/23, the MFS indicated, Resident 1 was a High Risk for Falling. During a record review of Resident 1's Nursing Progress Note (NPN), dated 12/2/23 at 7:48 a.m., the NPN indicated, while assisting Resident 1 to transfer from bed to wheelchair, Resident 1 slid off the wheelchair to the floor with the wheelchair breaks on. During an interview on 1/3/24 at 10:57 a.m. with Licensed Nurse (LN 1), LN 1 confirmed while Resident 1 was being transferred from the bed to the wheelchair, the wheelchair was locked but the wheelchair slid backwards, and Resident 1 slid to the floor. During an interview on 1/17/24 at 1:21 p.m. with Facility Engineer (FE), the FE confirmed the left side lock on Resident 1's wheelchair was not working, causing the wheelchair to move backwards. During a review of the facility's policy and procedure (P&P) titled, Bio Medical Equipment, dated 3/16/21, the P&P indicated, PURPOSE: To assure that medical equipment is maintained at an acceptable level of quality and safety . POLICY: the organization shall make adequate provisions to ensure the availability and reliability of equipment needed for its operations and services.

Based on interview and record review, the facility failed to provide evidence that an allegation of abuse was thoroughly investigated for one of two residents (Resident 1). This failure had the potential for further abuse to occur to residents. Findings: During a review of Resident 1's Face Sheet, (a document that gives a patient's information at a quick glance) the Face Sheet indicated, Resident 1 was admitted to the facility on ,d+[DATE]//23 is with a diagnoses that included, Cardiac Arrest (when the heart stops beating suddenly), Heart Failure (condition that develops when your heart doesn't pump enough blood for your body's needs), Chronic Kidney Disease (condition in which kidneys are damaged and cannot filter blood as well as they should) and an Aneurysm (an abnormal bulge or ballooning in a blood vessel). During a review of Resident 1's Nursing Progress Note (NPN), dated 12/12/23 at 9:20 a.m., the NPN indicated, Alerted by CNA (certified nursing assistant) Resident 1's responsible party (RP) had phoned the facility while on the phone with Resident 1', she stated, she was going to call the police to report molestation (sexual assault or abuse of a person) occurring at the facility. Supervisor was immediately informed and DON was notified of the conversations. During a review of Resident 1's General Nursing Note, dated 12/14/23, the Note indicated, Resident 1 was pleasant and cooperative with personal and nursing care (2 person assist) and Resident 1 was able to verbalize needs and needs were met. During a review of a Facility Reported Incident (FRI) dated 12/12/23 indicated, Social Services (SS) was immediately called to speak to the resident following the incident and Resident 1 had stated that he felt violated when the CNA asked him to roll over to clean his buttock. Further reviews did not show any evidence that the alleged violations were thoroughly investigated. During a review of the facility's policy and procedure (P/P) titled, Prevention of Abuse, last revised 4/22, the P&P indicated, 1. Policy. It is the policy of this facility to take every proactive measure to prevent the occurrence of alleged abuse to any resident. 7. All incidents of witnessed, suspected, or alleged abuse are investigated and information is delivered to the supervisor on duty or the Director of Nursing. Upon receiving the report, the supervisor or Director of Nursing communicates allegation to Administrator and status of investigation. The P&P further indicated, The investigation and report shall include . outcome of investigation, and follow-up resolution or further action if necessary. Further review of records did not show the alleged abuse was investigated and information delivered to the supervisor on duty or the DON upon receiving the report. Nor was there evidence the facility immediately put effective measures in place to ensure further potential abuse or mistreatment did not occur while the investigation was in process. During a concurrent interview and record review on 1/2/24 at 12:19 p.m., with Director of Nursing (DON), the facility's P&P titled, Prevention of Abuse, last revised 4/22 was reviewed. DON confirmed there was no outcome of the investigation reported and stated, There was no formal investigation, there are no results.

Based on interview and record review, the facility failed to ensure one of 3 sampled residents (Resident 1), was free from physical restraint when Resident 1 was tied to a wheelchair with a scarf. This facility failure has the potential to cause injury to the resident. Findings: During a review of Resident 1's clinical records titled History and Physical on 8/1/23 at 8:20 p.m., indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that include hypertension (high blood pressure), ataxia (loss of muscle control in the arms and legs), major depressive disorder, and Dementia (the loss of cognitive functioning thinking, remembering, and reasoning to such an extent that it interferes with a person's daily life and activities). Further review of clinical records indicated, Resident 1 is non-verbal, wheelchair bound, requires extensive assistance and supervision. During an interview with Licensed Nurse (LN 1) on 8/3/23, at 3:11 p.m., LN 1 explained that Resident 1 was sitting in the middle nursing station when she observed the resident with a leopard print scarf wrapped around her upper chest, and tied in the back, underneath the wheelchair handles, preventing her from moving. During a review of Resident 1's medical record on 8/11/23, at 1:55 p.m., there was no documentation indicating a medical symptom that required the use of a restraint and no physician's order for restraint were noted. Further reviews did not show, there were any nursing notes documenting the use of restraint. During an interview with LN 2 on 8/14/23 at 2:00 p.m., LN 2 acknowledged Resident 1 was restrained with a scarf on her wheelchair on the night of 7/28/23. LN 2 confirmed, the facility was a restraint free facility and there was no order for restraints for Resident 1. During a review of the facility's policy & procedure (P&P) titled, Physical Restraints dated 9/2019, the P&P indicated, 2. Background: All residents have the right to be free from restraint of any form, imposed as a means of coercion, discipline, convenience, or retaliation by staff and not required to treat the resident ' s medical symptom . 3. Definitions: a. Physical restraint: Physical restraint is any manual method, physical or mechanical device, material, or equipment attached or adjacent to the resident ' s body that the individual cannot remove easily which restricts freedom of movement or normal access to ones ' body .Placing a resident in a chair that prevents from rising. The P&P further indicated, d. Restraint Order 1. A licensed independent practitioner must give an order for the use of restraints . F. Documentation 1. The use of a restraint must be addressed in the resident's care plan.

Based on observation, interview, and record review, the facility failed to ensure a call light was within reach, for one of three sampled residents (Resident 1). This facility failure had the potential for Resident 1 not being able to call for help, and a delay in receiving care. Findings: During a concurrent observation and interview on 6/21/23 at 10:15 a.m. with Resident 1, inside Resident 1 ' s room, Resident 1 was instructed to push the call light (device for residents to be able to request assistance from staff). Resident 1 verbalized, the call light was not within reach. Resident 1 stated would have to get out of the wheelchair and sit on the bed to reach the call light. Resident 1 ' s bed was observed positioned in the corner of the room, against the wall lengthwise with the top right bed rail against the wall, and the head of the bed against the adjoining wall. The call light was vertical, with the upper end of the call light extended from the wall above the top right bed rail, and the bottom end of the call light, which contained the button to push for help, downward on the right side of Resident 1 ' s bed. During a concurrent observation and interview on 6/21/23 at 11:16 a.m. with Licensed Nurse (LN 1) and the Social Worker (SW), in Resident 1's room, Resident 1's call light was observed. Resident 1's bed was positioned in the corner of Resident 1's room, against the wall lengthwise with the top right bed rail against the wall, and the head of the bed against the adjoining wall. The call light was vertical, with the upper end of the call light extended from the wall above the top right bed rail, and the bottom end of the call light, which contained the button to push for help, downward on the right side of Resident 1's bed. LN 1 and SW both stated Resident 1 could not reach the call light when sitting in the wheelchair. During a review of Resident 1's Face Sheet, dated 7/2/22, the face sheet indicated, Resident 1 had diagnoses including, syncope (fainting or passing out) and collapse, anemia (lack of healthy red blood cells), abnormal electrocardiogram (records electrical signals from the heart to check for different heart conditions), fracture (break in a bone) of one rib - right side, fracture of third metacarpal (bone in the hand) bone -right hand, fracture of fourth metacarpal bone - right hand, nontraumatic (not caused by or associated with an injury) subarachnoid hemorrhage (bleeding in the brain), hypoosmolality (common disorder of fluid and electrolyte balance produced by retention of water, by loss of sodium or both) and hyponatremia (low sodium), residual effects of cerebral infarction (disrupted blood flow to the brain), monoplegia (complete or partial loss of muscle function to one area of the body) of upper limb of dominant side, polyneuropathy (multiple peripheral nerves become damaged). During a review of Resident 1's Care Plan date initiated 07/02/2022, the Care Plan indicated in part, keep call light within reach while in the room . keep call light to resident ' s left side. During a review of Resident 1's Care Plan, date initiated 06/07/2023, the Care Plan indicated in part, Ensure . call light and personal items are within reach. During a record review of Resident 1's Order Summary, dated 6/08/23, the order summary indicated in part, ensure . call light and personal items are within reach.

Based on interview, and record review, the facility failed to ensure when they posted the signage facility closed for visitation on 11/17/22 through 11/22/22 because of increased cases of respiratory infections inside the facility, the directions were explained and communicated to residents' families, other staff, and visitors. This failure resulted in family members and visitors not able to visit their loved ones for interpreting the signage as visitors not allowed. Findings: During an interview on 12/15/22, at 11:11 a.m., with the ombudsman (an advocate for residents of nursing homes), the ombudsman stated that during a visit at the facility on 11/18/22, a sign was posted at the facility main entrance that indicated, The CCC is currently closed for visitation due to an increase in respiratory infections. Please call for more information. The ombudsman further stated the director of nursing (DON) clarified the signage and stated to the ombudsman that the facility consulted with the Santa [NAME] County Public Health Department (SBCPHD) to close visitation at the facility due to a potential outbreak of Respiratory Syncytial Virus (RSV). During an interview on 12/08/22 at 10:02 a.m., with the DON, the DON verbalized that the facility has Corona Virus (COVID) positive residents and residents who had respiratory symptoms. The DON consulted with SBCPHD with the decision and verbalized that in-door visitation would be put on hold until the outbreak was under control but would continue window visits, zoom calls and visitors who wanted to feed family members were allowed. During a review of an electronic mail dated 12/16/22, the Long-Term Care Ombudsman of Santa [NAME] wrote in part, Out of the 14 Skilled Nursing Facilities (SNF's) in the county, the facility was the only one that stopped visitation . We are all concerned about the outbreaks .the facility has to be proactive . but not placing a sign at the front door where anyone reading it will turn around and go back home. The DON was not able to provide evidence that residents' families, other staff, and visitors, were informed of visitation and/or alternatives.

Based on interview, and record review, the facility failed to maintain an effective pest control program, when a termite infestation was discovered in one of two sampled residents (Resident 1) rooms. This failure resulted in termites being found in Resident 1's room and had the potential to be a contributing factor in Resident 1 sustaining a fall at the facility. Findings: During a review of General Nursing Notes dated 9/3/22 at 5:52 p.m., the General Nursing Note indicated in part, Resident 1 was found on the floor after trying to kill a bug. During an interview on 9/21/22, at 11:54 a.m., with Resident 1, Resident 1 stated I did see a black bug and I just pushed it away. During an interview, on 9/20/22, at 1:30 p.m., with facility administrator (ADM), ADM verbalized They were flying termites seen in the resident's (Resident 1) room . During a review of Wood Destroying Pests and Organisms Inspection Report , dated 9/7/22, the report indicated in part, evidence of drywood termite infestation was found in Resident 1's room, the Soiled Utility Room and Clean Utility Room, and appears to extend into inaccessible areas of the structure . During an Interview on 9/20/22 at 1:40 p.m., with maintenance representative (MNT 1), MNT 1 stated We have also seen termites in the patio and there is nothing we can do .complete termination will include tenting of the facility and fumigation, we need to close down the facility.

Based on observation, interview, and record review, the facility failed to maintain infection control practices when: 1. Glucometers (machine used to measure blood sugar) were not cleaned and disinfected per manufacturer's instructions for use. 2. Staff did not change gloves after cleaning dirty surfaces in the resident's room before getting supplies from the clean supply cart. 3. N95 respirators were not disposed after use per infection control guidelines. 4. Dirty personal protective equipment (PPE) was reused by staff while collecting laundry. These facility failures had the potential to result in cross-contamination (the transfer of harmful bacteria) that could impact residents' health and safety and cause preventable HAIs (Healthcare Associated Infections) for residents in an already compromised condition. Findings: 1. Review of the manufacturer's instructions for use titled, Stat Strip, undated, indicated in part . Clean and disinfect after each patient use by following this protocol . cleaning is not the same as disinfecting . Warning: To ensure proper disinfection, it is important to clean the meter (step1) prior to disinfecting the meter (Step 2) 1. Clean the meter. Remove a fresh germicidal wipe from the canister. Wipe the external surface of the meter thoroughly with a fresh germicidal disinfecting bleach wipe. Discard the used wipe into an appropriate biohazard container. 2. Disinfect the meter. Using a new, fresh germicidal bleach wipe, thoroughly wipe the surface of the meter (top, bottom, left and right sides) a minimum of 3 times horizontally followed by 3 times vertically . 3. Observe surface contact time. Review of the label for wipes, Clorox Healthcare Bleach Germicidal Wipes, undated indicated in part . Bactericidal, Virucidal, Fungicidal, Tuberculocidal, Sporicidal . Disinfects in 3 minutes . 3-minute wet time. Review of label for wipes, Cavi Wipes, undated indicated in part . Tuberculocidal, Bactericidal, Virucidial, Fungicidal . 3 minute kill time . Cleaning procedure: Blood . must be thoroughly cleaned from surfaces and objects before application of this disinfecting towelette. During a concurrent interview, and observation, with licensed nurse (LN 1), on 11/29/22, at 12:30 p.m., LN 1 stated I use the alcohol wipes before and after use to not have cross contamination. LN 1 then proceeded to take out an alcohol wipe and wiped down the glucometer. During a concurrent interview, and observation, with LN 3 on 11/29/22, at 12:56 p.m., LN 3 stated I clean the glucometer with the Clorox Bleach Wipes, let it dry, and put in on the dock. LN 3 then wiped down a glucometer and immediately placed it on the dock. During an interview, and concurrent record review, on 11/29/22, at 1:05 p.m., with the director of staff development (DSD), DSD confirmed that staff are not following MFUs for cleaning and disinfecting glucometer between residents and they should. During an interview, and concurrent record review, on 11/29/22, at 1:07 p.m., with the director of nursing (DON), the DON confirmed staff were not following MFUs for cleaning and disinfecting the glucometer. 2. Review of the APIC website, https://infectionpreventionandyou.org/infographic/ppe-dos-and-donts/, accessed on 12/6/22, indicated Do clean hands and change gloves between each task (e.g., after contact with a contaminated surface or environment). During an observation, and concurrent interview, on 11/29/22, at 10:30 a.m., with environmental services (EVS 1), the EVS 1 removed clean supplies from the supply cart with dirty gloves on. The environmental services lead (EVSL) acknowledged that EVS 1 should not be touching clean supplies while wearing dirty gloves. During an observation, and concurrent interview, on 11/29/22, at 10:40 a.m., the EVS 2 removed clean supplies from the supply cart with dirty gloves on. The environmental services lead (EVSL) acknowledged that EVS 2 should not be touching clean supplies while wearing dirty gloves. 3. Review of the facility policy and procedure titled, Infection Prevention and Control Program, revised 8/10/22, indicated in part . Residents and staff are protected from the transfer of infectious diseases, using the CDC's Guidelines . According to the centers for disease control (CDC), updated 9/21, considerations are intended for use by federal, state, and local public health officials, respiratory protection program managers, leaders in infection prevention and control programs, and other leaders in healthcare settings who are responsible for developing and implementing policies and procedures for preventing pathogen transmission in healthcare settings. CDC indicated N95 respirators (face mask filtering 95% of particles, virus .) are the personal protective equipment (PPE) most often used to control exposures to infectious pathogens transmitted via the airborne route, though their effectiveness is highly dependent upon proper fit and use. N95 respirators are intended to be used once and then properly disposed of and replaced with a new N95 respirator. During an interview, and observation, with the director of nursing (DON) on 11/29/22, at 1:45 p.m., during a tour of the facility, two paper bags had staff names written on them and the DON confirmed that the paper bags contained used N95s being stored for reuse. The DON acknowledged staff should be throwing out their N95s after each use. 4. Review of the facility policy and procedure titled, Infection Prevention and Control Program, revised 8/10/22, indicated in part . Residents and staff are protected from the transfer of infectious diseases, using the CDC's Guidelines . Review of the CDC website, https://www.cdc.gov/niosh/npptl/pdfs/PPE-Sequence-508.pdf accessed on 12/6/22, indicated in part . How to safely remove . PPE . Gown front and sleeves are contaminated! . pull gown away from neck and shoulders, touching inside of gown only turn gown inside out fold or roll into a bundle and discard in a waste container. During an observation, and concurrent interview, with laundry staff (LS) and the environmental services lead (EVSL) on 11/29/22 at 10:51 a.m., LS explained that LS uses one gown for the day. Additionally, LS stated the gown is worn when picking up dirty laundry, hung up, and then put back on. EVSL confirmed the gown is considered dirty after use and a new gown should be used.

Based on interview, and record review, the facility failed to offer the influenza (Flu- a highly contagious infectious disease) vaccine (medication that helps the body fight infections) for one of five residents (Resident 1). This deficient practice placed Resident 1 at a higher risk of acquiring and transmitting influenza to other residents in the facility. Findings: During a review of Resident 1's clinical record, the record indicated Resident 1 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the facility policy and procedure titled, Influenza Vaccination Program for CCC Residents, revised 11/30/17, indicated in part . Purpose: To provide a safe environment for residents, staff, and visitors, to reduce morbidity and mortality from influenza by vaccinating all residents . Procedures: Resident screening: screening must be performed upon admission by admitting nurse during the flu season. Provide education regarding the benefits and potential side effects of the Influenza Vaccine and offer a copy of VIS (Vaccine Information Statement) to each resident . Check doctor's order. Obtain Influenza Immunization Informed Consent . Administer . inactivated influenza vaccine . Document each resident's vaccine administration information and follow up in the following places: Medical Record: If vaccine was not given, notify MD, record the reason for non-receipt of the vaccine (e.g., medical contraindication, resident refusal). During an interview, and concurrent record review, on 11/30/22, at 3:18 p.m., with the director of nursing (DON), the DON confirmed the facility was unable to provide documentation indicating the influenza vaccine was offered and refused or administered to Resident 1.

Based on interview, and record review, the facility failed to offer the COVID-19 (a highly contagious infectious disease) vaccine (medication that helps the body fight infections) for one of five residents (Resident 1). This deficient practice placed Resident 1 at a higher risk of acquiring and transmitting influenza to other residents in the facility. Findings: During a review of Resident 1's clinical record, the record indicated Resident 1 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the facility policy and procedure titled, COVID-19 Vaccination Program for CCC Residents, revised 8/10/22, indicated in part . Purpose: To prevent the spread of COVID-19 infection by vaccinating all residents . Procedures: residents are offered the COVID-19 vaccine . Admission screening: vaccination status being screened upon admission and the COVID-19 being offered . provide education regarding the benefits and potential side effects . obtain COVID-19 Vaccine Consent . Administer the vaccine per doctor's order . If vaccine was not given, notify MD, record the reason for non-receipt of the vaccine (e.g., medical contraindication, resident refusal) . The completed COVID-19 Informed Consent form shall be placed in the resident's medical record. During an interview, and concurrent record review, on 11/30/22, at 3:18 p.m., with the director of nursing (DON), the DON confirmed the facility was unable to provide documentation indicating the COVID-19 vaccine was offered and refused or administered to Resident 1.

Based on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food and ice in accordance with professional standards when: 1. ambient room temperature foods were not monitored for cooling, and 2. two of three ice machines had a pink substance on the ice machine chute and had not been cleaned and sanitized routinely. These failures had the potential to result in the growth of microorganisms for 79 residents at the facility. Findings: 1. During an observation in the initial kitchen tour on 5/2/22 starting at 10:10 a.m., there was chicken salad dated 4/30/22 and tuna salad dated 4/27/22 located in the sandwich refrigerator. During an interview on 05/3/22 at 10:03 a.m., with Cook 2, Cook 2 verbalized that she makes the tuna and chicken salad. She stated that the tuna or chicken in can is taken from the dry storage, so it is warm and is mixed with mustard, sometimes dill seasoning and mayo from the fridge if a jar is already open or get a new jar from the dry storage. Once mixed, they store the tuna salad in the refrigerator and monitor the temp of the fridge to keep track of temperatures. Cook 2 stated that they do not record temperatures of the tuna salad after they make it. During an interview on 5/3/22 at 3:42 p.m. with the DD regarding cooling of ambient foods like tuna and chicken salad, DD verbalized that as soon as the tuna salad is mixed, it is put in the fridge and has a 6-hour process to cool down. The cook who makes them does not have to take or record temperatures. The DD acknowledged that the tuna can comes from the dry storage and not from the fridge. According to the Food and Drug Administration (FDA) Food Code 2017, Section 3-501.14 Cooling, Time/Temperature control for Safety Food shall be cooled within 4 hours to 5oC (41oF) or less if prepared from ingredients at ambient temperature, such as .canned tuna P. 2. During a concurrent interview and observation in the presence of the Facilities Engineer (FE) on 5/4/22 at 9:46 a.m. of the ice machine located in the facility kitchen. The surveyor wiped the chute and lip of the ice machine with a clean white paper towel. A light pink substance was seen on the paper towel. The FE acknowledged there was a pink substance on the paper towel. A sheet of ice was unable to fall out because ice was so high up in the bin. During a concurrent observation and interview with the FE on 5/4/22 at 09:49 a.m., at the utility room C, the Hoshizaki ice machine was observed. The water and ice dispenser were clean to sight. The FE verbalized that he takes a picture of the inside of the chute for ice and water for inspection and then wipes off any substances using a paper towel. He stated he also washes out the filter with a hose monthly. During a concurrent observation and interview with the FE on 5/4/22 at 09:53 a.m., at the clean utility room D by the east dining room, the Manitowoc ice machine was observed. The ice machine was a below counter ice machine and there was a small ice grate and chute that would flip down when ice would be filled then dropped in the bin. The Surveyor used a white paper towel to wipe the flap/chute and a dark pink substance was seen on the paper towel. The FE acknowledged the presence of a dark pink substance on the paper towel. During a telephone interview with the Refrigeration Representative (RR) on 5/4/22 at 2:38 p.m., RR stated the last 2 cycles the tech was turned away since not vaccinated but they had been out before. He stated they usually routinely come out on a quarterly basis. During an interview on 5/4/22 at 2:42 p.m., with the DD, DD stated that they had gotten two of the ice machines brand new last year June 2021. The DD was unable to show latest invoices for maintenance of the ice machine. The DD stated he did not think the contractor had been out at all last year and the irregularity to maintain scheduled sanitation of ice machines may be due to COVID outbreaks and refusal of entry of contracted vendor due to their vaccination status. During a record review of the Ice Machine Instruction Manual, dated 3/25/20, the instruction manual indicated in part the Maintenance Schedule for the area and task to maintain the ice machine. The schedule includes a Bi-weekly, Monthly, every 6 months, yearly and after 3 years, and then yearly. More frequent maintenance may be required depending on water quality, the appliance's environment, and local sanitation regulations. During an interview on 5/4/22 at 9:58 a.m., with LN3 at the east nursing station, LN3 stated they use the ice from the ice machine in the utility room D to fill up the water pitchers for the residents during the day and for use in their medication carts.

Based on record review and interview, the facility failed to ensure: 1.an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . This failure placed Resident 24 at risk to developed [CONDITION(S)] (low blood sugar ) or [CONDITION(S)] (high blood sugar) with no monitoring and intervention causing a sudden change in the resident's condition. 2. Indwelling urinary care ( IUC-plastice device inserted into the urinary area for urine passage) was documented for one of 18 sampled residents (Resident 16). This failure had the potential and risk for uncoordinated and unmonitored IUC care which can affect the resident's overall wellbeing. Findings: 1. Review of Potter and Perry, seventh Edition, Mosby's Fundamentals of Nursing, page 336 in the section titled, Physician's Orders, indicates, Nurses follow physician orders unless they believe the orders are in error or harm clients. Therefore you need to assess all orders, and if you find one to be erroneous or harmful, clarification from the physician is necessary. During a review of the clinical record for Resident 24, the admission notes indicated diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician order dated 2/17/22 indicated an order for [MEDICAL RECORD OR PHYSICIAN ORDER] [CONDITION(S)] (blood sugar below 60) protocol - call MD (physician) Give insulin for the following blood sugar level subcutaneously (SC -under the skin) before meals (breakfast ,luch, dinner) and at bedtime (blood level to be check by fingerstick /pricking before meals and bedtime) as follows : 151-200 -3 units 201-250 -5 units 251-300 -7 units 301-350- 9 units 351-400 - 11 units 401-600 - 13 units and call MD The Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The document titled, Weights and Vitals Summary (WVS) dated from 2/17/22 to 4/30/22 indicated, documentations of the residents blood sugar check by fingerstick at bedtime with results ranging from 59 mg/dl to 371 mg/dl. During a review of the document titled Order Recap Report ,(ORR), dated 4/1/22 - 5/31/22 indicated, Resident 24's order for [MEDICATION(S)] insulin sliding scale and fingerstick before meals and bedtime was discontinued on 4/7/22. Further review of Resident 24's clinical record indicated no physician order was obtained by staff to justify the blood sugar fingerstick procedure done by staff to the resident from 4/8/22 to 4/30/22 at bedtime as reflected on the WVS document dated 2/17/22 to 4/30/22. During an interview on 5/4/22 at 12:05 PM with the Director of Nursing (DON), the DON indicated, the [MEDICATION(S)] sliding scale order was discontinued on 4/7/22 per pharmacy reason of non coverage from insurance of the [MEDICATION(S)], but the blood sugar check is still needed . The DON stated, Staff should have asked the physician for a new order on blood sugar check after 4/7/22 and this was missed. 2. According to Nursing Fundamentals by [NAME], [NAME] and Wilkins, second edition, 2010 p. 322, Documentation is the professional responsibility of all health care practitioners. It provides written evidence of the practitioner's accountability to the client, the institution, the profession, and society. Review of a concurrent observation and the clinical record review for Resident 16 on 5/4/22 at 11:36 AM, the resident was without any IUC. The undated careplan in the clinical record indicated a plan for catheter care each shift and as necessary.No documentation was located in the clinical record when did the resident had an IUC, and what was the care rendered. During an interview on 5/4/22 at 2:45 PM with the director of nursing (DON), the DON indicated Resident 16 had an IUC which was discontinued on 5/2/22. The DON further indicated the IUC care rendered when the resident still had the device in place was not documented so with monitoring and care after discontinuance and that should have been done.

Based on observation and interview the facility failed to ensure a resident with impaired upper mobility was provided with other form of communication system or device to call for assistance for one of 18 sampled residents (Resident 60). This failure has the potential for Resident 60 to be isolated, and unmonitored for communication needs . Findings: During an observation inside the resident's room on 5/2/22 at 11:20 AM, Resident 60 was sitting on a chair by the right side of the bed with the push call light situated on the left side of the bed. During an interview on 5/2/22 at 11:29 AM, with the director of rehab (DOR),the DOR indicated Resident 60 has contractures (stiff, hard muscles, bones) on the upper extremities ,not able use the regular push call light and an adaptive device should be in place. During the review of the resident's minimun data sheet (MDS -assessment) dated 1/22/22, Resident 60 requires extensive to total dependence on staff for activities of daily living ( ADLS -hygiene, eating, bathing, toileting) with limitation on the upper and lower extremities, and able to perform ADLs with at least one person assist. During an interview on 5/2/22 at 11:39 AM, with licensed nurse (LN4). LN4 indicated the call light should be within the resident's reach and since the resident is not able to use the regular push call light an adaptive device, like a touch pad (movement) should be provided to call for assistance. According to California Advocates to Nursing Home Reforms Titled Nursing Home Care Standards (http://www.canhr.org/factsheets/nh_fs/html/fs_CareStandards.html). Accommodation of needs, A resident has the right to reside and receive services in the facility with reasonable accommodations of individual needs and preferences. The facility should attempt to adapt such things as schedules, call systems, staff assignments and room arrangements to accommodate residents' preferences, desires and unique needs. During an interview on 5/3/22 at 4:03 PM the director of nursing (DON), the DON indicated the facility does not have a policy for adaptive call lights.

Based on observation, interview, and record review the facility failed to ensure: 1. Hydration needs were met for Resident 61 when a water pitcher was not accessible to the resident. This failure placed the resident at for dehydration (lack of fluids body needs daily). 2. Nutritional needs were met for Resident 77 when meal intakes were not documented accurately for the resident. This failure placed the resident at risk for for weight loss and malnutrition ( inadequate nutritional consumption). Findings: 1. During a concurrent observation and interview on 5/2/22, at 11:30 a.m., with Resident 61's representative (RP 1), in Resident 61's room ,109-A, RP 1 verbalized Resident 61 had a stroke and has right sided paralysis. RP 1 verbalized Resident 61's belongings and bedside table are on the right side of the bed. Resident 61's bed was observed to be next to the wall on the left side of the room, the bedside table was on the right side of bed, with a water pitcher. RP 1 verbalized Resident 61 cannot use her right arm. RP 1 verbalized when Resident 61 wants to get a drink of water she cannot reach the water pitcher, it is too far away. RP 1 verbalized the water pitcher is always empty and has to ask for water cups. RP 1 further verbalized Resident 61 gets dehydrated and contributes to her urinary tract infections. During an observation on 5/3/22, at 8:18 a.m., in room [ROOM NUMBER]-A, Resident 61's water pitcher was observed on the bedside table on the right side of the bed. The water pitcher was half full and there were no water cups. During a concurrent observation and interview on 5/3/22, at 4:25 p.m., with the registered dietician (RD), it was observed that Resident 61 had moved from room [ROOM NUMBER]-A to room [ROOM NUMBER]-B. In room [ROOM NUMBER]-B, Resident 61 was observed sitting up in the wheelchair. Resident 61's bed was next to the right side of the wall and bedside table was on the left. There was no water pitcher on the bedside table. The RD acknowledged Resident 61 did not have a water pitcher at the bedside and needed one. During a review Resident 61's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Encourage and offer fluids. Make sure water pitcher is within reach every hour for poor fluid intake. During a review of the facility's policy and procedure titled, Feeding Residents dated 5/18 .indicated in part Diets are ordered for each resident by the physician according to caloric and hydration restrictions/needs as well as chewing and swallowing ability .percentage of food intake is to be recorded for each resident meal .offer meal substitute it the resident is consuming less than 50% of their meal .amounts of fluid intake are recorded each shift. 2. During a review of Resident 77's nutrition assessment dated [DATE], indicated in part .Resident current BMI (body mass index) is 23.4 underweight .potential for inadequate energy intake related to chronic conditions and advanced age as evidenced by inability to self feed, [CONDITION(S)], dementia, and advanced age of 99 .continue to monitor weight monthly, PO (by mouth) intakes, and additional nutritional needs. During a concurrent observation and interview on 5/2/22, at 12:22 p.m., with Resident 77's representative (RP 2), in Resident 77's room ,110-B, RP 2 verbalized Resident 77 needs full assistance with eating. RP 2 verbalized the nursing assistants (CNAs) do not know how to calculate meal percentages and documents that Resident 77 is eating more than she actually does. Resident 77 lunch tray was observed to have a puree of protein and gravy, sweet potatoes, veggies, and red velvet cake. The tray also had two coffee cups of hot water for tea, a cup of room temperature water, two-handled sippy cup, and a bottle of Strawberry Ensure supplement shake. It was observed and confirmed by RP 2 that Resident 77 ate most of the protein and the sweet potatoes, but did not eat the veggies, cake, or gravy. It was also observed Resident 77 drank most of the Strawberry Ensure supplement shake and confirmed by RP 2. During a review of the facility's Point System for Determining Percent of Food Consumed indicated: If resident has 4 items on the meal tray and consumes: 1 item that equals 25% of meal eaten. 2 items that equals 50% of meal eaten. 3 items that equals 75% of meal eaten. 4 items that equals 100% of meal eaten. If resident has 5 items on the meal tray and consumes: 1 item that equals 20% of meal eaten. 2 items that equals 40% of meal eaten. 3 items that equals 60% of meal eaten. 4 items that equals 80% of meal eaten. 5 items that equals 100% of meal eaten. Fluids and supplements are listed on the bottom of the point system to determine fluid intake: Ensure equals 240ml Coffee cup equals 240 ml Paper cup equals 100 ml During a concurrent observation and interview on 5/2/22, at 1:00 p.m., with the nurse assistant (CNA 1), CNA 1 observed Resident 77 meal tray. When asked how much % of meal Resident 77 had eaten, CNA 1 verbalized Resident 77 had 5 items on the tray, protein, sweet potatoes, veggie, cake and Ensure shake. When asked if the Ensure shake was a supplement and if it should be counted as part of % of meal intake, CNA 1 stated, Yes, it is part of the meal tray and is counted as an item eaten. CNA 1 verbalized Resident 77 had 5 items on the tray and consumed 3 items which equals 60% of meal eaten. During a concurrent interview and record review on 5/3/22, at 4:27 p.m. with the RD, Resident 77's meal intake log dated 5/2/22 was reviewed. The log indicated Resident 77 ate 25% meal intake at breakfast, 66% intake at lunch, 33% intake at dinner. RD was informed CNA 1 included Ensure, the supplemental shake, as part of the % of meal intake. RD verbalized that Ensure is a supplement and should not be documented as part of the % of meal intake, Ensure should be documented separately. RD was shown a picture of Resident 77's meal intake at lunch on 5/2/22, and was reviewed. RD verbalized Resident 77 had 4 items on the tray not 5, and consumed 2 items on the tray not 3. RD verbalized the % of meal intake according to the facility's point system, indicated Resident 77 had a 50 % meal intake for lunch not 66%. RD acknowledged the meal intake % was calculated incorrectly. RD verbalized she relies on the % of meal intakes as part of the resident's nutritional assessment in determining if the residents nutritional and caloric needs have been met. RD further verbalized moving forward, that the CNAs needed more training and in-services on meal intakes, and will be held twice a month.

Based on record review, interview, and observation, the facility failed to maintain an acceptable body weight for one of seven sampled residents (Resident 1). The facility failed to: implement the administration of [MEDICATION NAME] (an appetite stimulant) timely; failed to evaluate the effectiveness of Med Pass (a high calorie drink); failed to follow and monitor care plan interventions. These failures resulted in a loss of 13.8 pounds for Resident 1, greater than 10% body weight loss over 31 days. Findings: On 12/14/12, review of the facility policy and procedure titled "Weight Loss", dated 2/3/12, indicated when residents are losing weight or refusing to eat the dietician will do the following: 1. Review the chart upon admission to assess the resident's nutrition and fluid requirements, dining assistance needs, food preferences/allergies and frequency of meals. 2. Residents on weekly weights will be assessed at the end of 14 days. 3. The physician will be contacted for special supplements and/or fortified diets. 4. A care plan will be developed, evaluated and revised based on response, outcomes, and needs. Review of the facility policy and procedure titled "Restorative Dining Program," dated 9/7/12, indicated the program is meant to instruct and reinforce maximum potential in residents ability to feed themselves. It also provides an environment that fosters acceptable behavior at mealtime and promotes socialization. Potential candidates for the program may be referred for evaluation by anyone recognizing a resident's need for the program. A physician's order is not required for a restorative program screening. "Residents who may be appropriate candidates include but are not limited to: multiple fractures...Poor eye-hand coordination due to tremor or [DIAGNOSES REDACTED]... recent weight loss due to physical limitations or regression in medical status.. irreversible dementia in the early stages..." Review of Resident 1's record, on 12/14/12, revealed an initial admission to this facility on 10/31/12. Resident 1's initial weight taken on 11/1/12 was 141.8 pounds with a height of 5' 7". On 11/9/12, Resident 1's weight was recorded as 135.2 pounds (6.6 pounds loss in 9 days). Resident 1 was transferred to the hospital on [DATE]. Review of Resident 1's record upon readmission on 11/16/12 revealed a physician's order, dated 11/16/12, Resident 1 may eat a regular soft diet. Review of the initial care plan titled "Nutrition Status/Diet" dated 11/16/12 identified Resident 1's goal as "will be able to consume diet to at least 50% of meal" and included interventions to "monitor meal percentages." Review of the "Initial skin assessment", dated 11/16/12, indicated Resident 1 had slight swelling over the surgical incisions on the shoulder and hip. The comprehensive assessment dated [DATE] indicated Resident 1 was readmitted to the facility after surgical repair of a fractured upper left arm and right hip. Additional [DIAGNOSES REDACTED]. Resident 1 was assessed to have severe cognitive impairment, wore upper and lower dentures, had no evidence of a swallowing disorder, and required assistance of one person while eating. During an interview with the nurse who assessed the resident for the comprehensive assessment (LN 8) on 2/14/13 at 4:45 p.m., she explained when a resident is assessed to require assistance of one person during eating, it means a staff member should sit with the resident during his meals to encourage him to eat, assist as needed, and if the resident can hold the utensil, to help guide it to his mouth. Review of Resident 1's nutrition care plan dated 11/28/12 revealed no interventions prior to 12/4/12 even though Resident 1 had already lost 8.8 pounds over the previous two weeks. The 12/4/12 interventions included: "continue to offer snacks, may like a health shake (high calorie shake)" and Med Pass, two ounces, to be given by the licensed nurse with medications. Review of Resident 1's weekly weight record dated 11/16/12, revealed the following weekly weights over a period of 31 days: 11/17/12 - 136.2 pounds - re-admission weight (gain of one pound while hospitalized ) 11/20/12 - 134.9 pounds - loss of 1/3 pounds 11/27/12 - 127.4 pounds - loss of 7.5 pounds 12/04/12 - 126.8 pounds - loss of 0.6 pounds 12/11/12 - 122.8 pounds - loss of 4 pounds 12/18/12 - 122.4 Pounds - loss of 0.4 pounds Resident 1 lost a total of 13.8 pounds, greater than 10% of his weight, over this 31 day period. Review of the nursing notes dated from 11/17/12 through 12/14/12 revealed no documented evidence of staff encouraging Resident 1 to eat between meal snacks as indicated in the care plan. The nursing note dated 11/27/12 at 1:30 p.m. indicated, "Daughter notified of weight loss down 7.5 pounds, started on medication to improve appetite did eat lunch, will fax Dr....", however, there was no fax in the medical record and review of the mediation profile for 11/12 revealed no appetite stimulant was started at this time as indicated in the 11/27/12 nursing note. There was no documented evidence in the medical record that the physician was also notified of Resident 1's significant weight loss. Review of the "Nutrition Risk Assessment" dated 11/26/12, 10 days after Resident 1's was readmitted , the registered dietitian (RD) identified Resident 1 as a high nutrition risk who fulfilled the following criteria: Resident 1 consumes 44% of meals, has dementia, and takes more than 5 medications per day. Review of the RD's "Dietary Progress Notes" dated 11/26/12 indicated Resident 1's oral intake is not yet adequate to meet his needs. The plan was to increase calories/protein via nourishments between meals. On 11/27/12, the RD documented that she faxed the physician to request Med Pass. The RD wrote that the plan was to "offer health shake to gauge acceptance" and possibly "offer if he agrees to drink" and continue to encourage meals. RD documented she visited Resident 1 to offer the health shake but Resident 1 was sleeping. On 11/28/12 the RD documented she again visited Resident 1 to offer a health shake and Resident 1 was sleeping. The RD wrote the plan was to "engage assistance of other staff to offer the health shake when he is awake." Review of the physician's order dated 11/30/12 indicated an order for [REDACTED]. Review of the November 2012 medication record indicated Med Pass was administered to Resident 1 beginning 11/30/12. Review of Resident 1's RD notes, nurses notes, physician progress notes [REDACTED]. During an observation on 12/14/12 at 8:55 a.m., Resident 1 was sitting in a wheelchair in the middle dining room, his partially eaten breakfast of french toast and cereal was in front of him. There was no facility staff sitting with or assisting the resident as indicated in the comprehensive assessment. During an observation on 12/14/12 at 1:13 p.m., Resident 1 was in the middle dining room sitting at a table with other residents eating lunch. There were no facility staff assisting Resident 1 with his lunch as indicated in the comprehensive assessment. Resident 1 asked for help to open his tartar sauce package. A certified nursing assistant (CNA 4) assisting a resident at another table came to Resident 1 and stated, "You already ate one tartar sauce." When the surveyor informed CNA 4 that Resident 1 had lost a significant amount of weight, CNA 4 stated she was not aware Resident 1 had been losing weight. The CNA 4 opened the tartar sauce container. Resident 1 said to the surveyor that he liked the fish and he ate all of it including the two packages of tartar sauce. During an interview with CNA 2 on 12/14/12 at 1:30 p.m., CNA 2 indicated she was assigned to Resident 1 today. CNA 2 calculated that Resident 1 ate 50% of his lunch, even though he ate all of his fish, he did not eat the other items on the tray which consisted of potatoes and vegetables. CNA 2 stated she would not offer the resident more fish because he ate 50% of the entire meal and they only offer another meal if the resident ate less than 50%. CNA 2 confirmed she was not aware of Resident 1's weight loss and stated no one suggested she encourage him to eat. Review of the physician's orders and the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]'s notes indicating Resident 1 had started on an appetite stimulant. During an interview with Resident 1's facility physician on 12/21/12 at 11:55 a.m., the physician confirmed not being aware of the extent of Resident 1's weight loss. During an interview with a licensed nurse (LN 2) on 12/21/12 at 12:45 p.m., LN 2 stated Resident 1 "needs a lot of encouragement, reminded to take a bite and ask more than once. He probably eats better if he gets reminders." Despite this knowledge, there was no staff providing assistance to Resident 1 during the 12/14/12 meal observations, as indicated in his initial comprehensive assessment. During an interview with a certified nurse assistant (CNA 1) on 12/14/12 at 2:30 p.m., she explained that she was responsible for delivering snacks to the residents twice a day. She had a list of resident names who have physician ordered snacks including health shakes to be delivered. CNA 1 confirmed that Resident 1 was not on the list. During an interview with the RD on 12/14/12 at 2 p.m., she explained that she does not automatically order health shakes (high calorie drink) for residents losing weight because if they do not like it, "it gets thrown away" and "it's wasteful." The RD confirmed she had not reassessed to see if Resident 1 ever drank or liked health shakes nor if the ordered Med Pass was an effective intervention for Resident 1's weight loss. Resident 1 continued to lose weight and had lost 4.6 pounds since her last documentation 16 days ago. During an interview with a responsible party (RP) on 12/18/12 at 5 p.m., the RP explained that Resident 1's usual weight over the past few years has been around 147 pounds, Resident 1 lived at home and ate independently. The RP explained that the family has observed Resident 1 in the dining room trying to eat without his dentures on more than one occasion, stating that Resident 1 needs his dentures to eat. The RP stated the facility staff notified the family one time that Resident 1 lost 7 pounds and told the family an appetite stimulant would be ordered. The RP was not aware that Resident 1's current weight was 122.4 pounds (a loss of 24.6 lbs. from the stated RP usual weight of 147 lbs.) During an observation and consecutive interview on 12/21/12 at 8:30 a.m., Resident 1 was sitting in a wheel chair in the middle dining room, no dentures in place, while his breakfast tray was on the table in front of him. He was quickly wheeled out of the dining room to a nursing care plan office. LN 1 said that Resident 1 had refused his dentures and was disrupting the residents in the dining room, so she took him to her office because it was quiet and she thought it might calm him down. Review of Resident 1's flow sheet for documentation of the percent of meals eaten, dated 12/21/12, revealed the resident refused breakfast. During an interview with the nursing supervisor (NS) on 12/21/12 at 10:30 a.m., the NS explained that the RD was responsible for analyzing residents weights and their oral intake. During an interview and consecutive observation on 12/21/12 at 12:30 p.m., the restorative nurse assistant (RNA 1) stated Resident 1 "has never been assigned to the RNA program for dining", even though the resident met the criteria to be included in the restorative dining program. RNA 1 explained how she weighed Resident 1 on the "EZ Way Smart Lift" scale. She stated she always used this scale to weigh Resident 1. RNA 1 demonstrated how the scale works and how she weighs a resident. RNA 1 explained the facility practice when a weight loss is identified, the resident is weighed twice and a licensed nurse verifies and initials the weight sheet. RNA 1 explained the staff were aware of Resident 1's weight loss because their practice is to make ten copies of the weight sheet and distribute to a list of staff members, two of which are the director of nurses and the registered dietitian, thereby notifying them of the weight loss. On 12/21/12, review of Resident 1's 2012 November and December ADL (activities of daily living) Flow Sheet revealed Resident 1 consumed an average of 52.3% of his meals during the 34 days since admission to this facility. The 12/12 ADL flow sheet indicted that Resident 1 refused the offer of a meal substitute every time it was offered, with only one the exception. In this instance on 12/8/12, there was no record of whether he accepted or refused the offer. "Snacks in between meals and at bedtime" was recorded on the same ADL flow sheets. Between meal snacks were offered three times daily at 10 a.m., 3 p.m., and 9 p.m. The flow sheet indicated that Resident 1 was offered a between meal snack 81 times and refused it 74 times. During a second interview with the RD on 12/21/12 at 10:35 a.m., she explained the process for tracking resident's weights. She stated "I am normally the one who is responsible for watching weights and intakes." She explained that she runs the weekly weight variance meetings. The RD explained that the weight variance committee reviews "all" of the weekly weights for new residents and always includes residents with weight loss. She confirmed Resident 1 had not been discussed at the weight variance committee since 11/27/12 (when the resident was placed on weekly weights) despite having lost 13.8 pounds. The RD explained that not all residents were discussed at the weight variance meeting every time, and that she prioritizes new patients with weight loss. The RD stated "He (Resident 1) will eat what he eats and that's about it." The RD stated there was no policy and procedure for the weight variance meetings. The RD described the process of increasing a resident's calories by fortifying the diet. She stated they could add "super cereal" to hot cereal for extra calories and extra fat into vegetables and gravies. The RD stated they can add 600 calories and 27 grams of protein to the diet, however, the RD confirmed she did not assess Resident 1 as a possible candidate for the fortified diet and confirmed Resident 1 was not receiving a fortified diet. The RD confirmed she had not monitored and evaluated the effectiveness of the Med Pass intervention or revised the interventions as appropriate since 11/29/12, in response to Resident 1's continued weight loss, and therefore did not know if he drank the one health shake she left in his room on 11/29/12 or if the 11/30/12 ordered Med Pass was an effective intervention. The RD stated she also works at a hospital and "didn't have time to go to the CCC (this facility)." She stated she has "other patients, so have not had a chance." During review of Resident 1's record on 12/21/12 of the RD notes, physician orders, and care plans revealed no evidence that the RD instructed the staff regarding the health shake. There was no evidence that Resident 1 was assessed for RNA dining program or a fortified diet. There was no evidence Resident 1 was assessed after 14 days from the onset of weekly weights, as indicated in the facility weight loss policy. During an interview with the administrator (ADM) on 12/21/12 at 11:03 a.m., the ADM confirmed that he would expect the RD to discuss Resident 1's weight loss at the weight variance meeting.

Based on interview and record review the facility failed to ensure one of eight sampled residents (Resident 2) was administered a medication as ordered and did not follow manufacturer's guidelines for administration. Resident 2 had a physician's order for [MEDICATION NAME] (a highly concentrated opioid-a narcotic medication used to control moderate to severe chronic pain) patches (topical), which carries a "Black Box Warning" (most serious labeling indicating significant risk of serious or life threatening adverse effects) indicating that each patch may be worn continuously for 72 hours. The next patch should be applied to a different skin site after removal of the previous [MEDICATION NAME] system. On 1/4/13 Resident 2 became unresponsive after being transferred to the hospital for tests. Resident 2 was found to have three [MEDICATION NAME]es affixed to various areas his body and [MEDICATION NAME] (a potent medication for reversal of side effects suspected with narcotic overdose) 0.4 mg. (milligram) IV (intravenous) was administered to reverse Resident 2's altered level of consciousness / mentation. After administration of [MEDICATION NAME], Resident 2 became more alert. The failure to remove previous [MEDICATION NAME]es before the application of a new patch placed Resident 8 at risk for serious harm or death related to narcotic overdose. Findings: On 1/11/13, review of the facility policy and procedure titled "Drug Administration", dated 3/18/11, revealed the policy's purpose is to have all drugs administered according to the physician's order. The Black Box Warnings (BBW) are to "identify medications and assist healthcare providers in promoting the safe and effective use of these identified medications." A BBW is the "strongest medication related warning issued by the Food and Drug Administration (FDA) and is generally reserved for warning healthcare providers about adverse drug reactions that can cause serious injury or death." The facility shall establish a "High Priority BBW" list (see attached) of FDA BBW with specified actions to be taken by facility staff. It is applicable to to all areas of the facility for staff within the medication use process. The summary of BBW [MEDICATION NAME] (medications delivered through the skin) patch specified to use the "[MEDICATION NAME] Patch order form." Review of the "[MEDICATION NAME] Order" form revealed "All [MEDICATION NAME]es must be ordered using this form...Nursing Measures...Remove old patch prior to placing new patch..." Review of the manufacturer's specifications regarding "[MEDICATION NAME] ([MEDICATION NAME] System) prescribing information indicated...Dosage and Administration...each [MEDICATION NAME] system is intended to be worn for 72 hours...Warnings and Precautions...Fatal respiratory depression can occur with [MEDICATION NAME] of [MEDICATION NAME] may be worn continuously for 72 hours. The next patch is applied to a different skin site after removal of the previous [MEDICATION NAME] system..." Review of the Emergency Department (ED) record for Resident 2 dated 1/4/13 revealed Resident 2 was taken to the ED due to a decreased mental status. The record further revealed three [MEDICATION NAME]es were found on Resident 2 and were removed. [MEDICATION NAME] was administered IV. Resident 2 "woke-up" and "improved." after administration of the [MEDICATION NAME] IV. ED nursing Notes with the same date indicated that three [MEDICATION NAME]es were identified and removed form Resident 2's "right anterior (front) and right posterior (back) chest." During an interview with the acute Hospital Quality Improvement Nurse on 1/11/13 at 10:45 a.m. confirmed the director of the emergency department was present when staff found three [MEDICATION NAME]es on Resident 2. She indicated the patches were found on the right anterior chest in the clavicle (collarbone) area, one on the right scapula (shoulder blade) and one right below that. During interviews with the facility licensed nurses' (LN) 3, 4, 5, 6, 7, 8 , 9, 10, and 11 on 1/11/13 starting at 12:15 p.m. regarding the protocol for putting on [MEDICATION NAME]es they were all in agreement that the the old patch is to be removed before a new one is placed on the resident. During interview on 1/11/13 at 3:45 p.m., LN 10 stated on 12/24/12 she placed a [MEDICATION NAME] on Resident 2's upper left chest. She checked Resident 2's back and chest and saw a patch that was a "darker brown patch " on Resident 2's back LN 10 explained thinking it was [MEDICATION NAME] or [MEDICATION NAME] (transparent film dressings used for wounds). LN 10 explained she was going to check the treatment book to see if Resident 2 had something that needed a dressing but instead got busy and did not check. LN 10 explained that the patch was "wider, different type then what we have" and only saw one on Resident 2's back. LN 10 confirmed not having inspected Resident 2's body for other patches. During an interview on 1/11/13 at 3:48 p.m., LN 11 stated the old patch wasn't on Resident 2's right upper back (# of site on MAR) but was midsternum (breast bone). LN 11 explained she then placed a patch on Resident 2's right upper back but the edges were peeling up so she put a [MEDICATION NAME] dressing over it. During interview on 2/20/13 at 9:15 a.m. ED physician stated "the three patches contributed to the residents condition."